An interpretative phenomenological analysis of service users' experiences in a psychosocial addictions intervention.

OBJECTIVES: The aim of this study was to explore the subjective experiences of participants who: (1) received a psychosocial intervention as part of an addiction recovery research trial, and (2) responded to treatment through drug reduction, with the intention of eliciting qualitative change processes of recovery. DESIGN: Data were collected using semi-structured interviews designed to capture detailed descriptions of participants' experiences of recovery within the intervention. METHODS: Eleven participants who had achieved drug abstinence or significant drug reduction by successfully completing the psychosocial intervention took part in the study. The data were analysed using interpretative phenomenological analysis (IPA). RESULTS: Five superordinate themes were identified relating to (1) An active, individualised and skills-based intervention that validates a new way of being; (2) Staff that foster good working relationships based on trust and safety within services that do not stigmatise; (3) To be understood individually, historically and psychologically, and with regard to the pernicious relationship with drugs; (4) Motivation is personal, intrinsic, requires vigilance and is driven forward by periods of success through abstinence; and (5) Interpersonal connectedness is essential to recovery; family is a key reason to abstain and friendships can either facilitate or hinder success. CONCLUSIONS: These findings suggest that the success of the psychosocial intervention may be due to a combination of modality specific factors and also broader holistic aspects that were provided through intervention. Future research is required to generalise these findings to wider addiction populations. PRACTITIONER POINTS: Review of the evidence base suggests the need to move beyond testing addiction interventions and instead understand change processes through psychosocial intervention. Narratives of lived experience of those undergoing psychosocial intervention inform us that specific features relating to intervention, working relationship, motivation, identity and interpersonal factors instigate recovery. Practitioners should consider a multi-faceted approach in designing and applying psychosocial intervention for addiction.

Towards Automaticity in Reinforcement Learning: A Model-Based Functional Magnetic Resonance Imaging Study.

INTRODUCTION: Previous studies showed that over the course of learning many neurons in the medial prefrontal cortex adapt their firing rate towards the options with highest predicted value reward but it was showed that during later learning trials the brain switches to a more automatic processing mode governed by the basal ganglia. Based on this evidence, we hypothesized that during the early learning trials the predicted values of chosen options will be coded by a goal directed system in the medial frontal cortex but during the late trials the predicted values will be coded by the habitual learning system in the dorsal striatum. METHODS: In this study, using a 3 Tesla functional magnetic resonance imaging scanner (fMRI), blood oxygen level dependent signal (BOLD) data was collected whilst participants (N=12) performed a reinforcement learning task. The task consisted of instrumental conditioning trials wherein each trial a participant choose one of the two available options in order to win or avoid losing money. In addition to that, depending on the experimental condition, participants received either monetary reward (gain money), monetary penalty (lose money) or neural outcome. RESULTS: Using model-based analysis for functional magnetic resonance imaging (fMRI) event related designs; region of interest (ROI) analysis was performed to nucleus accumbens, medial frontal cortex, caudate nucleus, putamen and globus pallidus internal and external segments. In order to compare the difference in brain activity for early (goal directed) versus late learning (habitual, automatic) trials, separate ROI analyses were performed for each anatomical sub-region. For the reward condition, we found significant activity in the medial frontal cortex (p<0.05) only for early learning trials but activity is shifted to bilateral putamen (p<0.05) during later trials. However, for the loss condition no significant activity was found for early trials except globus pallidus internal segment showed a significant activity (p<0.05) for later trials. CONCLUSION: We found that during reinforcement learning activation in the brain shifted from the medial frontal regions to dorsal regions of the striatum. These findings suggest that there are two separable (early goal directed and late habitual) learning systems in the brain.

Common and Distinct Functional Brain Networks for Intuitive and Deliberate Decision Making.

Reinforcement learning studies in rodents and primates demonstrate that goal-directed and habitual choice behaviors are mediated through different fronto-striatal systems, but the evidence is less clear in humans. In this study, functional magnetic resonance imaging (fMRI) data were collected whilst participants (n = 20) performed a conditional associative learning task in which blocks of novel conditional stimuli (CS) required a deliberate choice, and blocks of familiar CS required an intuitive choice. Using standard subtraction analysis for fMRI event-related designs, activation shifted from the dorso-fronto-parietal network, which involves dorsolateral prefrontal cortex (DLPFC) for deliberate choice of novel CS, to ventro-medial frontal (VMPFC) and anterior cingulate cortex for intuitive choice of familiar CS. Supporting this finding, psycho-physiological interaction (PPI) analysis, using the peak active areas within the PFC for novel and familiar CS as seed regions, showed functional coupling between caudate and DLPFC when processing novel CS and VMPFC when processing familiar CS. These findings demonstrate separable systems for deliberate and intuitive processing, which is in keeping with rodent and primate reinforcement learning studies, although in humans they operate in a dynamic, possibly synergistic, manner particularly at the level of the striatum.

Negative and positive illness representations of rheumatoid arthritis: a latent profile analysis.

This study extends previous work to consider whether individuals with rheumatoid arthritis (RA) can be categorised into groups with similar illness representations. Data from 227 RA patients attending outpatient clinics were collected prospectively at two time points, 6 months apart. The optimal number of illness representation groups at the baseline assessment was identified using latent profile analysis. Two groups of individuals sharing similar illness perception profiles were identified. The smaller group (43%), characterised by a negative representation of their illness, attributed more symptoms to their condition and reported stronger perceptions of the consequences, chronicity and cyclicality of their condition, and lower control compared to the positive representation group (57%). Cross-sectionally, membership of the negative representation group was associated with higher levels of pain and functional disability and, longitudinally, with increases in levels of pain, functional disability and distress. These data highlight the central role of illness perceptions in RA and suggest that individuals with RA can be categorised into groups with similar illness representations.

A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs.

BACKGROUND: Taking DMARDs as prescribed is an essential part of self-management for patients with Rheumatoid Arthritis. To date, the Compliance Questionnaire for Rheumatology (CQR) is the only self-report adherence measure created specifically for and validated in rheumatic diseases. However, the factor structure of the CQR has not been reported and it can be considered lengthy at 19 items. The aim of this study was to test the factor structure of the CQR and reduce the number of items whilst retaining robust explanation of non-adherence to DMARDs. Such a reduction would increase the clinical utility of the scale, to identify patients with sub-optimal adherence to DMARDs in the clinic as well as for research purposes. METHODS: An exploratory factor analysis was performed to reduce the number of items in the CQR and then a confirmatory factor analysis was run to establish the fit of a 5 item version (CQR5) to the data. A discriminant function analysis was performed to determine the optimal combination of questions to identify suboptimal adherence. RESULTS: The factor analyses identified a unidimensional 5 item model that explains 50.3% of the variance in adherence and has good internal consistency and fit to the data. Discriminant function analysis shows that the CQR5 can affectively detect 69% of low adherers to DMARDs using Fisher's weighted regression equation. CONCLUSION: A shortened version of the CQR increases the clinical utility by reducing the patient burden whilst maintaining a good level of reliability and validity for a short, self-administered, self-report questionnaire.

Trajectories of functional limitation in early rheumatoid arthritis and their association with mortality.

OBJECTIVE: This study aimed to identify subgroups with distinct trajectories of functional (HAQ) progression over 10 years following diagnosis of RA and identify baseline characteristics associated with the trajectories and their prognostic value for mortality. METHODS: Between 1986 and 1998, 1460 patients with RA symptoms <2 years and prior to disease-modifying treatment (DMARDs) were recruited to an inception cohort (Early RA Study). Standard clinical, functional and laboratory assessments were performed at presentation and annually. Deaths were tracked by the National Health Service Central Register. Growth mixture modelling was used to identify distinct trajectories of HAQ score progression and survival analysis employed to compare all-cause mortality across the trajectory classes. RESULTS: Four HAQ score progression classes were identified: moderate increasing (46%), low stable (6%), moderate stable (28%) and high stable (20%). Only the moderate-increasing class exhibited an accelerated decline in function over normal ageing. Compared with the moderate-increasing class, individuals with high-stable HAQ scores were more likely to be female, have more severe disease and other coexistent conditions. Low-stable class patients were more likely to be male and report less pain. The high-stable class had increased risk of mortality compared with the moderate-increasing class after adjusting for potential confounding factors, whereas low-stable and moderate-stable classes were at reduced mortality risk. CONCLUSION: The effect of RA on function is set within the first few years and is affected by comorbidity. Identifying distinct groups of patients may help to target those at greater risk of poor functional outcome and mortality.

A simple solution for model comparison in bold imaging: the special case of reward prediction error and reward outcomes.

Conventional neuroimaging techniques provide information about condition-related changes of the BOLD (blood-oxygen-level dependent) signal, indicating only where and when the underlying cognitive processes occur. Recently, with the help of a new approach called "model-based" functional neuroimaging (fMRI), researchers are able to visualize changes in the internal variables of a time varying learning process, such as the reward prediction error or the predicted reward value of a conditional stimulus. However, despite being extremely beneficial to the imaging community in understanding the neural correlates of decision variables, a model-based approach to brain imaging data is also methodologically challenging due to the multicollinearity problem in statistical analysis. There are multiple sources of multicollinearity in functional neuroimaging including investigations of closely related variables and/or experimental designs that do not account for this. The source of multicollinearity discussed in this paper occurs due to correlation between different subjective variables that are calculated very close in time. Here, we review methodological approaches to analyzing such data by discussing the special case of separating the reward prediction error signal from reward outcomes.

Prediction error in reinforcement learning: a meta-analysis of neuroimaging studies.

Activation likelihood estimation (ALE) meta-analyses were used to examine the neural correlates of prediction error in reinforcement learning. The findings are interpreted in the light of current computational models of learning and action selection. In this context, particular consideration is given to the comparison of activation patterns from studies using instrumental and Pavlovian conditioning, and where reinforcement involved rewarding or punishing feedback. The striatum was the key brain area encoding for prediction error, with activity encompassing dorsal and ventral regions for instrumental and Pavlovian reinforcement alike, a finding which challenges the functional separation of the striatum into a dorsal 'actor' and a ventral 'critic'. Prediction error activity was further observed in diverse areas of predominantly anterior cerebral cortex including medial prefrontal cortex and anterior cingulate cortex. Distinct patterns of prediction error activity were found for studies using rewarding and aversive reinforcers; reward prediction errors were observed primarily in the striatum while aversive prediction errors were found more widely including insula and habenula.

The Hospital Anxiety and Depression Scale: a meta confirmatory factor analysis.

OBJECTIVE: To systematically evaluate the latent structure of the Hospital Anxiety and Depression Scale (HADS) through reanalysis of previous studies and meta confirmatory factor analysis (CFA). METHOD: Data from 28 samples were obtained from published studies concerning the latent structure of the HADS. Ten models were considered, including eight previously identified models and two bifactor models. The fit of each model was assessed separately in each sample and by meta CFA. Meta CFA was conducted using all samples and using subgroups consisting of community samples, cardiovascular disease samples and samples from studies administering the English language version of the HADS. RESULTS: A bifactor model including all items loading onto a general distress factor and two orthogonal anxiety and depression group factors provided the best fit for the majority of samples. Meta CFA provided further support for the bifactor model with two group factors. This was the case using all samples, as well as all subgroup analyses. The general distress factor explained 73% of the covariance between items, with the (autonomic) anxiety and (anhedonic) depression factors explaining 11% and 16%, respectively. CONCLUSION: A bifactor structure provides the most acceptable empirical explanation for the HADS correlation structure. Due to the presence of a strong general factor, the HADS does not provide good separation between symptoms of anxiety and depression. We recommend it is best used as a measure of general distress.

Not 2 old 2 TXT: there is potential to use email and SMS text message healthcare reminders for rheumatology patients up to 65 years old.

Short message service (SMS) and email reminders have the potential to improve adherence to appointments and medication taking. Within the UK, information and communication technology (ICT) is widely used with a very high proportion of people having access to the internet and mobile phones. Little is known about ICT use by older adults and those with chronic illness. A feasibility survey was carried out with 112 rheumatology patients in Hertfordshire, UK to determine their current use of the internet, email and SMS and their willingness to receive electronic reminders in the future. A high proportion of patients up to age 65 are successfully using ICT despite older age or functional disability caused by rheumatic disease. Forty-four percent would be willing to receive an electronic appointment reminder and 25% a medication reminder. The results suggest that reminders would be welcomed by some patients and extensive patient training would not be needed before implementation.

Distinct psychological distress trajectories in rheumatoid arthritis: findings from an inception cohort.

OBJECTIVE: As with other chronic physical illness, rates of depressive disorder are high in rheumatoid arthritis (RA). The aim of the current study was to identify distinct trajectories of psychological distress over 10 years in a cohort of RA patients recruited very early in the course of the disease. METHODS: Psychological distress as measured by the Hospital Anxiety and Depression Scale total score was assessed annually in a subgroup of 784 patients enrolled in a multi-centre RA inception cohort (Early RA Study). A latent growth mixture modelling (GMM) approach was used to identify distinct psychological distress patterns. RESULTS: Four distinct psychological distress trajectories were observed: low-stable (68%), high-stable (12%), high-decreasing (9%) and low-increasing (11%). Symptoms of pain, stiffness and functional impairment were significantly associated with levels of psychological distress at the time of diagnosis and after 3 years; serological markers of disease activity (ESR and CRP) were not. CONCLUSIONS: Although the majority of individuals developing RA experience little or no impact of the effects of the disease on their psychological well-being, a significant proportion experience high levels of distress at some point which may be related to their subjective appraisal of their condition. Assessment and treatment of psychological distress should occur synchronously with somatic symptoms.

Peer victimisation and internalising difficulties: The moderating role of friendship quality.

A cross-sectional study is reported in which loneliness and emotional problems are explored in adolescent victims of direct or relational bullying, together with the potentially moderating influence of friendship quality. Adolescents (N=401, mean age 13.5) completed the School Relationships Questionnaire, to identify bullying and victimisation roles, the Friendship Activity Questionnaire (FAQ), the Strengths and Difficulties Questionnaire (SDQ) to assess emotional problems, and the Loneliness and Social Dissatisfaction Questionnaire (LSDQ). Relational victims, but not direct victims reported significantly elevated feelings of loneliness and emotional problems compared to non-victims. Direct victims reported a significantly higher quality of friendship, compared to non-victims. Poor quality of friendship was also associated with high levels of loneliness, and vice versa for direct victims, but not for relational victims. This indicates that the higher quality of friendship found in direct victims is associated with the reduced levels of loneliness found in this group. Given the cross-sectional nature of this study, it is not possible to ascertain whether this association truly reflects the role of friendship quality as a moderator, and hence protective factor against adverse influences of victimisation. The different mechanisms underlying direct and relational victimisation are important for future research and intervention programmes.