How does loneliness interact with positive, negative and depressive symptoms of psychosis? New insights from a longitudinal therapy process study.

Cross-sectional research suggests an association between loneliness and psychotic symptoms, but the causal direction of this association is still unclear. Even though loneliness has been proposed as a potential treatment target to improve psychotherapy for psychosis, not much is known about its role in the treatment process. In this study, we re-analyzed data from a therapy process study to investigate the temporal dynamics between loneliness and psychotic symptoms throughout therapy and to explore whether state-of-the-art CBT for psychosis (CBTp) decreases loneliness. Over the course of up to 45 weekly sessions of CBTp, 57 patients reported their feelings of loneliness and current positive, negative and depressive symptom levels at each session. Multilevel regression revealed a reduction in all symptoms over time, but no reduction in loneliness. Time-lagged multilevel regression showed that loneliness predicted subsequent negative and depressive symptoms, whereas positive symptom levels predicted subsequent loneliness. Thus, changes in loneliness seem to be both cause and consequence of psychotic symptom changes. These findings highlight the importance of loneliness as a treatment target, particularly in patients with negative symptoms and depression. Future research should address loneliness-specific interventions as an augmentation of state-of-the-art CBTp.

Fostering coping as a mechanism of symptom change in cognitive behavioural therapy for psychosis.

INTRODUCTION: Cognitive behavioural therapy for psychosis (CBTp) has been repeatedly shown to ameliorate psychotic symptoms. However, so far we have little understanding of the mechanisms of change in CBTp. In this study, we tested whether improved cognitive and behavioural efforts to manage taxing external or internal demands (=coping) constitute a mechanism of change in CBTp. METHODS: Using data from a published trial for a secondary analysis, we tested whether the continuous symptomatic improvement of patients (n = 57) who received up to 45 sessions of CBTp and completed weekly self-assessments of symptoms (suspiciousness, individualised positive and negative symptoms, and individualised symptoms of depression) was mediated by preceding improvement in self-assessed coping using multilevel analysis. A reverse model in which symptom improvement predicted improved coping was also tested. RESULTS: Continuous improvement in suspiciousness, negative symptoms, and depression over the course of CBTp was preceded by improvement in coping. Improvement in suspiciousness or positive symptoms did not predict subsequent improvement in coping, whereas improvement in negative symptoms and depression predicted subsequent improvement in coping. CONCLUSION: Coping constitutes a mechanism of change, albeit to a different extent for different symptom clusters. Further research needs to explore how best to utilise this mechanism and optimise its integration with other active ingredients of CBTp to maximise therapeutic gain.

The impact of negative treatment experiences on persistent refusal of antipsychotics.

AIMS: We investigate reasons for persistent medication refusal in schizophrenia spectrum disorders and test whether factors that speak for a rational decision, such as negative experiences with medication or low symptom distress predict medication refusal, even after taking differences in insight into account. METHOD: We included 45 participants with schizophrenia spectrum disorders, of which 20 had refused antipsychotic medication for at least three months and assessed reasons for taking or not taking medication, labeling condition as mental disorder ("insight"), experiences with the previous treatments, symptoms and symptom distress, positive and negative consequences and experiences of psychosis, causal beliefs, therapeutic relationships with previous clinicians and attitudes towards medication. RESULTS: Groups did not differ in symptom severity but medication refusers reported significantly less insight, less satisfaction with their most-recent psychiatrist and with previous medication, and more negative beliefs about harmful effects of medication. They also felt less informed about medication. After controlling for insight, the perceived helpfulness of the previous treating psychiatrist (OR=0.30, z=5.58, p=0.018) and of previous medication (OR=0.27, z=6.87, p=0.009) and feeling insufficiently informed about medication (OR=0.53, z=3. 85, p=0.050) significantly predicted medication discontinuation. CONCLUSIONS: Building rapport with patients with a different view of the nature of their condition and encouraging informed decisions on medication are likely to improve medication adherence. However, the findings also suggest that refusing medication after a phase of initial adherence is also the consequence of negative experiences with medication and could result from weighing the pros against the cons.

The potential of continuum versus biogenetic beliefs in reducing stigmatization against persons with schizophrenia: An experimental study.

OBJECTIVE: A central aspect of previous anti-stigma campaigns was the promotion of biogenetic causes of schizophrenia. Although biogenetic beliefs have been shown to reduce the blame given to persons with schizophrenia, they tend to increase discrimination and stereotypes such as dangerousness and unpredictability. A novel anti-stigma approach is to incorporate continuum beliefs in order to oppose the perceived separation, which is a main component of the stigma process. The aim of the study was to compare the effects of a continuum, a biogenetic, and a control intervention on stereotypes, fear, and social distance towards persons with schizophrenia. Furthermore, it was intended to replicate earlier findings on the associations between continuum beliefs, biogenetic beliefs, and different facets of stigmatization. METHOD: In an online-experiment, 1189 participants from the general population randomly received either a continuum, a biogenetic, or a control intervention, which consisted of written information texts. RESULTS: The continuum group showed less endorsement of the stereotype incompetence/unpredictability than the biogenetic group. The biogenetic group ascribed less blame to persons with schizophrenia than the other groups. The correlation analyses indicated continuum beliefs to be consistently associated with lower stereotype scores, less fear, and less preferred social distance. LIMITATIONS: The sample was not fully representative and the experimental manipulations in our study consisted of relatively short information texts. CONCLUSION: It is concluded that continuum beliefs have the potential to reduce stigmatization against persons with schizophrenia. However, future studies need to investigate the effects of more powerful interventions to promote them.

Perceived therapist genuineness predicts therapeutic alliance in cognitive behavioural therapy for psychosis.

OBJECTIVES: The quality of therapeutic alliance is a consistent and stable predictor of therapy outcome. Recent studies have shown therapist characteristics to be relevant predictors of the alliance in psychological therapies in general. However, little is known about the specific therapist characteristics that explain differences in therapeutic alliance in cognitive behavioural therapy for psychosis (CBTp). The aim of this study was to identify relevant therapist characteristics that predict early therapeutic alliance in CBTp. DESIGN AND METHODS: Forty-eight patients with a DSM-IV diagnosis of a psychotic disorder participating in a CBTp trial and 11 therapists were included in the analysis. Therapist characteristics as perceived by the patients (empathy, genuineness, positive regard, competence, and convincingness) were assessed at baseline. Alliance was assessed after the fifth therapy session. Data were analyzed using bivariate correlations and multivariate hierarchic regression analysis. RESULTS: All therapist characteristics were positively associated with patient-rated alliance. Patient characteristics were not significantly associated with alliance and did not predict alliance in the multivariate analysis. Regression analysis revealed therapist genuineness and competence to significantly predict higher patient-rated alliance. CONCLUSIONS: Our results suggest that perceived therapist genuineness is the most relevant predictor of patient-rated therapeutic alliance in CBTp. Future trials using control samples with other mental disorders could clarify whether this finding is specific to CBTp. Therapist training concepts for increasing beneficial therapist qualities are needed. PRACTITIONER POINTS: The patients' perception of the therapist as empathic, genuine, accepting, competent and convincing is associated with therapeutic alliance in CBTp. Perceived therapist genuineness and competence are the most relevant predictors of patient-rated therapeutic alliance. Training and supervision should focus on increasing basic therapist qualities. Limitations of this study include homogeneity of therapists, small sample size, and lack of a control group.

Explaining attitudes and adherence to antipsychotic medication: the development of a process model.

Although nonadherence to antipsychotic medication poses a threat to outcome of medical treatment, the processes preceding the intake behavior have not been investigated sufficiently. This study tests a process model of medication adherence derived from the Health Belief Model which is based on cost-benefit considerations. The model includes an extensive set of potential predictors for medication attitudes and uses these attitudes as a predictor for medication adherence. We conducted an online study of 84 participants with a self-reported psychotic disorder and performed a path analysis. More insight into the need for treatment, a higher attribution of the symptoms to a mental disorder, experience of less negative side effects, presence of biological causal beliefs, and less endorsement of psychological causal beliefs were significant predictors of more positive attitudes towards medication. The results largely supported the postulated process model. Mental health professionals should consider attitudes towards medication and the identified predictors when they address adherence problems with the patient in a shared and informed decision process.

Negative, not positive symptoms predict the early therapeutic alliance in cognitive behavioral therapy for psychosis.

OBJECTIVE: The strength of therapeutic alliance is consistently associated with therapy outcome. The aim of this study was to identify relevant predictors for early therapeutic alliance in cognitive behavioral therapy for psychosis. METHOD: Fifty-six patients with schizophrenia spectrum disorders were included in the analysis. Possible predictors (positive and negative symptoms, depression, insight, social functioning, theory of mind, and medication adherence) were assessed at baseline. Alliance was assessed after each therapy session. RESULTS: Lower negative symptoms significantly predicted higher patient and therapist rated alliance. CONCLUSIONS: The findings indicate that negative symptoms might be a barrier to the development of therapeutic alliance. Assumed underlying processes and practical implications are discussed.