Dataset Information

A compassionate imagery intervention for patients with persecutory delusions.

ABSTRACT:

Background

Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia.

Aims

To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions.

Method

Twelve patients with persecutory delusions received an individual four-session compassionate imagery intervention. Assessments of self-concept and paranoia were completed before treatment, immediately after treatment, and at 1-month follow-up. A qualitative study exploring participants' experiences of the treatment was also completed.

Results

Twelve out of 14 eligible patients referred to the study agreed to take part. All participants completed all therapy sessions and assessments. Post-treatment, there were improvements in self-compassion (change score -0.64, 95% CI -1.04, -0.24, d = -1.78), negative beliefs about the self (change score 2.42, 95% CI -0.37, 5.20, d = 0.51), and paranoia (change score 10.08, 95% CI 3.47, 16.69, d = 0.61). There were no serious adverse events. Three themes emerged from the qualitative analysis: 'effortful learning', 'seeing change' and 'taking it forward'. Participants described a process of active and effortful engagement in therapy which was rewarded with positive changes, including feeling calmer, gaining clarity, and developing acceptance.

Conclusion

This uncontrolled feasibility study indicates that a brief compassionate imagery intervention for patients with persecutory delusions is feasible, acceptable, and may lead to clinical benefits.

SUBMITTER: Forkert A

PROVIDER: S-EPMC9019554 | biostudies-literature | 2022 Jan

REPOSITORIES: biostudies-literature

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Publications

A compassionate imagery intervention for patients with persecutory delusions.

Forkert Ava A Brown Poppy P Freeman Daniel D Waite Felicity F

Behavioural and cognitive psychotherapy 20210603 1

<h4>Background</h4>Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia.<h4>Aims</h4>To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions.<h4>Method</h4>Twelve patients with persecutory delusions received an individual four-sessio ...[more]

PMID: 34078499

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Project description:ObjectivePersecutory delusions typically build on feelings of inter-personal vulnerability linked to negative views of the self. Negative body image is an overlooked aspect of this link between the self-concept and paranoia.DesignThis study explores body image from the first-person perspective of patients with persecutory delusions.MethodSemi-structured interviews, analysed using interpretative phenomenological analysis, were conducted with twelve patients with persecutory delusions in the context of psychotic disorders.ResultsFour super-ordinate themes emerged. First, appearance as a source of threat accounted for how negative body image increased feelings of vulnerability and fed into the content of paranoia and voices (e.g., 'I feel that everybody is noticing that I'm getting bigger and bigger and laughing at me'). Second, there was the negative impact of uncontrollable and unwanted weight gain, especially following antipsychotic medication (e.g., 'I ballooned up to 23 stone'). Third, feeling stuck captured the hopelessness and resignation in relation to appearance (e.g., 'I've become so accustomed to being overweight that I've accepted it as my lot'). Finally, looking well symbolises feeling well represented the importance of appearance in determining mental well-being (e.g., 'If I've got clean clothes and I put makeup on, at least I feel that I'm looking after myself').ConclusionsPatients with persecutory delusions described appearance-related concerns making them feel negative towards themselves, inferior to other people, and vulnerable to harm. Appearance-related distress was broader than weight gain, including dissatisfaction with skin, clothing, and attractiveness. Negative body image may be a contributory factor in the occurrence of paranoia.Practitioner pointsBody image concerns may be of particular relevance in patients with persecutory delusions due to weight gain, inactivity, and medication side effects. Body image concerns include weight gain and broader aspects of appearance. Negative body image contributes to feelings of vulnerability, potentially worsening paranoid fears. It may be helpful for practitioners to explore the psychological impact of weight gain and body image concerns in patients with psychosis.

Project description:BackgroundPersecutory delusions are a major psychiatric problem and are associated with a wide range of adverse outcomes. Our theoretical model views these delusions as unfounded threat beliefs which persist due to defence behaviours (e.g. avoidance) that prevent disconfirmatory evidence being processed. The treatment implications are that patients need to (1) go into feared situations and (2) not use defence behaviours. This enables relearning of safety and hence paranoia diminution. However, this is very difficult for patients due to their severe anxiety. A solution is to use virtual reality (VR) social situations, which are graded in difficulty and which patients find much easier to enter. We have now automated the provision of cognitive therapy within VR using an avatar coach, so that a therapist is not required and the treatment is scalable. In the THRIVE trial, the automated VR cognitive treatment will be tested against a VR control condition. It will contribute to our wider programme of work developing VR for patients with psychosis.MethodsPatients with persistent persecutory delusions in the context of non-affective psychosis will be randomised (1:1) to the automated VR cognitive treatment or VR mental relaxation (control condition). Each VR treatment will comprise approximately four sessions of 30 min. Standard care will remain as usual in both groups. Assessments will be carried out at 0, 2, 4 (post treatment), 8, 16, and 24 weeks by a researcher blind to treatment allocation. The primary outcome is degree of conviction in the persecutory delusion (primary endpoint 4 weeks). Effect sizes will be re-established by an interim analysis of 30 patients. If the interim effect size suggests that the treatment is worth pursuing (d > 0.1), then the trial will go on to test 90 patients in total. Secondary outcomes include real world distress, activity levels, suicidal ideation, and quality of life. Mediation will also be tested. All main analyses will follow the intention-to-treat principle. The trial is funded by the Medical Research Council Developmental Pathway Funding Scheme.DiscussionThe trial will provide the first test of automated cognitive therapy within VR for patients with psychosis. The treatment is potentially highly scalable for treatment services.Trial registrationISRCTN, ISRCTN12497310 . Registered on 14 August 2018.

Project description:BackgroundWorry might be a contributory causal factor in the occurrence of persecutory delusions in patients with psychotic disorders. Therefore we postulated that reducing worry with cognitive behaviour therapy (CBT) would reduce persecutory delusions.MethodsFor our two-arm, assessor-blinded, randomised controlled trial (Worry Intervention Trial [WIT]), we recruited patients aged 18-65 years with persistent persecutory delusions but non-affective psychosis from two centres: the Oxford Health National Health Service (NHS) Foundation Trust (Oxford, UK) and the Southern Health NHS Foundation Trust (Southampton, UK). The key inclusion criteria for participants were a score of at least 3 on the Psychotic Symptoms Rating Scale (PSYRATS) denoting a current persecutory delusion; that the delusion had persisted for at least 3 months; a clinical diagnosis of schizophrenia, schizoaffective disorder, or delusional disorder; and a clinically significant level of worry. We randomly assigned (1:1) eligible patients, using a randomly permuted block procedure with variable block sizes and division by four strata, to either six sessions of worry-reduction CBT intervention done over 8 weeks added to standard care (the CBT-intervention group), or to standard care alone (the control group). The assessors were masked to patient allocations and did their assessments at week 0 (baseline), 8 weeks (end of treatment), and 24 weeks, follow-up. The primary outcomes were worry measured by the Penn State Worry Questionnaire (PSWQ) and delusions measured by the PSYRATS-delusion scale; we did the analyses in the intention-to-treat population, and also did a planned mediation analysis. This trial is registered with the ISRCTN Registry (number ISRCTN23197625) and is closed to new participants.FindingsFrom Nov 1, 2011, to Sept 9, 2013, we recruited 150 eligible participants and randomly assigned 73 to the CBT intervention group, and 77 to the control group. 143 patients (95%) provided primary outcome follow-up data. Compared with standard care alone, at 8 weeks the CBT intervention significantly reduced worry (mean difference 6·35 [SE 1·56] PSWQ units, 95% CI 3·30-9·40; p<0·001) and persecutory delusions (2·08 [SE 0·73] PSYRATS units, 95% CI 0·64-3·51; p=0·005). The reductions were maintained to 24 weeks follow-up. The mediation analysis suggested that the change in worry accounted for 66% of the change in delusion. No patients died or were admitted to secure units during our study. Six suicide attempts (two in the CBT intervention group, and four in the control group) and two serious violent incidents (one in each group) were noted, but no adverse events were deemed related to the treatments or the assessments.InterpretationTo our knowledge, this is the first large trial focused on persecutory delusions. We have shown that long-standing delusions were significantly reduced by a brief intervention targeted on worry, although the limitations for our study include no determination of the key elements within the intervention. Our results suggest that worry might cause paranoia, and that worry intervention techniques might be a beneficial addition to the standard treatment of psychosis.FundingEfficacy and Mechanism Evaluation programme, which is a UK Medical Research Council and National Institute of Health Research partnership.

Project description:BackgroundThere is a large clinical need for improved treatments for patients with persecutory delusions. We aimed to test whether a new theoretically driven cognitive therapy (the Feeling Safe Programme) would lead to large reductions in persecutory delusions, above non-specific effects of therapy. We also aimed to test treatment effect mechanisms.MethodsWe did a parallel, single-blind, randomised controlled trial to test the Feeling Safe Programme against befriending with the same therapists for patients with persistent persecutory delusions in the context of non-affective psychosis diagnoses. Usual care continued throughout the duration of the trial. The trial took place in community mental health services in three UK National Health Service trusts. Participants were included if they were 16 years or older, had persecutory delusions (as defined by Freeman and Garety) for at least 3 months and held with at least 60% conviction, and had a primary diagnosis of non-affective psychosis from the referring clinical team. Patients were randomly assigned to either the Feeling Safe Programme or the befriending programme, using a permuted blocks algorithm with randomly varying block size, stratified by therapist. Trial assessors were masked to group allocation. If an allocation was unmasked then the unmasked assessor was replaced with a new masked assessor. Outcomes were assessed at 0 months, 6 months (primary endpoint), and 12 months. The primary outcome was persecutory delusion conviction, assessed within the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. Each intervention was provided individually over 6 months. This trial is registered with the ISRCTN registry, ISRCTN18705064.FindingsFrom Feb 8, 2016, to July 26, 2019, 130 patients with persecutory delusions (78 [60%] men; 52 [40%] women, mean age 42 years [SD 12·1, range 17-71]; 86% White, 9% Black, 2% Indian; 2·3% Pakistani; 2% other) were recruited. 64 patients were randomly allocated to the Feeling Safe Programme and 66 patients to befriending. Compared with befriending, the Feeling Safe Programme led to significant end of treatment reductions in delusional conviction (-10·69 [95% CI -19·75 to -1·63], p=0·021, Cohen's d=-0·86) and delusion severity (PSYRATS, -2·94 [-4·58 to -1·31], p<0·0001, Cohen's d=-1·20). More adverse events occurred in the befriending group (68 unrelated adverse events reported in 20 [30%] participants) compared with the Feeling Safe group (53 unrelated adverse events reported in 16 [25%] participants).InterpretationThe Feeling Safe Programme led to a significant reduction in persistent persecutory delusions compared with befriending. To our knowledge, these are the largest treatment effects seen for patients with persistent delusions. The principal limitation of our trial was the relatively small sample size when comparing two active treatments, meaning less precision in effect size estimates and lower power to detect moderate treatment differences in secondary outcomes. Further research could be done to determine whether greater effects could be possible by reducing the hypothesised delusion maintenance mechanisms further. The Feeling Safe Programme could become the recommended psychological treatment in clinical services for persecutory delusions.FundingNIHR Research Professorship and NIHR Oxford Health Biomedical Research Centre.

Dataset Information

A compassionate imagery intervention for patients with persecutory delusions.

Background

Aims

Method

Results

Conclusion

Publications

A compassionate imagery intervention for patients with persecutory delusions.

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