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The influence of thought control on the experience of persecutory delusions and auditory hallucinations in daily life
Behaviour Research and Therapy 65 (2015) 1e4
Contents lists available at ScienceDirect
Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat
Shorter communication
The influence of thought control on the experience of persecutory delusions and auditory hallucinations in daily life bora Vasconcelos e Sa a, Richard Emsley d, Samantha Hartley a, b, *, Gillian Haddock a, c, De Christine Barrowclough a, c a
School of Psychological Sciences, University of Manchester, UK Greater Manchester West Mental Health NHS Foundation Trust, UK Manchester Mental Health and Social Care Trust, UK d Centre for Biostatistics, University of Manchester and Manchester Academic Health Sciences Centre, UK b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 April 2014 Received in revised form 21 November 2014 Accepted 1 December 2014 Available online 6 December 2014
Attempts to control or suppress thoughts are often unsuccessful and may even lead to an increase in the unwanted content. Intrusive thoughts and thought control are influential in the experience of psychosis, although recent findings have arisen from non-clinical samples and data tend to be retrospective in nature. The current study utilised repeated momentary assessments (experience sampling methodology) delivered as part of participants' daily routine to examine the associations between thought control and the experience of persecutory delusions and auditory hallucinations. The findings revealed that thought control was related to the subsequent severity and distress in relation to psychotic symptoms. Moreover, most of these effects persisted over two subsequent monitoring timepoints, although their size was diminished. These findings add weight to models of psychosis that include a role for thought control, and also highlight opportunities for targeted momentary interventions. Future work might seek to elucidate which specific aspects of thought control are important, alongside the use of more multifaceted measures of psychotic experiences. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Psychosis Delusion Hallucination Experience sampling Thought control Suppression
Introduction When people experience distressing, intrusive or otherwise unwanted thoughts they may attempt to regain control of their thinking. Thought control can include attempts to distract oneself, engage in social interaction, worry, shift focus to other negative thoughts, punish oneself or re-appraise the thought (Wells & Davies, 1994). However, these strategies are not always effective. Suppressing one's thoughts can be particularly troublesome as it often results in a rebound effect whereby the frequency of the thought actually increases, and the thought content becomes even more accessible than before (Wegner, Schneider, Carter, & White, 1987; Wenzlaff & Wegner, 2000). Intrusive thoughts have been identified as a feature of psychosis (Morrison, 2001); thus the exploration of thought control in this
* Corresponding author. School of Psychological Sciences, 2nd Floor, Zochonis Building, University of Manchester, Brunswick Street, M13 9PL, UK. Tel.: þ44 0161 275 8497. E-mail address: [email protected] (S. Hartley). http://dx.doi.org/10.1016/j.brat.2014.12.002 0005-7967/© 2014 Elsevier Ltd. All rights reserved.
context is a natural extension of this line of investigation. Studies have shown that people meeting criteria for a diagnosis of schizophrenia differ from those without a diagnosis in terms of the control strategies they employ (Morrison & Wells, 2000). Moreover, there is evidence that thought control strategies are similar for those diagnosed with Generalised Anxiety Disorder (GAD) and psychosis (Freeman & Garety, 1999), and that those predisposed to experience hallucinations have a propensity towards punishment strategies and the re-appraisal of thoughts (Morrison, Wells, & Nothard, 2000). Recently, work with sub-clinical samples has demonstrated that thought suppression and anxiety interact to predict persecutory beliefs (Jones & Fernyhough, 2008) and that suppression forms part of a model linking rumination, intrusive thoughts and hallucination proneness (Jones & Fernyhough, 2009). This body of work seems to suggest that thought control, particularly suppression, punishment and reappraisal strategies might be influential in the experience of psychosis. What has not yet been explored is how this relationship plays out in the daily life of people experiencing clinical levels of delusional beliefs and/or auditory hallucinations. The current study utilised experience sampling methodology (ESM; Myin-Germeys et al., 2009; Palmier-
2
S. Hartley et al. / Behaviour Research and Therapy 65 (2015) 1e4
Claus et al., 2010), which involves repeated unpredictable assessments of experiences during the course of participants' daily life. We investigated the hypotheses that antecedent thought control would be related to current levels of persecutory delusions and auditory hallucinations, and the distress that these experiences elicit. The data were captured momentarily as part of participants' daily routine, thus providing a greater degree of ecological validity, reduced chance of retrospective recall bias and a rich dataset within which to examine these relationships. Method Design The study combined within-subjects (momentary assessments) and between-subjects (semi-structured interview) measures; the latter to assess general levels of symptomatology. Participants Following approval by the North West 12 NHS Research Ethics Committee and local research and development offices, participants were recruited from five mental health trusts between March 2011 and April 2012. Recruitment was implemented via community mental health teams and early intervention services, where key workers passed information onto potentially eligible participants, who were then contacted by the research team prior to written consent being obtained. The study was also advertised within independent sector service user and carer groups. Participants met the following inclusion criteria: 1. Diagnosis of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder or psychotic disorder (not otherwise specified). 2. Receiving mental health services in North West NHS trusts. 3. Able to provide informed consent. 4. Experiencing persecutory delusions and/or auditory hallucinations as evidenced by Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Fiszbein, 1987) [a score 3 or more on the delusions subscale (P1) with content of a persecutory nature; a score of 3 or more on hallucinations (P3) subscale, with auditory content]. As per the inclusion criteria of an adjoined study, participants also had at least 10 h per week contact with a key relative (such as a parent, sibling or partner), although did not necessarily share residence with them. Potential participants were excluded if: 1. They had a primary organic disorder 2. Their comprehension or production of the English language was insufficient to support the questionnaire and ESM assessments
Measures I. Experience sampling method (ESM) Item development. ESM items used in the current study were produced following a rigorous process involving several stages of design, review, consultation and revision. In order to capture both momentary experiences and more protracted processes, the final items were preceded by one of two phrases: ‘Just before the beep’ or ‘Since the last beep’. The items analysed in the current study formed part of a larger set, some analyses from which are reported elsewhere (Hartley, Haddock,
, Emsley, & Barrowclough, 2014). Each item folVasconcelos e Sa lowed the same response format, which used a Likert scale ranging 1e7 anchored at 1(Not at all), 4 (Moderately) and 7 (Very much). Items explored auditory hallucinations (‘Just before the beep went off I was hearing voices that other people cannot hear’), persecutory delusional ideation (‘Just before the beep went off I was feeling that someone may try to cause me harm’), and thought control (‘Since the last beep I have been trying to stop unwanted thoughts’). Where participants responded with ‘2’ or above, items regarding auditory hallucinations and delusions were followed by an additional item, ‘This was distressing’. ESM hardware, software and sampling scheme. The ESM items were presented and data collected via a Palm computer (model Tungsten E2) with ESP software installed (Barrett & Feldman Barrett, 2000). Participants were prompted to fill out the diary questions on the Palm in response to an electronic beep of a programmed watch (Timex Iron Man). The beeps were delivered within a pseudo-random stratified scheme, which was implemented between 0900 and 2400, 10 times per day over six days. The random scheme allowed a range of 90 min within which at least one beep would occur, and a maximum of 3 h and minimum of 15 min between each beep. Participants were informed only of the start and end points of the scheme and unpredictability of the prompts. ESM reports were considered valid if completed within a 15 min window of the beep, a criteria that was applied as part of data preparation. II. Non-ESM measures Demographic information was collected at baseline via a brief interview assessment including questions on ethnicity, marital and employment status, living arrangements and education. The severity of positive, negative and general psychotic experiences was assessed using the Positive and Negative Syndrome Scale (Kay et al., 1987), with more detail regarding the experiences of interest (delusions and auditory hallucinations) provided by the Psychotic Symptoms Rating Scales (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999). The PSYRATS consists of two scales designed to rate auditory hallucinations and delusions and demonstrates good inter-rater reliability and correlations with PANSS scores. Inter-rater reliability within the current study was assessed using a random sample of three of the 36 cases. Intra-class correlations showed that reliability was good for both the PANSS (ICC ¼ .985) and the PSYRATS (ICC ¼ .863). Procedure Screening using the PANSS and PSRYATS was completed and reviewed prior to the ESM phase. Participants identified as ineligible according to their current levels of symptomatology were debriefed and thanked for their time. Eligible participants were briefed prior to the commencement of the ESM phase; this involved explanation of the equipment and questions, practice data inputting and discussions around any concerns or ambiguities. Participants were then contacted on the first day of data collection to explore any concerns and check compliance. Following the ESM data collection phase, researchers met with participants again to complete debrief procedures and a feedback questionnaire. Statistical analyses ESM data were analysed using the XTMIXED command in Stata (Version 12). As the ESM measures have a 3 level hierarchical structure (beeps nested within days nested within participant) we used multilevel modelling to account for the clustering in outcomes
S. Hartley et al. / Behaviour Research and Therapy 65 (2015) 1e4
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within participants. We fitted 3-level random intercept models containing in the error structure a random intercept for each participant, a random intercept for each participant-day and participant-beep specific error term. The outcome variables were persecutory delusion severity and distress, and auditory hallucination severity and distress, each considered in a separate model, with the thought control item being the predictor variable. The main analyses were performed separately including proximal (the time period preceding the current beep) and lagged (the time period preceding the previous beep) effects of thought control on outcomes. The dual (proximal and lagged) analysis method was intended to provide an estimation of the short term longevity of the predictor effects and to reduce the potential of concurrent reporting of delusions/hallucinations and thought control confounding one another. We did not adjust for measures of the outcome at earlier time periods, since the random intercept is correlated with the lagged outcome, and our hypotheses did not involve an interpretation of change.
Table 1 displays the results from the multilevel regression analyses for each dependent variable. The results indicate that thought control in both the proximal antecedent period and as a lagged variable is significantly associated with persecutory delusion severity and distress, although the reduced coefficient values indicate that this effect diminishes over time. In terms of auditory hallucinations, thought control is influential in the proximal period and lagged for the distress associated hallucinations but is only significantly associated with their severity in the short term. The nature of the coefficient indicates that in all cases, greater thought control is associated with greater severity of symptoms, and the distress associated with these.
Results
Discussion
Sample
The results of the multilevel regression analyses demonstrate that attempts at thought control are positively associated with subsequent symptom level and associated distress. Moreover, analyses using the lagged variables indicate that the significance of this effect is maintained over short time periods (although its size diminished) for persecutory delusion severity and distress, and for auditory hallucination distress. It may be that thought control backfires (Wegner et al., 1987), resulting in more intrusive thoughts and cognitive events. Increased intrusions would provide more material with the potential to be misinterpreted and thus give rise to more severe and distressing symptoms (Morrison, 2001). The current study is not without its limitations. Although adequately powered, the sample is not representative of the wider population, with all but one participant identifying themselves as White British, and all with contact with a family member/friend/ spouse. It has previously been shown that level of symptomatology does not necessarily relate to ability to comply with ESM (Hartley, Varese et al., 2014), although the possibility remains that the study sample does not fully represent the range of severity in the clinical population. There is also a lack of information regarding the clinical characteristics of the sample, over and above specific symptomatology, such as medication, additional diagnoses and independent confirmation of the recorded primary diagnosis. Moreover, the ESM items represent quite simplistic conceptualisations of experiences; future work might explore other dimensions of delusions and hallucinations (Peters, Williams, Cooke, & Kuipers, 2012), such as beliefs regarding control and omnipotence or conviction and additional types of thought control (Wells & Davies, 1994), such as
Thirty-six people consented to take part in the study and of these, 32 met eligibility criteria following the screening assessment. The sample of eligible participants had a mean age of 33 years (SD ¼ 10.7), were predominantly male (n ¼ 22) and all but one classed themselves as white. Most of the sample (n ¼ 22) were unemployed and not studying, although over half had completed some form of post-16 education (n ¼ 20). Participants predominantly classed themselves as single (n ¼ 20) and tended to live with their parent(s) (n ¼ 15), which may be a result of the large proportion of recruits from early intervention services (n ¼ 14). The most prevalent diagnosis was Schizophrenia (n ¼ 15) but participants also met criteria for Psychotic disorder not otherwise specified (n ¼ 14; 8 of which were noted as first episode), Schizoaffective disorder (n ¼ 2) and Acute psychotic disorder (n ¼ 1). In terms of specific experiences, 26 participants were experiencing persecutory delusions, 26 were experiencing auditory hallucinations and 20 were experiencing both type of symptoms, as defined by a score of at least ‘mild’ on the relevant PANSS items. Mean scores on the PANSS subscales were 16.13 (SD 3.91) for the positive subscale, 14.28 (SD 4.24) for the negative subscale and 32.19 (SD 6.90) for the general subscale. Retention and adherence Of the 32 participants who entered the ESM data collection phase, 27 successfully completed this and provided data at an average of over half the assessment points (M ¼ 35.4, SD ¼ 13.9). Twenty-four participants met the traditional cut-off of at least 33% of the assessment points (Palmier-Claus et al., 2010). Analyses were run with and without those who did not meet cut-off; removing these individuals did not affect the significance levels or direction of the effects and therefore the findings from the larger sample were retained. Data used for analysis ranged from 965 observations to 357 observations and between 23 and 27 participants, depending on the analysis being conducted. After confirming the normal distribution of the data, independent samples t-tests were used to assess differences between those who completed the ESM phase and those who did not. These tests revealed that there were no differences in age, positive-, negativeor general symptoms or the severity of delusions or hallucinations between the two groups.
Chi squared tests indicated no differences in these aspects between those who did complete the ESM phase and those who did not in terms of education, employment status or gender. Effects of antecedent thought control on current levels of persecutory delusion ideation and auditory hallucinations
Table 1 Associations between thought control and psychotic experiences from multilevel regression analyses. Top row: proximal analyses, bottom row: lagged analyses. b represents unstandardised coefficient values, SE is the standard error of the coefficient, 95% CI represents the 95% confidence interval for the coefficient. Dependent variable
Coefficient
b
SE
P-value
95% CI
Persecutory delusion severity Persecutory delusion distress Auditory hallucination severity Auditory hallucination distress
Proximal Lagged Proximal Lagged Proximal Lagged Proximal Lagged
0.334 0.140 0.389 0.307 0.579 0.081 0.517 0.371
0.058 0.064 0.101 0.115 0.062 0.074 0.082 0.089
<0.001 0.028 <0.001 0.007 <0.001 0.268 <0.001 <0.001
0.220e0.448 0.015e0.266 0.190e0.587 0.082e0.532 0.457e0.701 0.063e0.226 0.356e0.677 0.196e0.545
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S. Hartley et al. / Behaviour Research and Therapy 65 (2015) 1e4
reappraisal (‘trying to analyse my thoughts’) or distraction (‘trying to distract myself from thoughts by doing something else instead’). In particular, the current study does not allow for the delineation between the presence of unwanted thoughts and attempts to control them-i.e. low scores on the thought suppression item could be indicative of a low need to suppress thoughts (due to a paucity of unwanted intrusions) or few attempts in the context of a high level of intrusions. People experiencing psychosis are especially prone to cognitive intrusions (Morrison & Baker, 2000) and also display characteristic attempts to control thoughts (Morrison et al., 2000), therefore the assumption that this is the process taking place here has grounds but should be taken with caution, as the findings may ultimately reflect a low level of cognitive intrusions. Further work should attempt to tease apart these processes in the context of momentary experience. Finally, as with any correlational analysis, the causal nature and direction of effects cannot be confirmed; it may be that increased levels of delusional and hallucinatory experience result in more fervent attempts at thought control and it is likely that bidirectional relationships operate, which should be explored by future research that seeks to build on these initial findings. Acknowledging the limitations outlined above, the results of the current study may nevertheless highlight opportunities for focussed intervention strategies, especially if future research is able to replicate and build on the current findings. We have demonstrated that the effect of thought control on psychotic experiences is pronounced in the short term, and therefore as momentary interventions develop (Depp et al., 2010; Kelly et al., 2012; PalmierClaus, 2011), there is an opportunity to use these to reduce thought control, or to encourage more helpful coping strategies that may be effective in reducing the impact on distressing symptoms. For instance, the use of detached mindfulness techniques might enable disengagement from cognitive processing (Wells & Roussis, 2014) and thus refrain from thought control. In contrast, interventions might draw on acceptance and commitment based approaches to transform thoughts and promote a more accepting attitude towards inner experiences (as opposed to attempts to actively push away intrusions) and an accompanying focus on value-led activities (Hayes, Strosahl, & Wilson, 1999). Finally, there is scope to draw on metacognitive interventions that examine and challenge beliefs around the utility of controlling thoughts (Wells, 2000), an approach which is already being piloted with those experiencing psychosis (Hutton, Morrison, Wardle, & Wells, 2014). Funding This work was supported by the Recovery programme (funded by the NIHR Programme Grants for Applied Research scheme; RPPG-0606-1086), which provided payment for the PhD fees of the first author. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Conflict of interest None. Acknowledgements We would like to thank two anonymous consultants and the MHRN FACTOR group, who reviewed the study materials. Thank you to Garry Byrne, for help with the Palm devices and data
extraction. Finally, thank you to the clinical studies officers and clinical teams for facilitating recruitment, and the participants themselves. References Barrett, D. J., & Feldman Barrett, L. (2000). The Experience-Sampling Program (ESP). Available http://www.experience-sampling.org/. Depp, C. A., Mausbach, B., Granholm, E., Cardenas, V., Ben-Zeev, D., Patterson, T. L., et al. (2010). Mobile interventions for severe mental illness: design and preliminary data from three approaches. Journal of Nervous and Mental Disease, 198(10), 715e721. Freeman, D., & Garety, P. A. (1999). Worry, worry processes and dimensions of delusions: an exploratory investigation of a role for anxiety processes in the maintenance of delusional distress. Behavioural and Cognitive Psychotherapy, 27, 47e62. Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: the Psychotic Symptom Rating Scales (PSYRATS). Psychological Medicine, 29, 879e889. , D., Emsley, R., & Barrowclough, C. (2014). Hartley, S., Haddock, G., Vasconcelos e Sa An experience sampling study of worry and rumination in psychosis. Psychological Medicine, 44(08), 1605e1614. Hartley, S., Varese, F., Vasconcelos e Sa, D., Udachina, A., Barrowclough, C., Bentall, R. P., et al. (2014). Compliance in experience sampling methodology: the role of demographic and clinical characteristics. Psychosis, 6(1), 70e73. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press. Hutton, P., Morrison, A. P., Wardle, M., & Wells, A. (2014). Metacognitive therapy in treatment-resistant psychosis: a multiple-baseline study. Behavioural and Cognitive Psychotherapy, 42(02), 166e185. Jones, S. R., & Fernyhough, C. (2008). Thought suppression and persecutory delusion-like beliefs in a nonclinical sample. Cognitive Neuropsychiatry, 13(4), 281e295. Jones, S. R., & Fernyhough, C. (2009). Rumination, reflection, intrusive thoughts, and hallucination-proneness: towards a new model. Behaviour Research and Therapy, 47(1), 54e59. Kay, S. R., Opler, L. A., & Fiszbein, A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 261e276. Kelly, J., Gooding, P., Pratt, D., Ainsworth, J., Welford, M., & Tarrier, N. (2012). Intelligent real-time therapy: harnessing the power of machine learning to optimise the delivery of momentary cognitiveebehavioural interventions. Journal of Mental Health, 1e11. http://dx.doi.org/10.3109/09638237.2011.638001. Morrison, A. P. (2001). The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257e276. Morrison, A. P., & Baker, C. A. (2000). Intrusive thoughts and auditory hallucinations: a comparative study of intrusions in psychosis. Behaviour Research and Therapy, 38(11), 1097e1106. Morrison, A. P., & Wells, A. (2000). Thought control strategies in schizophrenia: a comparison with non-patients. Behaviour Research and Therapy, 38(12), 1205e1209. Morrison, A. P., Wells, A., & Nothard, S. (2000). Cognitive factors in predisposition to auditory and visual hallucinations. British Journal of Clinical Psychology, 39, 67e78. Myin-Germeys, I., Oorschot, M., Collip, D., Lataster, J., Delespaul, P., & van Os, J. (2009). Experience sampling research in psychopathology: opening the black box of daily life. Psychological Medicine, 39(09), 1533e1547. http://dx.doi.org/ 10.1017/S0033291708004947. Palmier-Claus, J. (2011). The clinical uses of momentary assessment. Acta Psychiatrica Scandinavica, 124(4), 241e242. Palmier-Claus, J., Myin-Germeys, I., Barkus, E., Bentley, L., Udachina, A., Delespaul, P. A. E. G., et al. (2010). Experience sampling research in individuals with mental illness: reflections and guidance. Acta Psychiatrica Scandinavica, 123(1), 12e20. http://dx.doi.org/10.1111/j.1600-0447.2010.01596.x. Peters, E. R., Williams, S. L., Cooke, M. A., & Kuipers, E. (2012). It's not what you hear, it's the way you think about it: appraisals as determinants of affect and behaviour in voice hearers. Psychological Medicine, 42, 1013e1023. Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53(1), 5e13. Wells, A. (2000). Emotional disorders and metacognition. Chichester, UK: Wiley. Wells, A., & Davies, M. I. (1994). The thought control questionnaire: a measure of individual differences in the control of unwanted thoughts. Behaviour Research and Therapy, 32(8), 871e878. http://dx.doi.org/10.1016/0005-7967(94)90168-6. Wells, A., & Roussis, P. (2014). Refraining from intrusive thoughts is strategy dependent: a comment on Sugiura, et al. And a preliminary informal test of detached mindfulness, acceptance, and other strategies. Psychological Reports, 115(2), 541e544. Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51, 59e91.
Contents lists available at ScienceDirect
Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat
Shorter communication
The influence of thought control on the experience of persecutory delusions and auditory hallucinations in daily life bora Vasconcelos e Sa a, Richard Emsley d, Samantha Hartley a, b, *, Gillian Haddock a, c, De Christine Barrowclough a, c a
School of Psychological Sciences, University of Manchester, UK Greater Manchester West Mental Health NHS Foundation Trust, UK Manchester Mental Health and Social Care Trust, UK d Centre for Biostatistics, University of Manchester and Manchester Academic Health Sciences Centre, UK b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 April 2014 Received in revised form 21 November 2014 Accepted 1 December 2014 Available online 6 December 2014
Attempts to control or suppress thoughts are often unsuccessful and may even lead to an increase in the unwanted content. Intrusive thoughts and thought control are influential in the experience of psychosis, although recent findings have arisen from non-clinical samples and data tend to be retrospective in nature. The current study utilised repeated momentary assessments (experience sampling methodology) delivered as part of participants' daily routine to examine the associations between thought control and the experience of persecutory delusions and auditory hallucinations. The findings revealed that thought control was related to the subsequent severity and distress in relation to psychotic symptoms. Moreover, most of these effects persisted over two subsequent monitoring timepoints, although their size was diminished. These findings add weight to models of psychosis that include a role for thought control, and also highlight opportunities for targeted momentary interventions. Future work might seek to elucidate which specific aspects of thought control are important, alongside the use of more multifaceted measures of psychotic experiences. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Psychosis Delusion Hallucination Experience sampling Thought control Suppression
Introduction When people experience distressing, intrusive or otherwise unwanted thoughts they may attempt to regain control of their thinking. Thought control can include attempts to distract oneself, engage in social interaction, worry, shift focus to other negative thoughts, punish oneself or re-appraise the thought (Wells & Davies, 1994). However, these strategies are not always effective. Suppressing one's thoughts can be particularly troublesome as it often results in a rebound effect whereby the frequency of the thought actually increases, and the thought content becomes even more accessible than before (Wegner, Schneider, Carter, & White, 1987; Wenzlaff & Wegner, 2000). Intrusive thoughts have been identified as a feature of psychosis (Morrison, 2001); thus the exploration of thought control in this
* Corresponding author. School of Psychological Sciences, 2nd Floor, Zochonis Building, University of Manchester, Brunswick Street, M13 9PL, UK. Tel.: þ44 0161 275 8497. E-mail address: [email protected] (S. Hartley). http://dx.doi.org/10.1016/j.brat.2014.12.002 0005-7967/© 2014 Elsevier Ltd. All rights reserved.
context is a natural extension of this line of investigation. Studies have shown that people meeting criteria for a diagnosis of schizophrenia differ from those without a diagnosis in terms of the control strategies they employ (Morrison & Wells, 2000). Moreover, there is evidence that thought control strategies are similar for those diagnosed with Generalised Anxiety Disorder (GAD) and psychosis (Freeman & Garety, 1999), and that those predisposed to experience hallucinations have a propensity towards punishment strategies and the re-appraisal of thoughts (Morrison, Wells, & Nothard, 2000). Recently, work with sub-clinical samples has demonstrated that thought suppression and anxiety interact to predict persecutory beliefs (Jones & Fernyhough, 2008) and that suppression forms part of a model linking rumination, intrusive thoughts and hallucination proneness (Jones & Fernyhough, 2009). This body of work seems to suggest that thought control, particularly suppression, punishment and reappraisal strategies might be influential in the experience of psychosis. What has not yet been explored is how this relationship plays out in the daily life of people experiencing clinical levels of delusional beliefs and/or auditory hallucinations. The current study utilised experience sampling methodology (ESM; Myin-Germeys et al., 2009; Palmier-
2
S. Hartley et al. / Behaviour Research and Therapy 65 (2015) 1e4
Claus et al., 2010), which involves repeated unpredictable assessments of experiences during the course of participants' daily life. We investigated the hypotheses that antecedent thought control would be related to current levels of persecutory delusions and auditory hallucinations, and the distress that these experiences elicit. The data were captured momentarily as part of participants' daily routine, thus providing a greater degree of ecological validity, reduced chance of retrospective recall bias and a rich dataset within which to examine these relationships. Method Design The study combined within-subjects (momentary assessments) and between-subjects (semi-structured interview) measures; the latter to assess general levels of symptomatology. Participants Following approval by the North West 12 NHS Research Ethics Committee and local research and development offices, participants were recruited from five mental health trusts between March 2011 and April 2012. Recruitment was implemented via community mental health teams and early intervention services, where key workers passed information onto potentially eligible participants, who were then contacted by the research team prior to written consent being obtained. The study was also advertised within independent sector service user and carer groups. Participants met the following inclusion criteria: 1. Diagnosis of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder or psychotic disorder (not otherwise specified). 2. Receiving mental health services in North West NHS trusts. 3. Able to provide informed consent. 4. Experiencing persecutory delusions and/or auditory hallucinations as evidenced by Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Fiszbein, 1987) [a score 3 or more on the delusions subscale (P1) with content of a persecutory nature; a score of 3 or more on hallucinations (P3) subscale, with auditory content]. As per the inclusion criteria of an adjoined study, participants also had at least 10 h per week contact with a key relative (such as a parent, sibling or partner), although did not necessarily share residence with them. Potential participants were excluded if: 1. They had a primary organic disorder 2. Their comprehension or production of the English language was insufficient to support the questionnaire and ESM assessments
Measures I. Experience sampling method (ESM) Item development. ESM items used in the current study were produced following a rigorous process involving several stages of design, review, consultation and revision. In order to capture both momentary experiences and more protracted processes, the final items were preceded by one of two phrases: ‘Just before the beep’ or ‘Since the last beep’. The items analysed in the current study formed part of a larger set, some analyses from which are reported elsewhere (Hartley, Haddock,
, Emsley, & Barrowclough, 2014). Each item folVasconcelos e Sa lowed the same response format, which used a Likert scale ranging 1e7 anchored at 1(Not at all), 4 (Moderately) and 7 (Very much). Items explored auditory hallucinations (‘Just before the beep went off I was hearing voices that other people cannot hear’), persecutory delusional ideation (‘Just before the beep went off I was feeling that someone may try to cause me harm’), and thought control (‘Since the last beep I have been trying to stop unwanted thoughts’). Where participants responded with ‘2’ or above, items regarding auditory hallucinations and delusions were followed by an additional item, ‘This was distressing’. ESM hardware, software and sampling scheme. The ESM items were presented and data collected via a Palm computer (model Tungsten E2) with ESP software installed (Barrett & Feldman Barrett, 2000). Participants were prompted to fill out the diary questions on the Palm in response to an electronic beep of a programmed watch (Timex Iron Man). The beeps were delivered within a pseudo-random stratified scheme, which was implemented between 0900 and 2400, 10 times per day over six days. The random scheme allowed a range of 90 min within which at least one beep would occur, and a maximum of 3 h and minimum of 15 min between each beep. Participants were informed only of the start and end points of the scheme and unpredictability of the prompts. ESM reports were considered valid if completed within a 15 min window of the beep, a criteria that was applied as part of data preparation. II. Non-ESM measures Demographic information was collected at baseline via a brief interview assessment including questions on ethnicity, marital and employment status, living arrangements and education. The severity of positive, negative and general psychotic experiences was assessed using the Positive and Negative Syndrome Scale (Kay et al., 1987), with more detail regarding the experiences of interest (delusions and auditory hallucinations) provided by the Psychotic Symptoms Rating Scales (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999). The PSYRATS consists of two scales designed to rate auditory hallucinations and delusions and demonstrates good inter-rater reliability and correlations with PANSS scores. Inter-rater reliability within the current study was assessed using a random sample of three of the 36 cases. Intra-class correlations showed that reliability was good for both the PANSS (ICC ¼ .985) and the PSYRATS (ICC ¼ .863). Procedure Screening using the PANSS and PSRYATS was completed and reviewed prior to the ESM phase. Participants identified as ineligible according to their current levels of symptomatology were debriefed and thanked for their time. Eligible participants were briefed prior to the commencement of the ESM phase; this involved explanation of the equipment and questions, practice data inputting and discussions around any concerns or ambiguities. Participants were then contacted on the first day of data collection to explore any concerns and check compliance. Following the ESM data collection phase, researchers met with participants again to complete debrief procedures and a feedback questionnaire. Statistical analyses ESM data were analysed using the XTMIXED command in Stata (Version 12). As the ESM measures have a 3 level hierarchical structure (beeps nested within days nested within participant) we used multilevel modelling to account for the clustering in outcomes
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within participants. We fitted 3-level random intercept models containing in the error structure a random intercept for each participant, a random intercept for each participant-day and participant-beep specific error term. The outcome variables were persecutory delusion severity and distress, and auditory hallucination severity and distress, each considered in a separate model, with the thought control item being the predictor variable. The main analyses were performed separately including proximal (the time period preceding the current beep) and lagged (the time period preceding the previous beep) effects of thought control on outcomes. The dual (proximal and lagged) analysis method was intended to provide an estimation of the short term longevity of the predictor effects and to reduce the potential of concurrent reporting of delusions/hallucinations and thought control confounding one another. We did not adjust for measures of the outcome at earlier time periods, since the random intercept is correlated with the lagged outcome, and our hypotheses did not involve an interpretation of change.
Table 1 displays the results from the multilevel regression analyses for each dependent variable. The results indicate that thought control in both the proximal antecedent period and as a lagged variable is significantly associated with persecutory delusion severity and distress, although the reduced coefficient values indicate that this effect diminishes over time. In terms of auditory hallucinations, thought control is influential in the proximal period and lagged for the distress associated hallucinations but is only significantly associated with their severity in the short term. The nature of the coefficient indicates that in all cases, greater thought control is associated with greater severity of symptoms, and the distress associated with these.
Results
Discussion
Sample
The results of the multilevel regression analyses demonstrate that attempts at thought control are positively associated with subsequent symptom level and associated distress. Moreover, analyses using the lagged variables indicate that the significance of this effect is maintained over short time periods (although its size diminished) for persecutory delusion severity and distress, and for auditory hallucination distress. It may be that thought control backfires (Wegner et al., 1987), resulting in more intrusive thoughts and cognitive events. Increased intrusions would provide more material with the potential to be misinterpreted and thus give rise to more severe and distressing symptoms (Morrison, 2001). The current study is not without its limitations. Although adequately powered, the sample is not representative of the wider population, with all but one participant identifying themselves as White British, and all with contact with a family member/friend/ spouse. It has previously been shown that level of symptomatology does not necessarily relate to ability to comply with ESM (Hartley, Varese et al., 2014), although the possibility remains that the study sample does not fully represent the range of severity in the clinical population. There is also a lack of information regarding the clinical characteristics of the sample, over and above specific symptomatology, such as medication, additional diagnoses and independent confirmation of the recorded primary diagnosis. Moreover, the ESM items represent quite simplistic conceptualisations of experiences; future work might explore other dimensions of delusions and hallucinations (Peters, Williams, Cooke, & Kuipers, 2012), such as beliefs regarding control and omnipotence or conviction and additional types of thought control (Wells & Davies, 1994), such as
Thirty-six people consented to take part in the study and of these, 32 met eligibility criteria following the screening assessment. The sample of eligible participants had a mean age of 33 years (SD ¼ 10.7), were predominantly male (n ¼ 22) and all but one classed themselves as white. Most of the sample (n ¼ 22) were unemployed and not studying, although over half had completed some form of post-16 education (n ¼ 20). Participants predominantly classed themselves as single (n ¼ 20) and tended to live with their parent(s) (n ¼ 15), which may be a result of the large proportion of recruits from early intervention services (n ¼ 14). The most prevalent diagnosis was Schizophrenia (n ¼ 15) but participants also met criteria for Psychotic disorder not otherwise specified (n ¼ 14; 8 of which were noted as first episode), Schizoaffective disorder (n ¼ 2) and Acute psychotic disorder (n ¼ 1). In terms of specific experiences, 26 participants were experiencing persecutory delusions, 26 were experiencing auditory hallucinations and 20 were experiencing both type of symptoms, as defined by a score of at least ‘mild’ on the relevant PANSS items. Mean scores on the PANSS subscales were 16.13 (SD 3.91) for the positive subscale, 14.28 (SD 4.24) for the negative subscale and 32.19 (SD 6.90) for the general subscale. Retention and adherence Of the 32 participants who entered the ESM data collection phase, 27 successfully completed this and provided data at an average of over half the assessment points (M ¼ 35.4, SD ¼ 13.9). Twenty-four participants met the traditional cut-off of at least 33% of the assessment points (Palmier-Claus et al., 2010). Analyses were run with and without those who did not meet cut-off; removing these individuals did not affect the significance levels or direction of the effects and therefore the findings from the larger sample were retained. Data used for analysis ranged from 965 observations to 357 observations and between 23 and 27 participants, depending on the analysis being conducted. After confirming the normal distribution of the data, independent samples t-tests were used to assess differences between those who completed the ESM phase and those who did not. These tests revealed that there were no differences in age, positive-, negativeor general symptoms or the severity of delusions or hallucinations between the two groups.
Chi squared tests indicated no differences in these aspects between those who did complete the ESM phase and those who did not in terms of education, employment status or gender. Effects of antecedent thought control on current levels of persecutory delusion ideation and auditory hallucinations
Table 1 Associations between thought control and psychotic experiences from multilevel regression analyses. Top row: proximal analyses, bottom row: lagged analyses. b represents unstandardised coefficient values, SE is the standard error of the coefficient, 95% CI represents the 95% confidence interval for the coefficient. Dependent variable
Coefficient
b
SE
P-value
95% CI
Persecutory delusion severity Persecutory delusion distress Auditory hallucination severity Auditory hallucination distress
Proximal Lagged Proximal Lagged Proximal Lagged Proximal Lagged
0.334 0.140 0.389 0.307 0.579 0.081 0.517 0.371
0.058 0.064 0.101 0.115 0.062 0.074 0.082 0.089
<0.001 0.028 <0.001 0.007 <0.001 0.268 <0.001 <0.001
0.220e0.448 0.015e0.266 0.190e0.587 0.082e0.532 0.457e0.701 0.063e0.226 0.356e0.677 0.196e0.545
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reappraisal (‘trying to analyse my thoughts’) or distraction (‘trying to distract myself from thoughts by doing something else instead’). In particular, the current study does not allow for the delineation between the presence of unwanted thoughts and attempts to control them-i.e. low scores on the thought suppression item could be indicative of a low need to suppress thoughts (due to a paucity of unwanted intrusions) or few attempts in the context of a high level of intrusions. People experiencing psychosis are especially prone to cognitive intrusions (Morrison & Baker, 2000) and also display characteristic attempts to control thoughts (Morrison et al., 2000), therefore the assumption that this is the process taking place here has grounds but should be taken with caution, as the findings may ultimately reflect a low level of cognitive intrusions. Further work should attempt to tease apart these processes in the context of momentary experience. Finally, as with any correlational analysis, the causal nature and direction of effects cannot be confirmed; it may be that increased levels of delusional and hallucinatory experience result in more fervent attempts at thought control and it is likely that bidirectional relationships operate, which should be explored by future research that seeks to build on these initial findings. Acknowledging the limitations outlined above, the results of the current study may nevertheless highlight opportunities for focussed intervention strategies, especially if future research is able to replicate and build on the current findings. We have demonstrated that the effect of thought control on psychotic experiences is pronounced in the short term, and therefore as momentary interventions develop (Depp et al., 2010; Kelly et al., 2012; PalmierClaus, 2011), there is an opportunity to use these to reduce thought control, or to encourage more helpful coping strategies that may be effective in reducing the impact on distressing symptoms. For instance, the use of detached mindfulness techniques might enable disengagement from cognitive processing (Wells & Roussis, 2014) and thus refrain from thought control. In contrast, interventions might draw on acceptance and commitment based approaches to transform thoughts and promote a more accepting attitude towards inner experiences (as opposed to attempts to actively push away intrusions) and an accompanying focus on value-led activities (Hayes, Strosahl, & Wilson, 1999). Finally, there is scope to draw on metacognitive interventions that examine and challenge beliefs around the utility of controlling thoughts (Wells, 2000), an approach which is already being piloted with those experiencing psychosis (Hutton, Morrison, Wardle, & Wells, 2014). Funding This work was supported by the Recovery programme (funded by the NIHR Programme Grants for Applied Research scheme; RPPG-0606-1086), which provided payment for the PhD fees of the first author. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Conflict of interest None. Acknowledgements We would like to thank two anonymous consultants and the MHRN FACTOR group, who reviewed the study materials. Thank you to Garry Byrne, for help with the Palm devices and data
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