Appraisals, psychotic
symptoms and affect
in daily life, and changes
during CBT
Emmanuelle Peters
King’s College London, Institute of Psychiatry
U.K.
Collaborators
• Inez Myin-Germeys (University of Maastricht)
• Tineke Lataster (University of Maastricht)
• Sally Williams
• Kathryn Greenwood (Sussex Trust Partnership)
• Elizabeth Kuipers
• Jan Scott (Newcastle University)
• Philippa Garety
Background
What should we be measuring as
outcomes of CBT?
• Symptom dimensions
Conviction
Delusions
Preoccupation
Impact on
functioning
Distress
Beliefs
Voices
Distress
Impact on
functioning
What should we be measuring as
outcomes of CBT?
• Symptom dimensions
• Appraisals
A Cognitive Model of the Positive
Symptoms of Psychosis (Garety et al 01; 07)
Bio-psychosocial
vulnerability
Trigger
Basic cognitive
dysfunction
Anomalous
experience
Appraisal influenced by:
• reasoning & attributional
biases
• dysfunctional schemas
of self & world
• isolation & adverse
environments
Emotional
changes
Appraisal
of
experience
Maintaining factors
• reasoning & attributions
• dysfunctional schemas
• emotional processes
• appraisal of psychosis
Positive
Symptoms
Garety
What should we be measuring as
outcomes of CBT?
• Symptom dimensions
• Appraisals
• On-line measurement
Methods
The Experience Sampling Method
 10 times a day
 6 consecutive days
 at random moments
1.
2.
3.
4.
Multiple assessments
Real world, no lab
In the moment, not retrospective
Evaluation of the context
Delespaul, 1995;
Myin-Germeys et al (2001) Arch Gen Psychiat
Oorschot et al (2009) Psychol Assessment
Appraisals
Psychotic
Symptoms
Positive
&
negative
affect
ESM
booklet
Spontaneous
thoughts
Symptom
Distress
Variables assessed in ESM booklet
• Spontaneous thoughts (“What was I thinking just
before the beep went off?)

Content coded for presence of pathology
• Affect (positive & negative)
• Characteristics of key symptoms:
• Hallucinations: intensity, distress, interference
• Delusions: intensity, conviction, distress, interference,
preoccupation
Variables assessed in ESM booklet
• Appraisals:
• Hallucinations only: control (“my voices are out of my
control”) & power (“my voices are powerful”)
• Hallucinations and delusions:
(“my problem is due to the way my
mind works”)
 insight (“my problem is due to an illness”)
 ‘decentring’
• Activity
• Coping
1. What was I thinking just before the beep went off?
................................................................................................................................................................................................
2. I feel...



•





happy
low
guilty
ashamed
in a good mood
anxious
annoyed
scared
relaxed
Not at all
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Moderate
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
Very
7
7
7
7
7
7
7
7
7
3. My first problem (hallucinations, elicited at initial interview) ...................................................................................................... is ....

present
1
2
3
4
5
6
7

upsetting me
1
2
3
4
5
6
7

interfering with what I am doing
1
2
3
4
5
6
7

out of my control
1
2
3
4
5
6
7

powerful
1
2
3
4
5
6
7
4. Right now I believe this problem is to do with....

the way my mind works
1

an illness
1
•
due to X
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
5. My second problem. (delusions, elicited at initisl interview) .................................................................................................. is.....
•
present
1
2
3
4
5
6

I believe is true
1
2
3
4
5
6

upsetting me
1
2
3
4
5
6

interfering with what I am doing
1
2
3
4
5
6

going round and round
1
2
3
4
5
6
in my mind
6. Right now I believe this problem is to do with....
•
the way my mind works
1
•
an illness
1
2
2
3
3
4
4
5
5
6
6
7
7
7
7
7
7
7
7
7
7
7. Where am I?.................................................................................................................................................................................................
8. I am on my own
If no, I am with people that I like
yes/no
Not at all
1
2
3
Moderate
4
5
6
Very much
7
9. What am I doing..........................................................................................................................................................................................
Not at all
Moderate
Very
This is pleasant
-3
-2
-1
0
+1
+2
+3
This is difficult
-3
-2
-1
0
+1
+2
+3
10. Since the last beep,
my problems were present
Never
1
2
3
Some
4
5
6
All
7
IF PROBLEMS NOT PRESENT (score = 1), GO STRAIGHT TO END
11. When my problems happened.......
•
I pushed them to the back of my mind
yes/no
•
I shouted back
yes/no
•
I did something else
yes/no
•
I prayed
yes/no
•
I went to bed
yes/no
•
I reassured myself
yes/no
•
I thought about it differently
yes/no
•
I isolated myself
yes/no
•
I checked it out
yes/no
•
I talked to someone
yes/no
•
I just let it wash over me until it was over
yes/no
•
I took some medication
yes/no
•
I took some alcohol/streetdrugs
yes/no
•
Other (please specify).....................................................................................................................................................................
Not at all
Moderate
Very
12. The beep disturbed me
1
2
3
4
5
6
7
It is now exactly: .......hrs.......min
Write down the nicest thing that has happened since the last beep:............................................................................................................................
Design
1. Baseline
(at referral stage)
2. Pre-therapy
(after 3-6 months on waiting list)
3. Mid-therapy
(3 months into therapy)
4. End of therapy
(after 6-8 months of therapy)
5. Follow-up
(3 months post-therapy)
Results - baseline
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Baseline N= 12
(attending outpatients clinic for CBT for psychosis;
9 with hallucinations
9 with delusions)
Average observations
per person = 44.5
Total observations
= 534
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Psychosis related:
3.6% (range: 0-18)
Spontaneous
thoughts
Presence
of
symptoms
Anxiety & depression:
4.7% (range: 0-26)
Non-pathological:
73.7%
Hallucinations:
73% of observations
Key identified
symptoms
Delusions:
67% of observations
Symptom dimensions &
appraisals
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Hallucinations characteristics
NB: includes only
scores > 1 on
“hallucinations
present”
Mean (SD) Standardised ß (N =
(N = 9)
299) * = p < .001
(Multi-level linear regressions)
Potential range of
scores = 2-7
1
2
1. Intensity
4.0 (1.5)
1.0
2. Distress
2.9 (0.7)
.62* 1.0
3
4
3. Interference 2.3 (0.9)
.61* .89*
1.0
4. Control
3.0 (1.6)
.89* 1.22* .82* 1.0
5. Powerful
2.8 (1.0)
.63* .83*
.72* .24*
Intensity of voices, distress, interference, control
and power are all related to each other
Delusions characteristics
Mean (SD)
(N = 9)
Potential range of
scores = 1-7
Standardised ß (N =
399) * = p < .001
1
2
3
4
1. Intensity
3.5 (2.2)
1.0
2. Conviction
3.5 (2.4)
.82* 1.0
3. Distress
3.2 (1.8)
.57* .19* 1.0
4. Interference
2.5 (1.8)
.53* .24* .72* 1.0
5. Preoccupation 3.7 (1.6)
.55* .26* .69* . 62*
Intensity of delusions, distress, interference, &
preoccupation are all related to each other, but lower
effect sizes with conviction
Are symptom appraisals constant?
Difference between two
subsequent observations
Mean (SD)
HALLUCINATIONS
Voice appraisals all highly variable
1. Control
0.62 (.5)
3.8 (8)
.003
2. Power
0.77 (.5)
4.7 (8)
.001
3. Decentring
0.72 (.7)
2.9 (8)
.009
4. Insight
0.52 (.8)
2.0 (8)
.04
DELUSIONS
T-test (df)
p
Delusion appraisals also variable
1. Conviction
0.43 (.4)
3.5 (8)
.004
2. Decentring
0.34 (.4)
2.3 (8)
.02
3. Insight
0.38 (.6)
2.0 (8)
.04
Relationships between
symptoms, appraisals & affect
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Is affect related to symptoms?
Dependent
variables
Psychotic
thought
content
(ß)
1. Negative affect .30*
Delusions
intensity
ratings
(ß)
.68*
2. Positive affect
-.38*
-.46*
(Multi-level linear
regressions)
Voice intensity
ratings
(ß)
-.19*
.31*
* = p < .001
Intensity of symptoms and psychotic thoughts are
highly related to both negative and less positive affect
Are voice appraisals related to
distress?
Dependent
variables
Voice intensity
ratings
(Multi-level linear
(range 2-7)
regressions)
(ß)
1. Negative affect .07
Power
appraisals
(ß)
Control
appraisals
(ß)
.22*
.05
2. Symptom
distress
.36*
.35*
.62*
* = p < .001
Power appraisals are the only variable related to negative affect;
Power, control and intensity all related to symptom distress
Is insight related to distress?
Dependent
Negative
variables
affect (ß)
HALLUCINATIONS * p <.001
Distress
(ß)
Interferen Preoccup
ce (ß)
ation (ß)
1. Decentring
-.12
-.21
-.30*
/
2. Insight
.12
.11
.14
/
1. Decentring
-.29*
-.32*
-.44*
-.45*
2. Insight
.009
.01
-.03
.07
DELUSIONS
Decentring appraisals for delusions are related to less
distress/negative affect/preoccupation and disruption to
functioning, and to less interference for hallucinations.
Insight is not related to distress or functioning for either symptom
Conclusions - baseline
1)Despite psychotic symptoms being present a majority of
the time, people are not engulfed by their symptoms
2)Intensity and presence of psychosis-related thoughts
lead to more distress, less positive affect, and
interference with functioning
3)Delusional conviction is potentially a separate
dimension, and is not stable; nor are appraisals about
symptoms (control & power of voices; ‘decentring’ &
insight)
4)Power appraisals are a central factor related to
negative affect
5)‘Decentring’ from your delusions is related to less
distress and disruption to functioning; in contrast,
traditional insight does not influence distress
Results – longitudinal data
N= 12
(7 provided data on at least 2 time points;
6 with hallucinations; 7 with delusions
5 provided data at each time point)
Average observations
per person = 106
Total observations
= 1273
Hallucinations
Hallucinations: Intensity
Effect sizes (compared to baseline)
1
0.5
0
-0.5
*
-1
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Hallucinations: Distress
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Hallucinations: Interference
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
*
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Hallucinations: Control
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
Mid-therapy
End of therapy
*
-1.5
-2
Pre-therapy
* = p <.01
Follow-up
Hallucinations: Power
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
*
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Hallucinations: Decentring
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
*
*
0
-0.5
-1
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Hallucinations: Insight
(when hallucinations present only)
Effect sizes (compared to baseline)
1
0.5
0
*
*
*
Mid-therapy
End of therapy
*
-0.5
-1
-1.5
-2
Pre-therapy
* = p <.01
Follow-up
Delusions
Delusions: Intensity
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
*
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Delusions: Conviction
(when delusions present only)
Effect sizes (compared to baseline)
1
0.5
0
*
-0.5
*
-1
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Delusions: Distress
(when delusions present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
*
*
End of therapy
Follow-up
-1
*
-1.5
-2
Pre-therapy
Mid-therapy
* = p <.01
Delusions: Interference
(when delusions present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
End of therapy
Follow-up
-1.5
*
-2
Pre-therapy
Mid-therapy
* = p <.01
Delusions: Preoccupation
(when delusions present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
-1.5
*
*
Mid-therapy
End of therapy
*
-2
Pre-therapy
* = p <.01
Follow-up
Delusions: Insight
(when delusions present only)
Effect sizes (compared to baseline)
1
*
0.5
0
-0.5
-1
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Delusions: Decentring
(when delusions present only)
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
*
*
*
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
* = p <.01
Follow-up
Affect
Negative affect
Effect sizes (compared to baseline)
1
0.5
0
-0.5
*
*
End of therapy
Follow-up
-1
-1.5
-2
Pre-therapy
Mid-therapy
* = p <.01
Positive affect
Effect sizes (compared to baseline)
1
0.5
0
-0.5
-1
-1.5
-2
Pre-therapy
Mid-therapy
End of therapy
Follow-up
Conclusions – longitudinal data
1)For hallucinations, significant changes were
demonstrated from mid-therapy, and maintained
at follow-up, in:
• Interference
• Controllability
• Insight
• (power beliefs)
• (decentring)
2)Changes in intensity of voices and voice-related
distress not as robust
4)For delusions, significant changes were
demonstrated from mid-therapy, which were
maintained at follow-up, in:
• Intensity
• Distress
• Interference
• Preoccupation
5)Changes in conviction and insight not as robust,
decentring got worse (?)
6)Negative affect, but not positive affect, was
affected by therapy
Future research
1)ESM is powerful methodology to demonstrate
subtle changes in people’s daily lives
2)Ecological validity ++
3)Intensive methodology – not easily transferred
to the clinic?
4)Good for looking at relationships amongst
different variables
5)Good for looking at timeline of changes
6)Good for looking at causal mechanisms
THE END