Background: High rates of trauma and post-traumatic stress disorder (PTSD) are reported in people who hear voices (auditory hallucinations). A recent meta-analysis of trauma interventions in psychosis showed only small improvements in PSTD symptoms and voices. Imagery Rescripting (ImRs) may be a therapy that is more effective in this population because it generalizes over memories, which is ideal in this population with typically repeated traumas.

Aims: The primary aims of this study were to investigate whether ImR reduces (1) PTSD symptoms, and (2) voice frequency and distress in voice hearers.

Method: We used a single arm open trial study, case-series design. Twelve voice hearers with previous traumas that were thematically related to their voices participated. Brief weekly assessments (administered in sessions 1–8, post-intervention, and at 3-month follow-up) and longer measures (administered pre-, mid- and post-intervention) were administered. Mixed regression analysis was used to analyse the results.

Results: There was one treatment drop-out. Results of the weekly measure showed significant linear reductions over time in all three primary variables – voice distress, voice frequency, and trauma intrusions – all with large effect sizes. These effects were maintained (and continued to improve for trauma intrusions) at 3-month follow-up. On the full assessment tools, all measures showed improvement over time, with five outcomes showing significant time effects: trauma, voice frequency, voice distress, voice malevolence and stress.

Conclusions: The findings of the current study suggest that ImRs for PTSD symptoms is generally well tolerated and can be therapeutically beneficial among individuals who hear voices.

Background: Although internet-delivered cognitive behaviour therapy (ICBT) yields large clinical outcomes when accompanied by therapeutic support, a portion of clients do not benefit from treatment. In ICBT, clients review treatment materials online typically on a weekly basis. A key component of therapist-assistance involves answering questions as clients review and work on assignments related to the treatment materials. Aims: The goal of this study was to enhance understanding of the nature of client questions posed during ICBT and examine potential associations between the number of questions asked and treatment outcomes in order to provide insight into how to improve ICBT for future users. Method: Content analysis was used to qualitatively analyse and identify questions that 80 clients asked their designated therapist over the course of an 8-week ICBT programme for anxiety and depression. Results: On average, clients sent six emails during the course of treatment, of which less than two questions were asked. Of the 137 questions posed by clients, 46.72% reflected questions designed to enhance understanding and apply the material and techniques reviewed in the programme. Additional questions were categorized as clarifying the therapeutic process (22.62%), addressing technical challenges (18.25%), and seeking assistance with problems outside the scope of ICBT (12.41%). Number of client questions asked was not significantly correlated with the number of lessons completed, symptom change, or perceptions of therapeutic alliance. Conclusions: Findings can inform future practitioners who deliver ICBT of what to expect with this treatment approach and also assist in the development of future ICBT programmes.

Background: Identifying depressed patients unlikely to reach remission and those likely to relapse after reaching remission is of great importance, but there are few pre-treatment factors that can help clinicians predict prognosis and together these explain relatively little variance in treatment outcomes. Attentional control has shown promise in studies to date, but has not been investigated prospectively in routine clinical settings with depressed patients. Aims: This study aimed to pilot the use of a brief self-report measure of attentional control in routine care and investigate the associations between attentional control, psychological treatment response and relapse to depression up to 1 year post-treatment. Method: Depressed patients were recruited from two primary care psychological treatment (IAPT) services and completed the Attentional Control Scale (ACS) alongside routine symptom measures at every therapy session. Participants were tracked and followed up for 1 year post-treatment. Results: Baseline ACS scores were associated with remission and residual depressive symptoms post-treatment, and relapse within 12 months of ending treatment, all independent of pre-treatment depressive symptom severity, and the latter also independent of residual symptoms. Conclusion: A self-report measure of attentional control can potentially be used to predict levels of depressive symptoms post-treatment and can contribute to predicting risk of relapse to depression in IAPT services, without affecting rates of therapy completion/drop-out or data completion of standard IAPT measures. However, this pilot study had a small overall sample size and a very small number of observed relapses, so replication in a larger study is needed before firm conclusions can be made.

Background: Almost all patients admitted at acute crisis to a psychiatric ward experience clinically significant symptoms of insomnia. Ward environments pose challenges to both sleep and the delivery of therapy. Despite this, there is no description of how to adapt cognitive behavioural therapy (CBT) for insomnia to overcome these challenges. Aims: (i) To describe the key insomnia presentations observed in the Oxford Ward Sleep Solution (OWLS) trial and (ii) outline key adaptations aimed to increase accessibility and hence effectiveness of CBT for insomnia for a ward setting. Methods: Trial therapists collaboratively agreed the key insomnia presentations and therapy adaptations based on their individual reflective logs used during the trial. Results: Three key insomnia presentations are outlined. These are used to illustrate the application of 10 CBT for insomnia therapy adaptations. These include use of sleep monitoring watches to engage patients in treatment, stabilizing circadian rhythms, reducing the impact of night-time observations and managing discharge as a sleep challenge. Conclusions: Whilst inpatient wards bring challenges for sleep and therapy delivery, creative adaptations can increase the accessibility of evidence based CBT for insomnia techniques. This therapy has proven popular with patients.

Background: The impact of alcohol use disorders (AUD) on psychological treatments for depression or anxiety in primary care psychological treatment services is unknown. Aims: To establish levels of alcohol misuse in an Improving Access to Psychological Therapies (IAPT) service, examine the impact of higher risk drinking on IAPT treatment outcomes and drop-out, and to inform good practice in working with alcohol misuse in IAPT services. Method: 3643 patients completed a brief questionnaire on alcohol use pre-treatment in addition to measures of depression, anxiety and functioning. Symptom and functioning measures were re-administered at all treatment sessions. Results: Severity of alcohol misuse was not associated with treatment outcomes, although those scoring eight or more on the AUDIT-C were more likely to drop out from treatment. Conclusions: IAPT services may be well placed to offer psychological therapies to patients with common mental disorders and comorbid AUD. Patients with AUD can have equivalent treatment outcomes to those without AUD, but some higher risk drinkers may find accessing IAPT treatment more difficult as they are more likely to drop out. Alcohol misuse on its own should not be used as an exclusion criterion from IAPT services. Recommendations are given as to how clinicians can: adjust their assessments to consider the appropriateness of IAPT treatment for patients that misuse alcohol, consider the potential impact of alcohol misuse on treatment, and improve engagement in treatment for higher risk drinkers.

Background: Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences. A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences. However, the effects of psychological intervention for improving sleep have not been evaluated in young people at ultra-high risk of psychosis. Improving sleep might prevent later transition to a mental health disorder. Aims: To assess the feasibility and acceptability of an intervention targeting sleep disturbance in young people at ultra-high risk of psychosis. Method: Patients were sought from NHS mental health services. Twelve young people at ultra-high risk of psychosis with sleep problems were offered an eight-session adapted CBT intervention for sleep problems. The core treatment techniques were stimulus control, circadian realignment, and regulating day-time activity. Participants were assessed before and after treatment and at a one month follow-up. Results: All eligible patients referred to the study agreed to take part. Eleven patients completed the intervention, and one patient withdrew after two sessions. Of those who completed treatment, the attendance rate was 89% and an average of 7.6 sessions (SD = 0.5) were attended. There were large effect size improvements in sleep. Post-treatment, six patients fell below the recommended cut-off for clinical insomnia. There were also improvements in negative affect and psychotic experiences. Conclusion: This uncontrolled feasibility study indicates that treating sleep problems in young people at ultra-high of psychosis is feasible, acceptable, and may be associated with clinical benefits.

Background: The number of refugees is the highest ever worldwide. Many have experienced trauma in home countries or on their escape which has mental health sequelae. Intrusive memories comprise distressing scenes of trauma which spring to mind unbidden. Development of novel scalable psychological interventions is needed urgently. Aims: We propose that brief cognitive science-driven interventions should be developed which pinpoint a focal symptom alongside a means to monitor it using behavioural techniques. The aim of the current study was to assess the feasibility and acceptability of the methodology required to develop such an intervention. Method: In this study we recruited 22 refugees (16–25 years), predominantly from Syria and residing in Sweden. Participants were asked to monitor the frequency of intrusive memories of trauma using a daily diary; rate intrusions and concentration; and complete a 1-session behavioural intervention involving Tetris game-play via smartphone. Results: Frequency of intrusive memories was high, and associated with high levels of distress and impaired concentration. Levels of engagement with study procedures were highly promising. Conclusions: The current work opens the way for developing novel cognitive behavioural approaches for traumatized refugees that are mechanistically derived, freely available and internationally scalable.

Background: Many patients do not respond adequately to current pharmacological or psychological treatments for psychosis. Persistent persecutory delusions are common in clinical services, and cause considerable patient distress and impairment. Our aim has been to build a new translational personalized treatment, with the potential for wide use, that leads to high rates of recovery in persistent persecutory delusions. We have been developing, and evaluating individually, brief modular interventions, each targeting a key causal factor identified from our cognitive model. These modules are now combined in “The Feeling Safe Programme”. Aims: To test the feasibility of a new translational modular treatment for persistent persecutory delusions and provide initial efficacy data. Method: 12 patients with persistent persecutory delusions in the context of non-affective psychosis were offered the 6-month Feeling Safe Programme. After assessment, patients chose from a personalized menu of treatment options. Four weekly baseline assessments were carried out, followed by monthly assessments. Recovery in the delusion was defined as conviction falling below 50% (greater doubt than certainty). Results: 11 patients completed the intervention. One patient withdrew before the first monthly assessment due to physical health problems. An average of 20 sessions (SD = 4.4) were received. Posttreatment, 7 out of 11 (64%) patients had recovery in their persistent delusions. Satisfaction ratings were high. Conclusions: The Feeling Safe Programme is feasible to use and was associated with large clinical benefits. To our knowledge this is the first treatment report focused on delusion recovery. The treatment will be tested in a randomized controlled trial.

Background: Social anxiety disorder is common and typically starts in childhood or adolescence. Cognitive Therapy for Social Anxiety Disorder (CT-SAD) in adults is a well-established treatment that shows strong evidence of differential effectiveness when compared to other active treatments. In contrast, CBT approaches to social anxiety in young people have yet to demonstrate differential effectiveness and there is some evidence that young people with social anxiety disorder respond less well than those with other anxiety disorders. Aims: To adapt CT-SAD for use with adolescents and conduct a pilot case series. Method: Five adolescents, aged 11–17 years, with a primary DSM-5 diagnosis of social anxiety disorder received a course of CT-SAD adapted for adolescents. Standardized clinical interview and questionnaire assessments were conducted at pre and posttreatment, and 2 to 3-month follow-up. Results: All five participants reported severe social anxiety at baseline and achieved remission by the end of treatment. Significant improvements were also observed in general anxiety, depression, concentration in the classroom, and putative process measures (social anxiety related thoughts, beliefs and safety behaviours). Conclusions: An adapted form of CT-SAD shows promise as a treatment for adolescents.

Background: Worry about physical health is broadly referred to as health anxiety and can range from mild concern to severe or persistent anxiety such as that found in DSM-IV hypochondriasis. While much is known about anxiety regarding physical health, little is known about anxiety regarding mental health. However, recent conceptualizations of health anxiety propose that individuals can experience severe and problematic worry about mental health in similar ways to how people experience extreme worry about physical health. Aims: Given the paucity of research in this area, the aim of the current study was to explore anxiety regarding mental health through validation of the Mental Health Anxiety Inventory (MHAI), a modified version of the Short Health Anxiety Inventory. Method: The MHAI, and measures of state anxiety (Depression, Anxiety and Stress Scales-21), trait worry (Penn State Worry Questionnaire), and health anxiety (Short Health Anxiety Inventory) were administered to 104 adult volunteers from the general community. Results: The MHAI demonstrated high internal consistency, acceptable test-retest reliability, and good construct validity when correlated with other measures of anxiety. Results also indicated that participants worried about their mental health and physical health equally, and that almost 9% of participants reported levels of mental health anxiety that were potentially problematic. Conclusion: Preliminary results suggest that a small proportion of adults in the community may experience high levels of mental health anxiety requiring treatment, and that the MHAI, if validated further, could be a useful tool for assessing this form of anxiety.

Background: Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis. Aims: In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations. Method: Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described. Conclusions: Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.

Background: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. Aims: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. Method: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). Results: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. Conclusions: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.

Background: Clinical perfectionism is a risk and maintaining factor for anxiety disorders, depression and eating disorders. Aims: The aim was to examine the psychometric properties of the 12-item Clinical Perfectionism Questionnaire (CPQ). Method: The research involved two samples. Study 1 comprised a nonclinical sample (n = 206) recruited via the internet. Study 2 comprised individuals in treatment for an eating disorder (n = 129) and a community sample (n = 80). Results: Study 1 factor analysis results indicated a two-factor structure. The CPQ had strong correlations with measures of perfectionism and psychopathology, acceptable internal consistency, and discriminative and incremental validity. The results of Study 2 suggested the same two-factor structure, acceptable internal consistency, and construct validity, with the CPQ discriminating between the eating disorder and control groups. Readability was assessed as a US grade 4 reading level (student age range 9–10 years). Conclusions: The findings provide evidence for the reliability and validity of the CPQ in a clinical eating disorder and two separate community samples. Although further research is required the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism.

Background: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. Aims: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. Method: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. Results: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. Conclusions: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.

Background: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. Aim: To develop an internet based version of the treatment that requires less therapist time. Method: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. Results: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. Conclusions: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.

Background: Interpretation training programs, in which individuals are trained to interpret ambiguous scenarios in either a negative or benign way, have proven effective in altering anxiety-related cognitive biases in both children and adults. Aims: The current study investigated whether the effects of the interpretation training procedure in children are differentiated according to the mode of presentation of the training. Method: Ninety-four primary school children (aged 10–12 years) scoring above the mean on a social anxiety scale were randomly allocated to four groups, in which they were trained using written or spoken presentation of training materials in either the negative or benign direction. Results: For the negative training, children who heard the training material spoken aloud (spoken presentation) made more negative interpretations of ambiguous social events, compared to children who read the training material (written presentation). However, for the benign training, there was less clear evidence for a differentiation of the effects between the two modes of presentation, although children in the spoken presentation group performed better in a stressful task and showed a trend to rate their mood as more positive after the task than children in the written presentation group. Conclusions: These results not only forward our understanding of the mechanism of the genesis of cognitive bias in children, but also highlight the need for further investigation of how to optimize the effectiveness of interpretation training in children.

Background: Cognitive behavioural therapy for psychosis (CBTp) is currently a recommended form of psychosocial treatment for persons suffering from persistent psychotic symptoms. It has been argued that effect sizes from efficacy studies cannot be generalized to real clinical settings. Aims: Our aim was to evaluate whether the positive results from randomized controlled trials conducted by experts could be replicated in clinical setting with a heterogeneous sample of patients with psychotic disorder. Method: Patients referred to the study were either randomized to CBTp + TAU (the treatment group) or to a waiting-list group, only receiving TAU. The patients were assessed on different outcome measures such as the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS), and the Psychotic Symptom Rating Scales (PSYRATS), at pretreatment, at posttreatment (6 months), and at 12 months follow-up. In total, 45 patients participated in the study. Results: The results showed that 20 sessions of CBTp performed significantly better than the waiting list controls with respect to the global score on the BPRS, the delusional scale on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly changed for the total sample. Conclusions: The study revealed that CBTp delivered by non-experts in routine clinical settings can produce improvements in positive psychotic symptoms, and also that some of these improvements can be maintained at one year follow-up.