Assessment and treatment of personality disorder (PD) is a key issue in UK mental health service provision (NIMH report, 2003), but there is limited information on individuals with personality disorder presenting to primary care mental health services. This study investigates the characteristics of PD in individuals receiving cognitive behaviour therapy (CBT) following GP referral and its relationship with therapist ratings of treatment process and outcome. One hundred and forty-eight participants completed the Millon Multiaxial Clinical Inventory (MCMI-III: Millon, Davis and Millon, 1997). Therapists completed a measure of therapy process and outcome (TPOQ) on 100 participants. Key therapy and process questions were answered for 60 participants who attended a minimum of five therapy sessions. MCMI-III indicated a rate of PD of 56.4%. Factor analysis of PD scales identified two factors: inward looking/emotionally distanced, and aggressive/acting out. For clinical syndromes (CLS), the factors were general psychopathology and substance abuse. TPOQ had two factors: therapeutic alliance and complexity in therapy. Regression analyses indicated that only those PDs contributing to the inward looking/emotionally distanced scale score were associated with therapeutic alliance problems. Conversely, complexity in therapy was only predicted by general psychopathology and not by personality disorder. This study identified high rates of personality disorder in primary care referrals to a clinical psychology service. It also indicated that relationships between the presence of personality disorder and therapist ratings of treatment difficulties were only associated with certain types of personality disorder. These findings are discussed in relation to service and therapy planning in mental health.

A new model of therapist skill development is presented. Grounded in information processing theory, it provides a comprehensive framework that accounts for a range of phenomena encountered by trainers and trainees – for example, why different training methods are needed for different elements of therapist skill. The model features three principal systems: declarative, procedural and reflective (DPR). Reflection is identified as central to therapist skill development and, accordingly, a pivotal role is given to a reflective system, which enables therapists to reflect and build on their conceptual (declarative) knowledge and procedural skills. The DPR model incorporates a taxonomy of therapist skills, and explains why different skills develop in different ways at different rates. It highlights the centrality of therapists' perceptual skills, and of when-then rules, plans, procedures and skills (rules that determine when to implement what interventions with which patient under what conditions) in the development of therapist expertise. It makes a distinction between personal and professional selves (the self-schema vs. the self-as-therapist schema); and it identifies the role of the personal self in therapist skill development. While there are still many questions to be investigated, it is hoped that the model will stimulate researchers and provide guidance for trainers.

Dissociation often occurs after a traumatic experience and has detrimental effects on memory. If these supposed detrimental effects are the result of disturbances in information processing, not only subjectively assessed but also objectively assessed memory disturbances should be observed. Most studies assessing dissociation and memory in the context of trauma have studied trauma victims. However, this study takes a new approach in that the impact of experimentally induced state dissociation on memory is investigated in people with spider phobia. Note that the aim of the present study was not to test the effect of trauma on memory disturbances. We found indeed significant relations between state dissociation and subjectively assessed memory disturbances: intrusions and self-rated memory fragmentation. Moreover, although no relation was found between state dissociation and experimenter-rated memory fragmentation, we observed a relation between state dissociation and experimenter-rated perceptual memory representations. These results show that state dissociation indeed has detrimental effects on the processing of aversive events.

Treatment non-adherence is a common problem in mental health services but little is known about non-adherence to psychological therapy for psychosis. The main aim of the present study was to investigate the role of patients' recovery style and the therapeutic alliance in provoking or forestalling patient drop-out from cognitive behaviour therapy (CBT) for psychosis. Ratings were made by two independent observers on 29 recordings of sessions from a controlled trial of CBT for psychosis. Sessions of 10 patients who dropped out of treatment prematurely were matched with sessions of 10 patients who stayed in. Another nine sessions were selected at random from the middle and late stages of treatment so that the sample was representative of all sessions in the trial. Patients who dropped out of treatment, compared with those who stayed in, were less engaged in treatment, showed less agreement with their therapists, and had a sealing-over recovery style before they dropped out but did not differ in their therapeutic bonds. The results suggest that the premature termination of the drop-outs was not provoked by the therapists but was due to the patients' lack of curiosity about their psychotic episodes and minimization of the impact of their illness.

The development in science and practice of cognitive therapy for psychological disorders has benefited from coherent models that specify the key cognitions that can be targeted in therapy. A scale is required to identify the cognitions that characterize bipolar affective disorder and that may influence the development of mania or hypomania. In this pilot study, 104 items were generated within five theory-driven categories: Self-activation, Response style, Other-positive, Other-negative, and Self-catastrophic. The mean score for all items, and for each category of items, was significantly elevated in a group of individuals with a diagnosis of bipolar disorder (n = 22) relative to a group of non-clinical controls (n = 22). An exploratory analysis revealed the items that were significantly elevated in the bipolar group. Theoretical and clinical implications, limitations and plans for future research are discussed.

Acute stress disorder (ASD) is purportedly characterized by impaired encoding of aversive material. In this study ASD, trauma-exposed non-ASD, and non-traumatized control participants (N = 45) were administered intermixed presentations of either distressing (i.e. disfigured) or neutral faces. For each presentation, two words were presented centrally to the image and two were presented peripherally. Participants were subsequently administered recall and recognition tests for the presented words. Participants recalled more words presented centrally to neutral images than those presented centrally to trauma images. Dissociative tendencies were negatively correlated with recognition of words centrally presented with distressing stimuli. These findings are consistent with the proposal that dissociative reactions are associated with impaired memory for distress-related information.

The present study was designed to test the hypothesis that blood fearful and nonfearful individuals would be differentiated by their pattern of recall of schematic and non-schematic prose material. Blood fearful (n=36) and nonfearful (n=40) individuals were presented with five prose passages describing harm or injury. Nine sentences in each passage described events representative of the schema content of most individuals, whereas six sentences in each passage described events that are not representative of typical schema content. Participants read passages that either described themselves experiencing the situations or described themselves witnessing others in the situations and completed a free recall task in both immediate (i.e. 2 minutes) and delayed (i.e. one week) recall conditions. Results did not replicate studies from the cognitive psychology literature on which this study was based. Instead, participants who read passages describing themselves in these situations recalled the gist of the material more accurately than participants who read passages in which they witnessed another individual in the situation. Blood fearful participants recalled the affective tone of neutral passages less accurately than nonfearful participants. Results suggest that activation of schema content has little influence on memory performance, although assessing the affective tone of recalled material detected subtle differences in memory performance between fearful and nonfearful groups.

This study investigated whether anxiety in patients who have had a myocardial infarction is maintained through similar processes to those proposed in the cognitive models of panic disorder (Clark, 1986) and health anxiety (Warwick and Salkovskis, 1990). Anxious (n = 22) and non-anxious (n = 29) patients, who all had an MI 3–12 months before testing, participated. The groups were compared on self-report measures of risk perception, bodily vigilance, illness perceptions the type of causal attributions (somatic, normalizing and psychological) generated for congruent and incongruent types of anxiety-related bodily sensations (cardiac, respiratory, gastro-intestinal and cognitive dyscontrol). Anxious, compared to non-anxious, MI participants perceived themselves to be at higher risk of a further MI, had higher levels of bodily vigilance and more negative emotional and cognitive representations of their MI. Anxious participants generated significantly more somatic attributions and fewer normalizing attributions, than non-anxious participants for cardiac sensations. There was also a trend for anxious participants to generate this pattern of attributions for respiratory items. The study provides evidence that the models of health anxiety (Warwick and Salkovskis, 1990) and panic disorder (Clark, 1986) are useful in understanding persistent anxiety following an MI.

This study investigated the relationship of hyperarousal and dissociation in acute stress disorder (ASD). Civilian trauma survivors with ASD (n = 17) and without ASD (n = 15) and non-traumatized controls (n = 14) completed a hyperventilation provocation test and were administered the Beck Anxiety Inventory, the Anxiety Sensitivity Index, the Dissociative Experiences Scale, the Peritraumatic Dissociative Experiences Questionnaire, the Physical Reactions Scale, and the Agoraphobic Cognitions Questionnaire. Individuals with ASD demonstrated more panic, dissociation, and maladaptive interpretations about their arousal during the hyperventilation than non-ASD or control participants. Dissociation was associated with anxiety sensitivity and peritraumatic panic attacks. These findings suggest that hyperarousal and dissociation are highly associated in ASD and that catastrophic attributions may play a mediating role in this relationship.

The aim of this paper was to test the long-term contribution of cognitive-behavioural therapy to the treatment of mixed anxiety-depression disorder. Fifty-seven patients, selected according to DSM-IV diagnostic criteria, were assigned to: 1) cognitive-behavioural therapy; 2) combined therapy (drug and cognitive-behavioural therapy); or 3) a standard drug therapy control group. A multigroup experimental design with repeated measures of assessment (pretreatment, posttreatment, and 3-, 6- and 12 month follow-ups) was used. Most patients who were treated (71%) in experimental groups showed significant improvement at the 12-month follow-up, but there were no differences between the two therapeutic modes. No improvement was shown by the control-group participants at the 6-month follow-up. The results of the present trial do not support the beneficial effects of drug therapy by itself for this disorder. Finally, several topics that may contribute to future research in this field are discussed.

We describe the first application of Danger Ideation Reduction Therapy (DIRT) in the UK. It is a novel approach developed in Australia, for treatment resistant obsessive compulsive disorder with contamination fears. The DIRT program was administered to an inpatient at Springfield Hospital, South London, with severe, treatment resistant obsessive compulsive disorder. Treatment consisted of weekly one hour therapy sessions for 14 weeks. A reduction in symptom severity measured on all scales undertaken was seen by the end of treatment. The Padua Inventory had shown an 85% reduction; Activity checklist an 86% reduction; Y-BOCS an overall 41% reduction and a 33% reduction on the Beck Depression Inventory. The DIRT approach has demonstrated an impressive and consistent improvement, maintained to 6 months post-treatment. More studies are needed to evaluate this treatment further.

Schemata (and other cognitions) were investigated in depressed adolescent girls and their mothers and were compared to those in a control group. Links between adolescent and maternal cognitions were also examined. There were 14 girls and mothers in the clinical group and 15 in the control group. The depressed adolescents had higher total scores on a measure of schemata than the control adolescents, and higher scores on several of its sub-scales. They also scored more highly on two other measures of cognition (dysfunctional attitudes and negative automatic thoughts). The mothers of the depressed adolescents were more depressed than mothers of control adolescents. However, the two groups of mothers did not differ on the measures of cognition, including schemata. Depression and schemata in adolescents were related to these variables in their mothers but only in the depressed group. Possible explanations for the findings, including the nature of the link between mood and cognition in the groups studied, are considered. Implications for cognitive theory and therapy in depressed adolescents are briefly discussed.

Magical Ideation was examined in 71 individuals across four groups matched, where possible, for gender and age. These groups were: (1) Obsessive Compulsive Disorder (OCD) patients with cleaning compulsions (n = 11); (2) OCD patients with checking compulsions (n = 20); (3) panic disorder patients with minimal obsessive compulsive symptoms (n = 19); (4) a “normal” control group with minimal obsessive compulsive symptoms (n = 21). The Magical Ideation Scale (MI, Eckblad and Chapman, 1983), the Obsessive Compulsive Inventory- Short Version (OCI-SV; Foa et al., 2002) and the Maudsley Obsessional-Compulsive Inventory (MOCI, Hodgson and Rachman, 1977) were administered to all participants. A one-way Anova was conducted with four planned contrasts. As expected, the OCD groups obtained magical ideation scores higher than the normal subjects. This suggests that OCD patients engage in more magical thinking tendencies than non-anxious controls. Similarly, OCD participants obtained a mean magical ideation score significantly higher than the panic disorder group, suggesting that obsessional compulsive patients are more likely to exhibit magical thinking than individuals with panic disorder. Of note, panic disorder and control group means on MI did not differ significantly. Finally, individuals with obsessive cleaning compulsions displayed higher levels of magical thinking compared to individuals with obsessive checking compulsions, despite no difference in severity of their obsessive compulsive symptoms. This observation was counter to previous findings (Einstein and Menzies, 2004a; Einstein and Menzies, 2004b).

A specific type of social phobia – dictation phobia – was the main and unusual treatment problem in the cognitive-behavioural therapy for an 11-year-old schoolboy. For case formulation and treatment rationale, the social phobia model by Clark and Wells was used. The posttreatment assessment revealed clear positive treatment effects with respect to school grades, social anxiety and overall functioning. The model's applicability for children and adolescents is discussed.

The central aim of this study was to assess the effectiveness of object-affect fusion informed cognitive-behavioural therapy, with a patient presenting with compulsive hoarding. The methodology employed an A/B single case experimental design. Experimental measures illustrated an increased ability to be able to discard objects and an increased sense of associated ease of discard during treatment, with clinically significant change across a variety of robust psychometric measures in the pre-post data. The study illustrates the utility of single-case approaches in the evaluation of innovative clinical approaches and also the potential for utilizing the object-affect fusion concept in the treatment of compulsive hoarding.

The aim of this study was to validate the Body Checking Questionnaire (BCQ) in an eating disorder population, using students in psychology as control. Five hundred and seventy-three females (422 controls and 151 eating disorders patients, mean age 24.1 ± 5.9 years) completed the BCQ and measures of eating disorders psychopathology. Confirmatory factor analysis confirmed that the BCQ measures the global construct of body checking with three correlated subfactors. The BCQ has good test-retest reliability (0.90), and the subfactors had good internal consistency (0.90, 0.92, and 0.84). The BCQ correlates with other body image and eating disorders measures, indicating that the BCQ measure has good concurrent validity. Finally, the BCQ reliably distinguishes eating disorders patients from controls, as well as “dieters” from “non-dieters.” The study provides support for factor structure, validity and reliability of the BCQ on eating disorders population and supports the use of this questionnaire in cross-national studies.

In 1986, I suffered a psychotic breakdown. With support from the staff at Fulbourn Hospital, I was able to overcome my illness. My mental health had been blighted by fearful dark delusion and associated alarm for 15 years. As I recovered, I developed my own interpretation of psychosis and have constructed a personal theory that attempts to give form and structure to a nebulous and very disturbing state of mind. My theory is of the existence of an active and directive rogue psychotic mindset; hereafter referred to as the RPM. I would define this mindset as being a body of nonsensical thoughts, ideas, beliefs, suppositions and assumptions that occupy a volume in the mind. This body of cognitions is given credence by being tentatively linked to the factual world. It is active in the sense that one is influenced by its rogue contents. As such it is directive and can drive not only one's thoughts, but also one's behaviour. Other normal mindsets co-exist cerebrally with the RPM. Such mindsets serve to tip the balance and normalize behaviour. During and after psychotic breakdown; in the absence of clinical psychology knowledge, my RPM developed as I struggled and tried to explain the unusual experience of going psychotic.

To study the role of catastrophic interpersonal cognitions in panic disorder with or without agoraphobia, a questionnaire listing such items – the Interpersonal Panic Fear Questionnaire (IPFQ) – was constructed and administered to English and Norwegian samples. The results of the factor analysis indicated a three-factor structure of interpersonal fears: fear of negative evaluation, fear of being trapped and separated from safe persons and places, and fear of being neglected. The corresponding three IPFQ scales had satisfactory internal consistency and sensitivity to change following therapeutic intervention, discriminated well between diagnostic groups, and correlated moderately with measures of other dimensions of panic disorder and agoraphobia. The construct validity of the interpersonal fears was further supported by mostly significant relationships between the IPFQ scales and a measure of agoraphobic avoidance, when the contribution of intrapersonal (physical, loss of control) fears was controlled.

This paper describes a project set up to treat four homeless men using cognitive behavioural therapy (CBT). The referral criteria were that individuals had alcohol and/or substance misuse problems, were roofless (i.e. sleeping rough) immediately before the intervention began and found it difficult or impossible to access hostel places in Southampton. Excessive alcohol use, violence (against self, others and property) and prison sentences were all features of their presentation. The project involved three levels of CBT intervention provided by the clinical psychologist: 1) training for the staff to enable them to work within this model; 2) continued supervision within model to ensure consistency and sustainability; 3) individual formulation (description of the problem within the CBT framework) and psychotherapy. The house itself was also run on a collaborative basis. A number of measures including mental health and social functioning constructs were used to evaluate the project, in addition to some qualitative data. All residents reduced incidents of theft, violence and alcohol consumption. Risk to self and others was also reduced for all residents. Perceived self-efficacy increased slightly for all residents, and staff perceived that they could be more effective, less hopeless, and therefore possibly less stressed as a result of training. More data will be gathered over time.

Interpretation and judgmental biases for threat-relevant stimuli are thought to play a role in anxiety disorders. To investigate whether social anxiety is associated with interpretation and judgmental biases for unambiguous external social events, individuals high and low in social anxiety (N = 36 per group) were presented with unambiguous scenarios depicting positive and mildly negative social events. Interpretations were assessed by participants' answers to open-ended questions and by their ratings for experimenter-provided, alternative explanations. In addition, for each event, participants indicated the probability that the event would happen to them and estimated their own emotional reaction to it. Compared to low socially anxious group, individuals high in social anxiety were more likely to interpret positive social events in a negative way and to catastrophize in response to unambiguous, mildly negative social events. Also, they estimated the emotional cost of negative social events as higher and the probabilities of positive social events as lower.