Changes in delusions in the early phase of antipsychotic treatment – An experience sampling study
Introduction
Factor analyses have shown that the delusional experience consists of a number of dimensions, with the majority of studies identifying conviction, distress, preoccupation and disruption to life (Kendler et al., 1983, Garety and Hemsley, 1987, Appelbaum et al., 1999, Peters et al., 2004, Lincoln, 2007). It has been suggested that these dimensions respond to cognitive therapy differently (Brett-Jones et al., 1987, Chadwick and Lowe, 1990, Chadwick and Lowe, 1994). However, less is known about how they respond to antipsychotics. Jørgensen (1995) assessed changes in delusion dimensions in 50 patients with schizophrenia for 8 weeks after readmission. Conviction, extension (i.e. the areas of life affected by the delusional belief) and pressure (i.e. the degree to which one is preoccupied with the delusional belief) were found to be distinctly independent dimensions of delusions. Seventy per cent of the patients showed partial remission of delusional beliefs, whereby reduction in pressure preceded improvement in conviction. Jørgensen (1995) focused on changes after readmission, and the effect of antipsychotics was not specifically examined. Mizrahi et al. (2006) assessed dimensions of the principal psychotic experience with 17 patients during the first 10 weeks of antipsychotic treatment. They reported that behavioural impact and cognitive and emotional preoccupation changed more markedly and rapidly than conviction. The measures in these studies were not commonly used, and the dimensions measured were not the same as those generated in factor analysis studies. Nevertheless, these studies suggest a differential response of delusion dimensions to treatment, with conviction being less amenable to change than distress and preoccupation. This observation is consistent with patients’ reports that antipsychotics ‘detach’ them from their psychotic symptoms rather than eradicate or eliminate the symptoms (Mizrahi et al., 2005).
These findings raise the question of why conviction persists while other dimensions improve, and what might predict change in conviction. It has been suggested (Garety et al., 2001, Garety et al., 2007) that the way patients form appraisals of experience may be characterised by reasoning biases, including ‘Jumping to Conclusions’ (JTC) bias and lack of belief flexibility, which may contribute to the development and maintenance of delusions. The JTC bias refers to the tendency to reach a decision without gathering sufficient data (Garety et al., 1991, Garety and Freeman, 1999). JTC occurs in one half to two-thirds of individuals with delusions (see reviews by Fine et al., 2007, Freeman, 2007), as well as in people scoring highly on delusional ideation scales (e.g. Linney et al., 1998, Colbert and Peters, 2002, Moritz and Woodward, 2005, Van Dael et al., 2006, Warman and Martin, 2006) and in people who have remitted from delusions (Moritz and Woodward, 2005, Peters and Garety, 2006). In some studies, JTC has also been found to be associated with severity of delusions and delusional conviction (Garety et al., 2005, Peters and Garety, 2006). JTC may therefore be a stable predisposing factor for delusions (see review by So et al., 2010).
Menon et al. (2008) found that JTC at baseline predicted subsequent change in psychotic symptoms during the initial weeks of antipsychotic treatment, and argued that JTC was a moderator of treatment outcome. However, they measured delusions using clinical ratings and did not measure delusion dimensions. Treatments targeting reasoning biases (including JTC) have recently been developed, with preliminary evidence showing a reduction in both JTC and delusion conviction (Waller et al., 2011) and distress (Moritz et al., 2011). Therefore, dimensions of delusions are important indicators of treatment outcomes.
There is evidence that, like other psychotic symptoms, delusions improve most markedly in the early weeks of antipsychotic treatment, and that initial change predicts overall symptom improvement (Agid et al., 2003, Leucht et al., 2005). Agid et al. (2003) even found that improvement in psychotic symptoms may be seen in the very first few hours. Mizrahi et al. (2006) found that the different pattern of improvement in delusional dimensions was evident as early as 2 weeks after the start of treatment. Therefore, the very early stage of treatment is a critical period for the fine-grained analysis of delusion change and is a good test bed for the moderators and mediators of such change.
Experience Sampling Methodology (ESM), a structured diary technique, has been shown to be a well-suited method for assessing moment-to-moment levels and fluctuations of psychotic experiences (e.g. Myin-Germeys et al., 2001, Peters et al., 2012). So et al. (2013) recently showed that ESM assessment using a Personal Digital Assistant (PDA) is feasible and valid during the acute psychotic stage of psychosis. The present study uses this approach to investigate changes in delusion dimensions during the initial 2 weeks of antipsychotic treatment. It was hypothesised that delusion distress and preoccupation, but not conviction, would reduce significantly over 2 weeks of antipsychotic treatment. This study also aimed to explore the potential role of the JTC bias in predicting delusion change. It was predicted that there would be an association between JTC bias at baseline and change in delusion dimensions over time.
Section snippets
Participants
Ethical approval for the study was granted by the South East London Research Ethics Committee 4 (ref. 10/H0807/44). In-patients with delusions (scoring 4 or above on at least one of the PANSS delusion items) and a clinical diagnosis (based on clinical notes) of schizophrenia spectrum disorder or bipolar disorder were recruited. Patients were recruited and assessed as soon as they were admitted to the hospital for an acute psychotic episode, and no longer than 2 weeks after the start of
Demographic and clinical data
A total of 26 patients consented to participate in this study, among whom 16 completed at least 30 experience sampling assessments. The mean number of entries per participant was 59 (range 34–89). The mean rate of compliance was 70.7% (range 40.2–94.6%). The total number of observations available for multi-level models was 1306. There was no significant difference between the 16 participants who met the minimum compliance requirement and the ten participants who did not in age, duration and
Discussion
This study investigated changes over time in delusions among 16 inpatients as they began antipsychotic treatment on admission to hospital, as well as exploring the role of the ‘Jumping to Conclusions’ (JTC) bias in predicting delusion change. The main findings are that (i) distress and disruption, but not conviction and preoccupation, improved on PSYRATS and ESM; and (ii) the JTC bias predicted a difference in change over time in both conviction and distress measured by ESM.
Our sample, which
Acknowledgements
This work was supported by the Croucher Foundation Scholarship and the University of London Central Research Fund to SHS. SK receives Grant support from AstraZeneca, Bristol-Myers Squibb (BMS) and Glaxo Smith Kline. He is a consultant/speaker/advisor for the following companies: AstraZeneca, Bioline, Bristol Meyers Squibb, Eli Lilly, Janssen (Johnson and Johnson), Lundbeck, Otsuka, Organon, Pfizer, Servier, Solvay Wyeth. PG, SK and EP acknowledge support for some clinical sessions from the
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