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Title: Testing the role of social isolation and social cognition in thought disorder in service users diagnosed with psychosis
Author: de Sousa, Paulo Alexandre Brito
Awarding Body: University of Liverpool
Current Institution: University of Liverpool
Date of Award: 2018
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Thought disorder (TD) is a common and transdiagnostic feature in service users diagnosed with psychotic-spectrum disorders (e.g. schizophrenia; Roche, Creed, MacMahon, Brennan, & Clarke, 2014) and mood disorders (e.g. bipolar affective disorder; Yalincetin et al., 2016). The construct refers to a varied array of experiences ranging from poverty of speech (i.e. replies to questions are marked by a significant reduction in the amount of spontaneous speech), derailment (i.e. the discourse of the service user is marked by a sequence of apparently unrelated or remotely related ideas) or tangentiality (i.e. service user's replies appear to be tangential and off-topic). These experiences occur on a spectrum of severity ranging from mild and subtle speech atypicalities (e.g. word approximations) to incoherence and complete breakdown in communication between service user and interlocutor (Andreasen, 1982, 1986). There has been a considerable amount of research on TD in the last 50 years (McKenna & Oh, 2005). Much of this research effort has neglected the potential role of social factors in TD in favour of a genetic- or biological-oriented research agenda (e.g. Levy et al., 2010; Sumner, Bell, & Rossell, 2018) with some notable exceptions (e.g. Tienari & Wahlberg, 2008; Wahlberg et al., 2000). This has led to a paucity of models to inform and support specific psychological interventions for TD, especially models that bring together psychological mechanisms and social determinants (Bentall et al., 2014). This is an important point given the negative impact that TD has on therapeutic alliance (Cavelti, Homan, & Vauth, 2016) and the importance of the latter construct in the effective delivery of cognitive behavioural therapy for psychosis (CBTp; Goldsmith, Lewis, Dunn, & Bentall, 2015), which remains as one of the few gold standard psychological interventions for psychosis (National Institute for Health and Care Excellence; NICE, 2014). The importance of researching TD is further emphasised by the negative impact that it has on social (Bowie, Gupta, & Holshausen, 2011; Bowie & Harvey, 2008) and occupational functioning (Racenstein, Penn, Harrow, & Schleser, 1999; St-Hilaire & Docherty, 2005), quality of life (Tan, Thomas, & Rossell, 2014), and relapse (Wilcox, 1990). Some authors proposed adaptations of existing clinical models of psychosis to intervene in TD (Palmier-Claus et al., 2017). These helpful clinical models focus predominantly on the potential role of cognitive appraisals in the maintenance of TD (Beck, Rector, Stolar, & Grant, 2009; Grant & Beck, 2009). They suggest that unhelpful appraisals (e.g. "other people think I am stupid") exacerbate negative affect (e.g. anxiety), which in association with unhelpful behaviours (e.g. hypervigilance), lead to the worsening of TD. These models have the power to explain the well-documented worsening of TD during periods of heightened arousal and anxiety (Docherty, 1996) but they do not explain why the service user would come across as thought disordered. Moreover, these models do not attempt to explicitly explore the relationship between well-established psychological mechanisms in TD and social factors. Such effort is important because it is likely to inform more specific maintenance and developmental models of TD. In recent years, evidence has accumulated supporting the value of TD in the prediction of transition to psychosis in at-risk mental states (ARMS; Bearden, Wu, Caplan, & Cannon, 2011; Cannon et al., 2008; DeVylder et al., 2014), and in high-risk children long before the onset of illness (Gooding, Ott, Roberts, & Erlenmeyer-Kimling, 2012; Ott, Roberts, Rock, Allen, & Erlenmeyer-Kimling, 2002). These findings open important avenues for preventative work and highlight the importance of understanding not just how TD is maintained but also how it develops. In this context, the current thesis is an attempt to bring together both psychological mechanisms and social determinants of TD with the aim of understanding why service users appear thought disordered. Some authors have suggested that poor theory-of-mind (ToM) is an important core process in TD and in symptoms of disorganisation in psychosis (Frith, 1992; Hardy-Baylé, Sarfati, & Passerieux, 2003). TD is manifested through communication and communication is ultimately a social and interpersonal process (Clark & Wilkes-Gibbs, 1986). It follows that a difficulty inferring or monitoring the thoughts, intentions, emotions and state of knowledge of the listener during communication (i.e. poor ToM or an unawareness of the perspective of the listener; Harrow, Lanin-Kettering, & Miller, 1989) would render the service user vulnerable to communication breakdown and to an unawareness that communication has gone awry. However, other domains of socio-cognitive functioning may well be relevant to explain a construct that is highly heterogeneous (Cuesta & Peralta, 1999). Aspects of social cognition such as social perception or emotion recognition could also potentially explain communication difficulties such as TD (Docherty et al., 2013). Importantly, the strength of association between the different domains of social cognition and TD (and related constructs) has not been previously quantified. In this context, Chapter 1 of the dissertation reports on a meta-analytic review (studies published between 1980 and 2016) on the association between different domains of socio-cognitive functioning and TD (and related constructs). Chapter 2 of the dissertation reports on an empirical study with 68 participants diagnosed with psychotic-spectrum disorders that tested the effects of social isolation on poor ToM, and TD. It has been previously shown that social isolation is a specific predictor of TD (de Sousa, Spray, Sellwood, & Bentall, 2015) and given the sizable relationship between socio-cognitive functioning and TD a more complex mediation model was tested. It was hypothesised that poor ToM could work as mediating factor between social isolation and TD (i.e. the lack of social feedback in social isolation could impact on the service user's social cognition leading to TD). In order to test for symptom-specificity, the regression model was adjusted for the presence of hallucinations, suspiciousness, delusions, and negative symptoms. Interestingly, the analyses revealed that poor performance on the Hinting task fully mediated the relationship between social isolation and TD. Also, relevant was the independent contribution in the final model of delusions. We interpreted the latter finding as supportive of the previous suggestion that TD patients tend to intermingle worries and concerns (e.g. delusional beliefs) into their communications making them idiosyncratic, difficult to follow, and more likely to be labelled as "thought disordered" (Lanin-Kettering & Harrow, 1985). The potential clinical implications of the two papers comprising this thesis, as well as the limitations of the studies and avenues for future research, are explored in the respective chapters.
Supervisor: Bentall, Richard ; Sellwood, William Sponsor: Not available
Qualification Name: Thesis (D.Clin.Psy.) Qualification Level: Doctoral