Stephen Kellett BIGSPD Conference Manchester 2012

Stephen Kellett

BIGSPD Conference Manchester 2012

PPD: DSM-IV (APA, 2000) DEFINITION

suspects (without sufficient basis) that others are exploiting, harming or deceiving them

pre-occupied with trustworthinessinability to confidereads demeaning/threatening meanings into

eventsgrudgesperceives attacks on characterjealous

Existing PPD outcome evidence 2 qualitative case studies (Williams, 1989;

Dimaggio, Cantania, Salvatore, Carcione & Nicolo, 2006).

2 quantitative case studies (Nicolo, Centenero, Nobile & Porcari, 2003; Carvalho, Faustino, Nascimento & Sales, 2008)

Present StudyAssessment, case description, treatment and

long-term outcome of client presenting with PPD

Rich case record (Elliott 2002) in the SCED(1) traditional outcomes measures (2) personal questionnaire daily(3) perceptions of therapy and therapist(4) post therapy interview(5) well described case

The CaseCarl (pseudonym, aged 37, signed off work)Referred by Consultant Psychiatrist opinion re. thought disorderScreened and placed on waiting listAssessed via SCID-II (Spitzer et al, 1997)

Factor Description

CHILDHOOD father morbidly jealous of mother

used as a ‘spy’

interrogated

sibling

reinforcement of schema by step-father

OCCUPATION unskilled jobs 2 years

benefit fraud investigator 13 years

DWP currently

The Case cont

RELATIONSHIPS married – disconnected & distrustful of partner

1 child – few friends

‘COPING’ drugs & alcohol

MENTAL HEALTH history of depression

schizoid

anti-depressant/anti psychotic

SYMTOMATOLOGY disconnected

untrusting

suspicious

‘The Game’

vigilance; ‘the radar’

‘safety’ behaviours

conspiracy theories

SCED - what was done and when

(1) Traditional Outcome Measures reported at assessment, termination, and follow-up

Beck Depression Inventory-II (BDI; Beck et al, 1994) Brief Symptom Inventory (BSI; Derogatis, 1993) Inventory of Interpersonal Problems (IIP-32; Berkham et al, 1994) Personality Structure and Questionnaire (PSQ; Pollock et al, 2001)

(2) Personal Questionnaire

Actual Wording PPD criteria/concept Frequency Scale

Item 1 “I have felt suspicious of other motives today”

DSM-IV 301.0.1

Subjects that others are exploiting, harming or deceiving others

Daily 1 ‘not at all’ to

10 ‘all the time’

Item 2 “I have been scanning my environment today”

Hypervigilance

Daily 1 ‘not at all’ to

10 ‘all the time’

SCED cont

Actual Wording PPD criteria/concept Frequency Scale

Item 3 “I have been questionning the motives of others today”

301.0.2

Is preoccupied with unjustified doubts about loyalty or trustworthiness of others

Daily

1 ‘not at all’ to

10 ‘all the time’

Item 4 “I have been in a world of my own today”

Dissociation/

Disconnection

Daily 1 ‘not at all’ to

10 ‘all the time’

Item 5 “I have been looking for connections today” Conspiracy Daily 1 ‘not at all’ to

10 ‘all the time’

Item 6 “I have felt anxious today” Anxiety Daily 1 ‘not at all’ to

10 ‘all the time’

SCED cont

(3) Perception of therapy and therapist

Session Impact Questionnaire (Stiles et al, 1994) 5 ‘impacts’ measured after each session (understanding, problem

solving, relationship, unwanted thoughts, hindering aspects)

(4) Post-therapy Interview

Therapy change interview (Elliott, Slatick & Urman, 2001)

Structure of interventionReformulation (letter and diagram), Recognition (noticing)Revision (exiting)

Extracts from the reformulation letter“When you were growing up, the home was dominated by your father’s paranoia. As

you have stated ‘you lived in his world’ which was one dominated by distrust, jealousness and suspiciousness towards, in particular, your mother. It seems from an early age that you have learnt to be always on the defensive and you were taught a consistent lesson of distrust and oppressive suspiciousness of others. Your father used you as a source to check out his paranoia and you recall being frequently and frighteningly interrogated for facts and opinions by him. In the present day you continue to interrogate and distrust any person or evidence presented before you and you may be drawn into doing this with me.”

Target Problem = over vigilance Target Problem Procedure = “Believing that people are a direct threat to me, I feel I

need to protect myself by watching people closely all the time. This watchfulness means that I notice many small incidents or behaviours all the time and then join them together to make a conspiracy theory. When this happens, I then withdraw from social situations, which reinforces my belief in the conspiracy theory and so limits my opportunities to learn that people can be trusted.”

Diagram 1: Sequential Diagrammatic Reformulation for PPD Case

TOTALLYUNFEELING

CUT OFF&

EMPTY

CORE PAINanxiousfearful

insecurehectored

CAPTAIN PARANOIA

(though I feel complete)

INTERROGATINGI

INTERROGATED

`THE GAME`Players versus

non-playersOBSERVINGWATCHING

IMONITORED

SOCIALWITHDRAWAL

`the radar`SUSPICIOUS

IWARY

DISTRUSTFUL

find this frightening

after a while

start to feel

vulnerable

only way I know to feel safe

obsess about it

start to believe

thoughts

`peas in the bag`

try to see a pattern

need to make sense

anxiety triggeredsee threat

everywhere

when with people, always keep my distance

find it hard to `connect`

never develop `true` trust

start to see threatswithdraw into myself

mood plummets

Hard to tolerate this

feel totally exhausted

can’t ever relax

never ever stop thinking

try to make sense of confusion

need something to tie it all together

start to play

this game is real

`ha ha; I’ve seen you`

win / outwit/triumph

Key question 1At what stage does active therapy start to work

and are there any sudden gains?

Graph 1; levels of suspiciousness over the course of CAT and follow-up

0

5

10

15

20

25

30

35

40

45

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55

Weeks

To

tal

wee

kly

sco

re

Baseline CAT Follow-up

Table 1; means, (SDs) and F-values for the experimental variables

Baseline mean (SD)

Treatment mean (SD)

Follow-up mean (SD)

F-value

Suspicious 34.33 (2.08) 11.82 (7.12) 7.00 (0.00) 11.60**

Hypervigilent

23.67 (9.81) 9.61 (11.04) 7.00 (0.00) 0.06

Questioning 21.67 (16.67) 9.67 (2.76) 7.00 (0.00) 1.98

Dissociation 20.33 (14.01) 11.15 (7.15) 7.00 (0.00) 1.26

Conspiracy 19.67 (17.78) 10.48 (6.11) 7.00 (0.00) 2.49

Anxious 27.33 (11.52) 16.48 (10.30) 17.16 (9.06) 4.24** p < 0.05

** p < 0.01

What does a significant F value mean in

this analysis? • An overall change in both the intercept (i.e.

start of treatment post formulation) and the slope (regression line of change)

Key question 2Is there any clinically significant change in the

traditional outcome measures?

Key question 3; are some sessions more impactful/helpful than others?

Significant increase in ratings of problem solving in treatment sessions (t = -2.27, P < 0.05)

No difference in understanding, relationship, unwanted thoughts or hindering aspects

Key question 4Can the client describe what changes were due to

therapy and what made the difference?

The change interview conducted following the final follow-up session

The case for change

(1) evidence of non-trivial change in long-standing difficulties (evidenced by time series analysis of changes in the target complaint measures of suspiciousness and anxiety),

(2) non trivial psychometric change (evidenced by reliable pre-post change in the traditional outcome measures),

(3) the patient retrospectively attributing his reduced paranoia to the CAT conducted (evidenced by the Change Interview in terms of the statements and ratings of change) and

(4) evidence of an event (narrative reformulation) – shift (reduced paranoia) sequence (evidenced by the graphing of the suspiciousness target complaint measure).

Skeptical position

(1) there was insufficient change in the quantitative data (evidenced by no change in some of the target complaint paranoia measures over time and lack of reliable pre-post change in the IIP-32),

(2) that fidelity to the CAT model was not assessed (by use of the Competence in CAT measure for example, Bennett & Parry, 2008),

(3) that the SCID-II was not re-administered following therapy and therefore the patient still may have met DSM-IV (APA, 1994) diagnostic criteria for PPD,

(4) that the follow-up period was too short to truly assess long-term implications of treatment,

(5) whilst trust appeared to be the change mechanism, there was not evidence of change in the trust variable in the interrupted time series analysis and

(6) that the patient had replaced one fixed belief system (the game) with another, albeit slightly more functional, one (an unreflective relational model).

Thank you

Any questions

s.kellett@sheffield.ac.uk