Aim
This study investigated the interaction between appraisals and safety behaviours in the maintenance of psychotic symptoms.
Method
The study recruited a population who had persistent psychotic experiences but who had no ‘need-for-care’ (Persistence group; n = 39) as well as a population who had a diagnosed psychotic disorder and were receiving current treatment (Impairment group; n = 28). The participants were assessed on semi-structured interviews of appraisals and safety behaviours and on anxiety and depression questionnaires.
Results
The two groups did not differ in total or first rank psychotic experiences, but the Persistence group showed less anomaly-related distress, depression and anxiety than the Impairment group. As predicted, the Impairment group displayed more threat appraisals and safety behaviours than the Persistence group, with a greater frequency of safety behaviours being related to higher levels of threat appraisals and anomaly-related distress. Threat appraisals mediated the relationship between safety behaviours and anomaly-related distress, suggesting that threat appraisals may maintain distress, a defining feature of Impairment status.
Conclusions
These data provide support for the cognitive model of psychosis in suggesting that cognitive and behavioural factors are key in differentiating non-clinical anomalous experiences from clinical psychotic status. These data suggest that therapy should target threat appraisals and safety-seeking behaviours in order to decrease distress.
For over 40 years, investigators have explored the idea that psychosis symptoms are expressed at levels below their clinical manifestation (Chapman, Chapman, Kwapil, Eckblad, & Zinser, 1994; Claridge, 1997; van Os, Hanssen, Bijl, & Ravelli, 2000; Strauss, 1969; Wiles et al., 2006). van Os, Linscott, Myin-Germeys, Delespaul, and Krabbendam (2009) described a Proneness–Persistence–Impairment model of psychosis to explain these data. Many are prone to transitory psychotic experiences; for a smaller group the experiences persist but cause no impairment; for an even smaller group the experiences persist and lead to impairment. In this context the authors suggest that clinical psychotic disorders could be seen as “a rare poor outcome” (p. 190) of anomalous experiences. This alters the focus of models of psychosis away from the question of what factors cause unusual experiences to occur ( Broome et al., 2005) to what factors cause unusual experiences to continue and to cause distress. Cognitive models of psychosis, developed from clinical samples, focus on Impairment ( Garety, Bebbington, Fowler, Freeman, & Kuipers, 2007; Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). Differentiating between Persistence and Impairment is an important question which allows us to examine the factors which are hypothesised to maintain distress.
Cognitive models of psychosis have proposed that anomalous experiences become psychotic disorders depending on the appraisal of the experience and the subsequent emotional response (Chadwick & Birchwood, 1994; Freeman, 2007; Garety et al., 2001, 2007; Morrison, 2001). One aspect of cognitive models which may be particularly relevant is the concept of safety-seeking behaviours. Safety-seeking behaviours were first examined in cognitive theories of anxiety disorders (e.g. Clark, 1999; Salkovskis, 1996), but have also been included in cognitive models of psychosis (e.g. Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002; Morrison, 2001). Many delusional beliefs share with anxiety disorders a theme of “anticipation of danger” ( Freeman & Garety, 1999; Freeman, Garety, & Kuipers, 2001). Freeman et al. argue that individuals with delusions who anticipate danger may take preventative action in order to achieve safety. These actions nullify disconfirmatory evidence of the lack of threat by turning the situation into a “near miss”, thus maintaining the threat belief and never allowing the anxiety to habituate.
Some evidence supports the role of safety behaviours in maintaining impairment in psychosis (Campbell & Morrison, 2007; Freeman et al., 2007; Hacker, Birchwood, Tudway, Meaden, & Amphlett, 2008; Nothard, Morrison, & Wells, 2008). For instance, Freeman et al. (2007) examined 100 people with current persecutory delusions. Ninety-six percent of patients reported that they had used a safety behaviour in the last month, and a greater use of safety behaviours was related to higher levels of anxiety, depression and delusional distress.
Hacker et al. (2008) looked at safety behaviours in 23 voice hearers with psychosis diagnoses. Over 80% of the voice hearers had used a safety behaviour in the last month, and safety behaviour use was related to distress. The relationship between safety behaviours and distress was almost fully mediated by beliefs about the omnipotence of the voices. These results were in line with the cognitive formulation that the voice hearers engaged in safety behaviours to reduce the threat from powerful voices, not to reduce their distress per se.
