stephen kellett bigspd conference manchester 2012
TRANSCRIPT
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).
