Clinical trial NCT05042050: Attachment-focused iMAgery Therapy for PSychosis (A-iMAPS)
Official title: Attachment-focused iMAgery Therapy for PSychosis (A-iMAPS): a Case Series
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Psychosis
Psychosis-Related PTSD
Lead sponsor: University of Manchester
Sponsor class: OTHER
Collaborators: name: Pennine Care NHS Foundation Trust
name: Greater Manchester Mental Health NHS Foundation Trust
First posted: 2021-09-13
Enrollment: 12
Sex: ALL
Minimum age (years): 16
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: Proof of Concept Case Series Design
Primary purpose: TREATMENT

Brief summary: The relationships we have in childhood affect how we relate to others across our life, including how safe or secure we feel. If our caregivers do not meet our needs well enough in childhood, this can lead to an 'insecure attachment style'. This means we may push others away or cling to them, but never feel fully safe or secure with them. This style is common in people who have mental health problems. This includes psychosis, when people have unusual experiences such as hearing voices others cannot hear. A lot of people with psychosis have difficult experiences with mental health services. This includes involuntary treatments, traumatic interactions and hospital stays, where they may think staff are trying to harm rather than help them. As a result they may not feel safe working with staff and they might re-experience the negative memories of these events. This is known as psychosis-related Post-Traumatic Stress Disorder (PR-PTSD) and can lead to ongoing problems.

Imagery is often defined as mental pictures but it includes imagining our senses (smell, touch, taste) too. It can be a useful therapy tool to help people to work with difficult memories and can help them to feel more safe and secure. Research shows that this is helpful for people with psychosis and people who have been through trauma. Hence, it may be helpful for people with PR-PTSD. The study aims to see if it is viable to do a 6-session therapy using imagery to target PR-PTSD memories. The study will use a case series design where up to 12 people with psychosis will be able to try the therapy. They will be asked to complete questionnaires to understand any potential benefits of the therapy. The findings could inform the research and allow for further development of therapies in this area.

Detailed description: Attachment theory underpins human interpersonal experience: it suggests that our early relationships, typically those with our primary caregivers in infancy, have a profound effect on how we learn to relate to the others across the lifespan. Attachment styles in adulthood, particularly insecure styles, have been associated with mental health problems, and it has been noted that improving attachment security can improve mental health.

In the last decade, there has been an increase in research around the role of attachment in psychosis, with an over-representation of insecure attachment patterns seen in individuals with such diagnoses (76% in psychosis compared to 38% in non-clinical samples). A number of studies have identified links with insecure attachment in several aspects of psychopathology, including voice-hearing, persecutory delusions, social functioning and negative symptoms, though the mechanisms between such remain poorly understood.

Attachment insecurity is significantly associated with paranoia and recent research has focused on reducing this using the concept of "felt security", which is defined as "a sense of interpersonal safety associated with secure, protective relationships". In childhood, this sense of safety and security constitutes a 'secure base' from which the child is able to explore. Priming felt security through imagery (i.e. undertaking an imagery exercise focused on secure attachment with another individual in the image) has been found to reduce paranoia in non-clinical adult samples. Moreover, 'felt security' imagery has been deemed effective in engendering a sense of security and reducing paranoia prior to rescripting trauma memories with an individual with psychosis.

Imagery interventions have been long established for use as part of therapy for individuals with psychosis, and have been recognised as a frontier in therapeutic intervention across disorders, including working with negative imagery (e.g., imagery rescripting) and positive imagery. A case series was completed and subsequently a protocol published for a six-session imagery intervention, iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS), targeting intrusive mental imagery and negative beliefs about self and others in psychosis with a combination of negative and positive imagery techniques, which indicated feasibility of combining various imagery techniques in a short intervention for psychosis.

Individuals with psychosis may not only experience intrusive images as a component of their psychotic symptomology, but also as a consequence of their psychosis itself. Psychosis-Related Post-Traumatic Stress Disorder (PR-PTSD) is an under-researched area but a recent review suggested that between 14% and 47% of individuals with psychosis may have PR-PTSD, with associated factors including symptomology of psychosis, treatment factors (involuntary admissions, traumatic inpatient events, restraint) and attachment style. However, there appears to be minimal published literature on this beyond first-episode psychosis. Anxiety in attachment relationships has been identified as positively correlated with psychosis-related and hospital-related PTSD symptoms.

The present study aims to add to the limited literature on PR-PTSD by evaluating the feasibility of a short six-session attachment-focused imagery intervention for psychosis, based upon the iMAPS protocol, which will be adapted to include 'felt security' imagery and the imagery rescripting will focus on psychosis-related trauma. It is anticipated that this would reduce PTSD symptomology. Moreover, by using attachment security primes in conjunction with rescripting, paranoia may also be reduced.

Eligibility criteria: Inclusion Criteria:

* Is currently receiving care under an NHS Community Mental Health Team, and meets ICD-10 or ICD-11 criteria for a schizophrenia-spectrum diagnosis (schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder or psychotic disorder not otherwise specified) indicated by case notes, or under the care of an Early Intervention in Psychosis Service
* Aged 16 or above
* Medication stable for ≥ one month, as indicated by their Care Coordinator
* Has capacity to give written, informed consent
* Proficient in English to complete study questionnaires
* A score of one or more on the four psychosis-related trauma items (items 15 to 18) on the Trauma and Life Events Checklist (Carr et al., 2018b)

Exclusion Criteria:

* Has an acquired brain injury
* Has a history of substance misuse that is judged to be the acute cause of the psychotic experiences
* Currently experiencing an acute episode requiring inpatient care
* Currently undertaking psychological therapy

Primary outcomes:
measure: Number of participants approached and recruited to the intervention
timeFrame: Throughout recruitment phase of the study, an average of 24 weeks
measure: Number of sessions attended
timeFrame: Throughout the study, attendance recorded for each intervention session, an average of 1 year
measure: Number of participants who drop out of the intervention
timeFrame: For the duration of the study, an average of 1 year
measure: Number of Adverse Events and Serious Adverts Events recorded during the study
timeFrame: For the duration of the study, an average of 1 year
Secondary outcomes:
measure: The suitability of outcome measures used, determined by the number completed
timeFrame: For the duration of the study, an average of 1 year
measure: Change from baseline in PTSD score
timeFrame: For duration of intervention, up to 12 weeks
measure: Change from baseline in paranoia score
timeFrame: For duration of intervention, up to 12 weeks
measure: Change from baseline in core schemas
timeFrame: For duration of intervention, up to 12 weeks
measure: Change from baseline in attachment style
timeFrame: For duration of intervention, up to 12 weeks
measure: Change from baseline in felt security
timeFrame: For duration of intervention, up to 12 weeks
Other outcomes:
Locations:
city: Manchester
country: United Kingdom
facility: Pennine Care NHS Foundation Trust
Study officials:
affiliation: University of Manchester
name: Katherine Berry, PhD
role: PRINCIPAL_INVESTIGATOR
References:
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citation: Carr SC, Hardy A, Fornells-Ambrojo M. Relationship between attachment style and symptom severity across the psychosis spectrum: A meta-analysis. Clin Psychol Rev. 2018 Feb;59:145-158. doi: 10.1016/j.cpr.2017.12.001. Epub 2017 Dec 6.
citation: Lavin R, Bucci S, Varese F, Berry K. The relationship between insecure attachment and paranoia in psychosis: A systematic literature review. Br J Clin Psychol. 2020 Mar;59(1):39-65. doi: 10.1111/bjc.12231. Epub 2019 Aug 7.
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citation: Morrison AP. The use of imagery in cognitive therapy for psychosis: a case example. Memory. 2004 Jul;12(4):517-24. doi: 10.1080/09658210444000142.
citation: Holmes EA, Mathews A, Dalgleish T, Mackintosh B. Positive interpretation training: effects of mental imagery versus verbal training on positive mood. Behav Ther. 2006 Sep;37(3):237-47. doi: 10.1016/j.beth.2006.02.002. Epub 2006 May 24.
citation: Taylor CDJ, Bee PE, Kelly J, Emsley R, Haddock G. iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series. Behav Cogn Psychother. 2020 Sep;48(5):530-545. doi: 10.1017/S1352465820000168. Epub 2020 Apr 8.
citation: Buswell G, Haime Z, Lloyd-Evans B, Billings J. A systematic review of PTSD to the experience of psychosis: prevalence and associated factors. BMC Psychiatry. 2021 Jan 7;21(1):9. doi: 10.1186/s12888-020-02999-x.