1. Stephen Kellett BIGSPD Conference Manchester 2012

2. PPD: DSM-IV (APA, 2000) DEFINITION suspects (without sufficient basis) that others are exploiting, harming or deceiving them pre-occupied with trustworthiness inability to confide reads demeaning/threatening meanings into events grudges perceives attacks on character jealous

3. 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)

4. Present Study Assessment, 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

5. The Case Carl (pseudonym, aged 37, signed off work) Referred by Consultant Psychiatrist opinion re. thought disorder Screened and placed on waiting list Assessed via SCID-II (Spitzer et al, 1997) FactorDescription CHILDHOODfather morbidly jealous of mother used as a ‘spy’ interrogated sibling reinforcement of schema by step-father OCCUPATIONunskilled jobs 2 years benefit fraud investigator 13 years DWP currently

6. The Case cont RELATIONSHIPSmarried – disconnected & distrustful of partner 1 child – few friends ‘COPING’drugs & alcohol MENTAL HEALTHhistory of depression schizoid anti-depressant/anti psychotic SYMTOMATOLOGYdisconnected untrusting suspicious ‘The Game’ vigilance; ‘the radar’ ‘safety’ behaviours conspiracy theories

7. 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 WordingPPD criteria/conceptFrequencyScale Item 1“I have felt suspicious of other motives today” DSM-IV 301.0.1 Subjects that others are exploiting, harming or deceiving others Daily1 ‘not at all’ to 10 ‘all the time’ Item 2“I have been scanning my environment today” Hypervigilance Daily1 ‘not at all’ to 10 ‘all the time’

8. SCED cont Actual WordingPPD criteria/conceptFrequencyScale 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 Daily1 ‘not at all’ to 10 ‘all the time’ Item 5“I have been looking for connections today” ConspiracyDaily1 ‘not at all’ to 10 ‘all the time’ Item 6“I have felt anxious today” AnxietyDaily1 ‘not at all’ to 10 ‘all the time’

9. 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)

10. Structure of intervention Reformulation (letter and diagram), Recognition (noticing) Revision (exiting)

11. 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.”

12. Diagram 1: Sequential Diagrammatic Reformulation for PPD Case TOTALLY UNFEELING CUT OFF & EMPTY CORE PAIN anxious fearful insecure hectored CAPTAIN PARANOIA (though I feel complete) INTERROGATING I INTERROGATED `THE GAME` Players versus non-players OBSERVING WATCHING I MONITORED SOCIAL WITHDRAWAL `the radar` SUSPICIOUS I WARY 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 triggered see threat everywhere when with people, always keep my distance find it hard to `connect` never develop `true` trust start to see threats withdraw 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

13. Key question 1 At what stage does active therapy start to work and are there any sudden gains?

16. Table 1; means, (SDs) and F-values for the experimental variables Baseline mean (SD) Treatment mean (SD) Follow-up mean (SD) F-value Suspicious34.33 (2.08)11.82 (7.12)7.00 (0.00) 11.60 ** Hypervigilent23.67 (9.81)9.61 (11.04)7.00 (0.00)0.06 Questioning21.67 (16.67)9.67 (2.76)7.00 (0.00)1.98 Dissociation20.33 (14.01)11.15 (7.15)7.00 (0.00)1.26 Conspiracy19.67 (17.78)10.48 (6.11)7.00 (0.00)2.49 Anxious27.33 (11.52)16.48 (10.30)17.16 (9.06) 4.24 * * p < 0.05 ** p < 0.01

17. 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)

18. Key question 2 Is there any clinically significant change in the traditional outcome measures?

20. 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

21. Key question 4 Can the client describe what changes were due to therapy and what made the difference? The change interview conducted following the final follow- up session

23. 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).

24. 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).

25. Thank you Any questions s.kellett@sheffield.ac.uk