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Objective: To investigate whether orofacial tardive dyskinesia (OTD) is associated with frontal lobe dysfunction and whether either are related to the coping abilities independent of psychiatric symptoms in older people with psychotic disorders., Methods: A total of 52 patients, aged over 65 years or over, who satisfied International Classification of Diseases, Tenth Revision criteria for psychotic disorders (F20-F29) were recruited into the study. OTD was measured using the Abnormal Involuntary Movements Scale and Waddington et al.'s (1993) criteria. Neuropsychological measures were specifically selected to assess different aspects of frontal function and coping was measured using a semistructured interview. Psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS)., Results: Patients with OTD showed more severe global cognitive impairment compared to patients without OTD. Group differences on measures of frontal lobe dysfunction were not maintained following adjustment for global cognitive impairment. Patients with OTD did not differ from patients without OTD on coping measures. Scores on the general psychopathology subscale of the PANSS, which includes symptoms associated with depression and anxiety, consistently predicted patients' negative perceptions of stressors and appraisals of coping, but cognitive impairment did not predict coping independent of symptoms., Conclusion: The association between coping and general psychopathology in older patients with psychosis warrants further investigation as both variables may be amenable to psychological interventions.

Interventions for people suffering from borderline personality disorder (BPD), such as dialectical behaviour therapy, often include a problem-solving component. However, there is an absence of published studies examining the problem-solving abilities of this client group. In this study, the social problem-solving (SPS) abilities of three groups of participants were assessed: a BPD group (n=25), a clinical control (CC) group (n=25) procedure and a non-clinical control (NCC) group (n=25). SPS ability was assessed using the means-end problem-solving (MEPS) procedure and the Social Problem-Solving Inventory-Revised (SPSI-R). The BPD group exhibited deficits in their SPS abilities, however the majority of these deficits were not specific to the BPD group but were also found in the CC group, indicating that a common factor between these two groups, such as negative affect, may account for these observed deficits. Specific SPS deficits were identified in the BPD group: they provided less specific solutions on the MEPS and reported higher levels of negative problem orientation and a more impulsive/carelessness style towards solving social problems. The results of this study provide empirical support for the use of problem-solving interventions with people suffering from BPD.

Attachment styles reflect individual differences in beliefs about self and others, interpersonal functioning and affect regulation. We review and critically appraise studies suggesting higher levels of insecure attachment, and dismissing attachment in particular, in samples with psychosis compared to controls. We also review the role of social cognition, interpersonal factors, and affect regulation in the development and maintenance of psychosis, and specific symptoms associated with the diagnosis. We review studies showing that insecure attachment is associated with poorer interpersonal relationships and less integrative recovery styles and highlight how recent theories and empirical findings in the psychosis literature can be understood within the framework of attachment theory. In doing so, we argue that investigations of the nature of attachment styles in psychosis and how they relate to the cognitive, interpersonal and affective factors that have been implicated in psychosis will help develop theoretical knowledge in relation to the condition. We conclude by outlining the clinical implications of applying attachment theory to the understanding of psychosis and summarising the conceptual and methodological limitations of the theory which should be addressed, including the need for studies with longitudinal designs, larger, more representative samples, and more valid measures of assessing attachment styles in psychosis.

People with a diagnosis of schizophrenia are at increased risk of suicidal behaviour yet little is understood of the psychological underpinnings of this vulnerability. The biopsychosocial 'Cry of Pain' model [Williams, J.M.G. (1997). Cry of pain. Harmondsworth: Penguin.] provides a broad framework from which to understand suicidal behaviour. However, the utility of the model in relation to suicide in schizophrenia has not yet been explored. This was the primary goal of this paper. Six components of the 'Cry of Pain' model were identified and evaluated with respect to whether they contributed to i. common transdiagnostic factors underlying suicide, ii. factors relating to co-morbid depression which account for suicidal behaviour, or iii. factors which are specific to schizophrenia and underlie suicide risk. The potential for applying the model to clinical management of suicide in schizophrenia is illustrated.

Around half of all patients with schizophrenia are thought to abuse drugs or alcohol and there is good evidence to suggest that they have poorer outcomes than their non substance using counterparts. However, despite more than twenty years of research there is still no consensus on the aetiology of increased rates of substance use in people with psychosis. There is a clear need to understand the reasons for such high rates of substance use if treatments designed to help patients abstain from substance use are to be successful. This paper provides an update of the literature examining the reasons for substance use by people with psychosis, and includes a comprehensive review of the self report literature. The main theories as to why people with psychosis use substances are presented. There is evidence to suggest that cannabis may have a causal role in the development of psychopathology but not for other substances. The self report literature provides support for an 'alleviation of dysphoria' model of substance use but there is little empirical support for the self medication hypothesis, or for common factor models and bidirectional models of comorbidity. It is likely that there are multiple risk factors involved in substance use in psychosis and more work to develop and test multiple risk factor models is required.

Background: The efficacy of cognitive-behavioural therapy for schizophrenia is established, but there is less evidence for a group format., Aims: To evaluate the effectiveness of group cognitive-behavioural therapy for schizophrenia., Method: In all, 113 people with persistent positive symptoms of schizophrenia were assigned to receive group cognitive-behavioural therapy or treatment as usual. The primary outcome was positive symptom improvement on the Positive and Negative Syndrome Scales. Secondary outcome measures included symptoms, functioning, relapses, hopelessness and self-esteem., Results: There were no significant differences between the cognitive-behavioural therapy and treatment as usual on measures of symptoms or functioning or relapse, but group cognitive-behavioural therapy treatment resulted in reductions in feelings of hopelessness and in low self-esteem., Conclusions: Although group cognitive-behavioural therapy may not be the optimum treatment method for reducing hallucinations and delusions, it may have important benefits, including feeling less negative about oneself and less hopeless for the future.

Background: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment., Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention., Results: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological well-being, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer., Conclusions: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors' alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.

Background: According to vulnerability-stress models of psychosis, cognitive and behavioural coping strategies can help mediate the potentially negative effects of daily stressors. The nature, frequency and effectiveness of coping have been studied in people with psychosis under 65 years of age. However, these findings may not generalise to older people with the diagnosis, as the nature of stressors and coping strategies may change with increasing age. This study therefore aimed to explore coping in older patients with psychosis., Methods: A total of 48 older patients with psychosis (F20-29, ICD-10) and 25 non-clinical elderly controls were compared using self-report measures of stressors, perceived control over stressors, coping strategies, perceived coping efficacy and social support. A regression analysis was used to explore predictors of dysfunctional coping in the patient group., Results: Patients used a significantly higher proportion of problem-focused coping strategies, but they were more dysfunctional copers and rated their coping as less effective compared to controls. They also had fewer friends and less emotional support. Severity of symptoms was a significant predictor of dysfunctional coping when depression, cognitive impairment and functional disability were controlled., Conclusions: Patients with psychosis coped less well with daily stressors than controls and patients with more severe symptoms were more dysfunctional copers. The findings highlight the potential benefit of psychosocial interventions in old age psychosis.

Objectives: An attribution-emotion model of reactions to illness was tested in a sample of partners of 60 adult patients with type I diabetes., Methods: Partners were interviewed using the Camberwell family interview (CFI), from which spontaneous attributions for negative events were extracted and coded. Events were classified into diabetes and non-diabetes events. Partners also completed questionnaire measures of marital adjustment, anxiety and depression., Results: Compared with low expressed emotion (EE) partners, high-EE partners attributed proportionally more negative diabetes events (e.g. patient characteristics and behaviour) to factors controllable by and personal to the patient. High-EE partners were more anxious than low-EE partners, and made more responsibility attributions (attributions rated as both internal and controllable and personal). Partners with poorer marital adjustment made more responsibility attributions, but only for non-diabetes events., Conclusion: Whereas attributions for both diabetes and non-diabetes events were related to partners' EE, attributions for diabetes events were not significantly associated with partners' marital adjustment.

Background: This study examined the relationship between discrepancies in beliefs about schizophrenia and Expressed Emotion (EE) in family dyads., Method: Illness beliefs were assessed in patients with a diagnosis of schizophrenia and their relatives (N=49 dyads). The degree and the direction of discrepancy were calculated, and comparisons were made between dyads in which the relative was rated as high EE and dyads in which the relative was rated as low EE., Results: There was greater discrepancy between illness models of schizophrenia in dyads involving a high-EE relative than in dyads involving a low-EE relative. This difference was not accounted for by the differences in either relatives' or patients' beliefs alone., Conclusion: Further research is needed to understand EE in the context of discrepancies in beliefs between patients and relatives rather than focussing on relatives' beliefs alone.

Objective: To test the hypotheses that carers of patients with schizophrenia (single diagnosis) and schizophrenia and co-occurring drug or alcohol misuse (dual diagnosis) will differ in terms of expressed emotion (EE) and their attributions for patient problems., Method: In a cross-sectional study, two samples of 42 single- and dual-diagnosis carers are compared in terms of EE and attributions. Patient symptoms are assessed to control for differences other than substance misuse., Results: The study supports the hypothesis that high-EE, dual-diagnosis carers tend to see patient problems as more blaming (internal, controllable and personal) than do single-diagnosis patients. This difference was particularly marked when making causal ascriptions for deficit behaviours. Although there were no differences in overall EE levels in the two groups, there were significantly more carers who were rated as hostile and rejecting in the dual-diagnosis group., Conclusions: The findings highlight the importance of family intervention for this patient group.

Objective: To design a questionnaire to assess cognitive representations of mental health problems held by people diagnosed with schizophrenia., Background: Personal beliefs about health problems have been reliably associated with emotional and behavioural responses to those health problems and health outcomes. This area has been extensively explored in relation to physical health, but somewhat neglected in mental health. In this study, a questionnaire designed to assess key beliefs about physical illness (the Illness Perception Questionnaire - Revised) was modified for use in exploring beliefs about schizophrenia. The new measure was termed the Illness Perception Questionnaire for Schizophrenia (IPQS)., Method: Participants were 124 people with a diagnosis of schizophrenia who completed the IPQS and additional measures to assess symptom severity, emotional state, and attitudes towards medication. The psychometric properties of the IPQS were analysed, including internal consistency, test-retest reliability, and discriminant and concurrent validity., Results: The IPQS subscales were shown to be internally reliable, and reliable over time. Correlations with measures of symptom severity, emotional state, and attitudes towards adherence to medication showed that the subscales were measuring the constructs that they were designed to measure., Conclusions: The IPQS is a reliable and valid measure of cognitive representations of mental health problems held by people with a diagnosis of schizophrenia.

Aims: To predict the early therapeutic alliance from a range of potentially relevant factors, including clients' social relationships, motivation and psychological resources, and counsellors' professional experience and ex-user status., Design: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and client and counsellor ratings of the alliance were obtained during weeks 1, 2 and 3., Measurements: The intake assessment battery included scales on psychological wellbeing, treatment motivation, coping strategies and attachment style. Client and counsellor versions of the Working Alliance Inventory (WAI-S) were used for weekly alliance measurement. Hierarchical linear models were used to examine the relationship between alliance and predictor variables., Findings: Clients who had better motivation, coping strategies, social support and a secure attachment style were more likely to develop good alliances. Findings with regard to counsellor characteristics were not clear cut: clients rated their relationships with ex-user counsellors, experienced counsellors and male counsellors as better, but more experienced counsellors rated their alliances as worse., Conclusions: The findings offer important leads as to what interventions might improve the therapeutic alliance. Further work will need to establish whether the therapeutic alliance and ultimately treatment outcomes can be enhanced by working on improving clients' motivation and psychosocial resources.

Background: In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug treatment have been published and it is timely that their findings are brought together in a comprehensive review., Aims: This paper has two principal aims: (1) to assess the degree to which the relationship between drug user and counsellor predicts treatment outcome and (2) to examine critically the evidence on determinants of the quality of the alliance., Methods: Peer-reviewed research located through the literature databases Medline, PsycInfo and Ovid Full Text Mental Health Journals using predefined search-terms and published in the past 20 years is considered. Further papers were identified from the bibliographies of relevant publications., Findings: A key finding is that the early therapeutic alliance appears to be a consistent predictor of engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance appears to influence early improvements during treatment, but it is an inconsistent predictor of post-treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that are available, clients' demographic or diagnostic pre-treatment characteristics did not appear to predict the therapeutic alliance, whereas modest but consistent relationships were reported for motivation, treatment readiness and positive previous treatment experiences., Conclusions: The therapeutic alliance plays an important role in predicting drug treatment process outcomes, but too little is known about what determines the quality of the relationship between drug users and counsellors.

Background and Objectives: Illness representations in physical health problems have been studied extensively using the Self-regulation Model (SRM) focusing on five dimensions of illness beliefs (identity, consequences, causes, timeline and control, or cure). Associations have been found between beliefs about illness and a range of health outcomes. This study aimed to examine models of depression, to assess whether the five dimensions of the SRM are relevant, to compare depression models with those for physical illness, and to examine the psychometric properties of the Illness Perception Questionnaire (IPQ) when used with depression., Design and Method: A sample of 101 women either currently depressed or with a history of depression was asked to write about their experiences of physical sickness and depression. Their responses were analysed in terms of the dimensions of beliefs expressed and the two experiences were compared. The IPQ was also administered to assess the women's perceptions of depression., Results: The women used the same five dimensions of illness as identified in the SRM in describing both their experience of depression and physical sickness. There was evidence of some consistency across the models of the two illnesses in terms of their content and structure. The IPQ was a reliable measure for depressed experiences and discriminated between women who were currently depressed or not. Comparing the women's descriptions of their depression with their IPQ scores showed some relationships between their responses on the two different measures, at least for the consequences and cause dimensions., Conclusion: The SRM model and associated methodology may provide an appropriate framework to further explore illness representations in depression. Problems inherent in the study of illness models in depression including the influence of mood on the model are described. Applications of this research area to the understanding of treatment preferences and adherence to treatment in mood disorders are discussed.

Background: Suicide rates amongst schizophrenic patients are high. There are disadvantages in investigating successfully completed suicides which make suicidal ideation and previous attempts important proxy measures of suicidal risk. The aim of this study was to investigate factors associated with these risk measures., Method: Fifty-nine patients suffering recent onset schizophrenia were assessed for suicidal ideation and history, and a range of demographic, clinical, social (including relatives' Expressed Emotion) and self-esteem measures. Univariate comparisons were made between those with and without suicide ideation and previous attempts. Path analysis was conducted to identify factors directly or indirectly associated with a composite scale of risk (low, medium or high)., Results: Approximately 25% of the sample reported a current desire to kill themselves and 47% had made one or more previous attempts. There were numerous significant univariate differences between those with or without ideation or history. Path analysis indicated that greater hopelessness (OR 1.22) and longer duration of illness (OR 1.13) increased risk. Hopelessness was associated with higher negative self-evaluation and social isolation. Negative self-evaluation was associated with more relatives' criticism which was associated with more negative symptoms. Being a male, unmarried and unemployed were all significantly associated with an increase in negative symptoms. Social isolation was associated with being unemployed, older, more positive symptoms and longer illness duration. Duration of illness was not itself predicted by any other variables., Conclusion: Non-fatal suicide ideation and behaviour are significantly associated with an array of demographic, clinical, interpersonal and psychological factors. To reduce risk of suicide, these factors need to be assessed and methods developed to reduce their influence.

This review examines the contribution of an attribution-based framework to our understanding of both expressed emotion (EE) and the process of patient relapse. It considers all published studies that have assessed the attributions of high- and low-EE relatives and carers. Across these studies, a great deal of consistency is apparent. Critical relatives are more likely to hold patients responsible for their difficulties. On the other hand, attributions made by emotionally overinvolved relatives are similar to the attributions made by those who are low EE. In reviewing the association between attributions and patient relapse, it is concluded that carers' beliefs may play a role in the relapse process in a variety of ways. These include mediating controlling behavior, which may serve to increase patient stress or decrease patients' sense of self-worth. A major limitation of research in this area is the cross-sectional and correlational nature of the data. This makes it impossible to draw conclusions about directions of effect in the association of EE and attributions. Nonetheless, an argument can be made for the development and evaluation of interventions designed to help relatives adopt less blaming and more flexible beliefs about the nature of patients' problems. Particularly helpful in this regard may be interventions that use verbal and behavioral reattribution techniques similar to those described in the cognitive behavioral treatment of emotional disorders.

Background: Comorbid substance misuse in people with schizophrenia is associated with poor clinical and social outcomes. There are few studies of psychological treatments for this population and little long-term follow-up of their benefits., Aims: To investigate symptom, substance use, functioning and health economy outcomes for patients with schizophrenia and their carers 18 months after a cognitive-behavioural treatment (CBT) programme., Method: Patients with dual diagnosis from a randomised controlled trial of motivational intervention, individual CBT and family intervention were assessed on multiple outcomes at 18-month follow-up. Carers were assessed on symptom, functioning and needs over 12 months. Health economy data were collected over 18 months., Results: There were significant improvements in patient functioning compared with routine care over 18 months. No significant differences between treatment groups were found in carer or cost outcomes., Conclusions: The treatment programme was superior to routine care on outcomes relating to illness and service use, and the cost was comparable to the control treatment.

Background: Despite the frequently reported association between maternal depression and childhood psychopathological disorder, few studies have attempted to intervene with both conditions., Aims: To evaluate the effect of group cognitive-behavioural therapy (CBT) on child behaviour problems and maternal depression in a group of women with young children., Method: An assessor-masked, randomised placebo-controlled trial compared three treatments: CBT for depression and parenting skills enhancement; a mothers' support group; and no intervention. An epidemiological (general population) sample was recruited., Results: Analysis showed no significant difference between the groups. Within-group comparison suggested that at the end of treatment and at 6-month and 12-month follow-up, child problems and maternal depression had improved significantly in the CBT group., Conclusions: There was no statistically significant difference between groups. Both contact interventions seemed to provide some benefits to mothers with depression, with a possibly improved outcome resulting from CBT for children with behavioural problems. The results must be treated with caution.

The ways in which people think about illness experiences have been associated with a variety of important behaviours and emotional responses in patients, carers, and professionals. Some of these responses have been shown to be related to outcome. Explicit models such as the self-regulation model (SRM) [Leventhal, H., Nerenz, D. R., & Steele, D. F. (1984). Illness representations and coping with health threats. In A. Baum & J. Singer (Eds.), A handbook of psychology and health. Hillsdale, NJ: Erlbaum, 219-252.] have been shown to be useful in highlighting key beliefs across a wide range of different physical illnesses. The specific beliefs about mental illness that have been assessed have been varied and largely without a common theoretical framework. This has resulted in a literature from which it is difficult to draw firm conclusions. The central aim of this paper is to assess the applicability of the SRM to mental illness. To this end, we review studies to date that have examined the beliefs that people with a mental illness have about their experiences. In addition, we review studies that have examined the beliefs of relatives of people with a mental illness and professionals who work with this population. We assess to what extent these studies are consistent with the SRM before suggesting ways in which the model could be further developed and tested. The SRM is presented as a useful framework for more advanced investigations into the function of beliefs about mental illness and how these can be modified in order to effect outcome. Developing psychological theories common to both physical and mental health may eventually result in an integrated approach in which mental illness becomes less stigmatised within the treatment setting.

Background: This was an initial study seeking to examine the relationship between Expressed Emotion (EE), spontaneous causal attributions and depression in mothers of children referred for problem behaviour., Method: Sixty-one mothers were interviewed using the Camberwell Family Interview (CFI). The CFI was coded for maternal EE and spontaneous causal attributions regarding the child's behaviour. Self-report measures of child problem behaviour and maternal depressive symptoms were also completed., Results: Consistent with previous research, high EE mothers, compared to low EE mothers, were more likely to make attributions thatjudged the cause of problem behaviour to be personal to and controllable by the child and also made more 'child-blaming' attributions than low EE mothers. Mothers' scores on the Beck Depression Inventory were found to be associated with 'child-blaming' attributions and higher levels of EE. Regression analyses did not support the hypothesised role of attributions as a mediator between depression and EE but did identify EE as a potential mediator in the relationship between maternal depressed mood and ratings of child problem behaviour., Conclusions: These results indicate the relevance of both EE and attributions in mothers of children with problem behaviour and suggest that maternal depressed mood is an important factor which is related to both of these.

Participants with schizophrenia (N = 59) were assessed on self-evaluation, symptomatology, and positive and negative affect (expressed emotion) from significant others. An interview-based measure of self-evaluation was used and two independent dimensions of self-esteem were derived: negative and positive evaluation of self. As predicted, negative self-evaluation was strongly associated with positive symptoms, a more critical attitude from family members was associated with greater negative self-evaluation, and analyses supported a model whereby the impact of criticism on patients' positive symptoms was mediated by its association with negative self-evaluation. The interview-based method of self-esteem assessment was found to be superior to the questionnaire because its predictive effects remained after depressed mood was accounted for.

Paley and Shapiro conclude in their review (Paley & Shapiro, 2002) that there is clear evidence that cognitive-behaviour therapy (CBT) results in clear clinical benefits for people with schizophrenia. They argue that this research could be informed by the wider psychotherapy literature, specifically the 'equivalence paradox' and 'investigator allegiance', and that psychodynamic treatments for schizophrenia should be investigated and evaluated. We argue that their review of the literature is incomplete. We conclude that there is little evidence to support the 'equivalence paradox' generally, and where it is suggested, as in depression, this is most likely an artefact. In schizophrenia, there is consistent evidence that supportive psychotherapy performs poorly in treating hallucinations. We argue for improved methodology in carrying out randomized controlled trials, which would minimize bias, such as from 'investigator allegiance'. We consider evaluation of psychodynamic psychotherapy to demonstrate equivalence to CBT as a low priority and unlikely ever to be attempted. We consider the research and clinical priorities to be the further developments of CBT and family intervention methods, which could have significant benefits for sufferers of schizophrenia and their carers.

Burden of care, expressed emotion (EE), causal attributions, and salivary cortisol were assessed in 100 carers of patients with Alzheimer's disease. Forty-one carers were rated high EE, which was associated with higher scores of carer distress and strain, and greater reports of noncognitive features in the patient, but not with cortisol levels. High EE carers made more attributions personal to, and controllable by, the patient for negative events. Critical carers made more attributions of the patient's behavior that was idiosyncratic. Warmth toward the patient was associated with the opposite of this pattern. Overinvolved carers made attributions of the patient's behavior to causes external to the patient and internal to themselves. Cortisol levels were associated with self-reports of strain and distress.

Background: Although carers' reactions to schizophrenic illness in a close family member may have important implications for the patient and for themselves, little is known of factors that influence the way carers respond. In the area of physical health problems, people's models of their illness or illness representations have been found to be related to the ways they react and cope with their illness. This study examines the use of a modified form of the Illness Perception Questionnaire (IPQ) to investigate illness models in a sample of carers of schizophrenia patients., Methods: Forty-seven carers participated. The psychometric properties of the modified IPQ were examined, and a number of carer and patient outcomes were investigated in relation to carer scores on the illness identity, consequences, control-cure and timeline subscales of the modified IPQ. These outcomes included measures of carer distress and burden, expressed emotion dimensions, and patient functioning., Results: The modified IPQ was found to be a reliable measure of carers' perceptions of schizophrenia. Carer functioning, the patient-carer relationship and patient illness characteristics were associated with different dimensions of illness perceptions., Conclusions: The findings support the proposal that carer cognitive representations of the illness may have important implications for both carer and patient outcomes in schizophrenia.

Objective: Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders., Method: The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention., Results: The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up., Conclusions: These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.

The authors used a randomized trial to compare cognitive-behavioral therapy (CBT) and supportive counseling (SC) in the treatment of anxiety symptoms in older adults who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.: American Psychiatric Association, 1994) criteria for anxiety disorders. Both conditions had a 6-week baseline no-treatment phase. Treatment was delivered primarily in patients' own homes and in an individual format. Outcomes were assessed at posttreatment and at 3-, 6-, and 12-month follow-ups. There was no spontaneous improvement during the baseline phase. Both groups showed improvement on anxiety measures following treatment, with a better outcome for the CBT group on self-rating of anxiety and depression. Over the follow-up period, the CBT group maintained improvement and had significantly greater improvement than the SC group on anxiety and 1 depression measure. Treatment response for anxiety was also superior for the CBT group, although there was no difference between groups in endstate functioning.

A randomized trial was performed in which imaginal exposure (IE) and cognitive therapy (CT) were compared in the treatment of chronic posttraumatic stress disorder (PTSD). Patients who continued to meet PTSD caseness at the end of a 4-week symptom-monitoring baseline period (n = 72) were randomly allocated to either IE or CT. There was a significant improvement in all measures over treatment and at follow-up, although there were no significant differences between the 2 treatments at any assessment. A significantly greater number of patients who showed worsening over treatment received IE, although this effect was not found at follow-up. Patients who worsened showed a greater tendency to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the therapist. It was concluded that either exposure or a challenge to cognition can result in symptom reduction, although neither resulted in complete improvement.

Objectives: This study examines the spontaneous causal attributions made by mothers about their preschool children's problem behaviour and investigates the relationship between causal attributions and maternal depression., Design: Two groups of mothers were compared, a depressed and a non-depressed group, while all women included identified their preschool child as having some problem behaviours. There were 25 women in each group., Methods: The spontaneous attributions of mothers were assessed from audiotaped interviews using an adaptation of the Leeds Attributional Coding System for the extraction and analysis of attributional statements., Results: Depressed mothers made more spontaneous causal attributions about their children's problem behaviour than did the non-depressed group; and the depressed group perceived these causes as being more stable, more controllable and more personal to the child than their non-depressed counterparts. There was also evidence that depressed mothers made more internal attributions about themselves as the cause of their children's problem behaviour than non-depressed mothers. The study indicates that the personal-to-child dimension is the attributional variable most strongly associated with depression., Conclusions: This study provides evidence that depressed mothers have attributional biases when compared to non-depressed mothers. The authors suggest that their attributions may mediate coping responses and hence may influence parenting behaviour. The clinical and research implications of the findings are discussed.

Fifty-six patients who were hospitalised for a schizophrenic episode were followed up for nine months after discharge. The Psychiatric Assessment Scale (PAS, Krawiecka et al., 1977) was administered at monthly intervals during this period. Twenty-three patients relapsed of which data were available for sixteen. In these sixteen patients who relapsed comparisons were made of the PAS symptoms between the month prior to relapse and the month preceding this. Sixteen patients who did not relapse were randomly matched with the relapsing patients and an index point comparable in time to relapse onset in the matched relapsed patient was identified. Comparisons were made on the PAS symptoms using a repeated measures ANOVA to compare relapsers and non relapsers on the month prior to relapse and the month which preceded this. Discriminant function analysis was used to predict relapse by analysis of those PAS symptoms which showed an increase in the month before relapse. This suggested that the measures of depression and hallucinations significantly increased in the month prior to relapse compared to the preceding month in relapsers but not non-relapsers. The results of this study closely agree with previous published results even though there were some differences between studies in the patient samples.

Studies that have attempted to reduce schizophrenic relapse by the use of family interventions are described. Results from studies that implemented behavioral family interventions with patients who were identified as high risk because of the expressed emotion status of their relatives have demonstrated that relapse rates can be significantly reduced over a 2-year postdischarge follow-up period. A number of ongoing studies, especially those that are investigating the interaction of family interventions and different medication regimes, are also discussed. Areas for further investigation are identified, for example: the use of multiple outcome measures, the use of single-case studies and the development of ideographic assessment measures, the interaction of biological and environmental influences, the alleviation of the burden of care, the involvement of the consumer in services, the development of behavioral formulations and analysis of family engagement and compliance, staff training in intervention methods, and the translation of research results into clinical practice.

The relationship between the social functioning of schizophrenic patients and the EE levels of their relatives is examined. Patients living with a high EE relative function significantly worse than those living with low EE relatives. This appeared to be due to a poorer social functioning in patients who lived with hostile relatives. Patients who participated in a nine month behavioural family intervention showed greater improvements in social functioning than control groups. The improvements could not be explained as being due to medication since high neuroleptic dosage over nine months was associated with poorer social functioning.

The association between electrodermal arousal and social functioning was investigated. It was predicted that poor social functioning would be associated with higher levels of arousal. Patients were tested for a 15 minute period without their relative and for 15 minutes with their relative present. The prediction received some support from the results in that three subscales of the Social Adjustment Scale (SAS) showed a significant association between lower social functioning and higher arousal. This association showed a trend towards significance in the SAS Overall Score. When patients with high EE and low EE relatives were analysed separately, significant associations were only found for the high EE group. These results were interpreted as giving some support to the hypothesis that patients who are functioning poorly have relatively stable high levels of arousal.

Schizophrenic patients were recruited into a trial of a prophylactic behavioural intervention with families. Families with at least one high Expressed Emotion (EE) relative were randomly allocated to one of four intervention groups: Behavioural Intervention Enactive; Behavioural Intervention Symbolic; Education Only; Routine Treatment. Patients from low-EE families were randomly allocated to two groups: Education Only or Routine Treatment. Relapse rates over nine months after discharge were significantly lower for patients in the two Behavioural Intervention, compared with Education Only and Routine Treatment groups. There was little difference between the two low-EE groups. Patients returning to high-EE relatives showed significantly higher relapse rates than those returning to low-EE relatives, in groups not receiving active intervention. Changes from high to low EE occurred in the Behavioural Intervention groups, and similar although less extensive changes occurred in the Education Only and Routine Treatment groups. Changes in criticism and marked emotional over-involvement (EOI) occurred generally in high-EE groups but were larger in magnitude in the Enactive and Symbolic groups. Reduction of hostility only occurred in the Behavioural Intervention groups. These results give partial support for the causal role of EE in relapse. There were no significant differences between the groups with respect to contact with the psychiatric services or medication.

The measure of expressed emotion (EE) of the relative has been found to be an important predictor of schizophrenic relapse. Electrodermal measures were recorded when the schizophrenic patient was talking to an experimenter, and when the patient was talking to a relative. Although there were no differences during the relative-absent period, patients with a high-EE relative present exhibited significantly higher frequencies of non-specific skin-conductance responses (NS-SCRs) than patients with a low-EE relative present. Patients show a significant decrease in NS-SCRs on the entry of low-EE, but not high-EE relatives. Patients with high-EE relatives show overall higher levels of skin-conductance levels (SCLs) than patients with low-EE relatives. Although patients with high-EE relatives rate themselves significantly more tense and anxious on self-rating scales, there are no significant correlations between self-ratings and electrodermal measures. The use of electrodermal reactivity as an assessment measure of relapse risk is discussed.

Previous research has demonstrated a different psychophysiological response of schizophrenic patients depending on whether their key relative was rated high or low on Expressed Emotion (EE). A case assessment is described in which a young man suffering from schizophrenia, who lived with both a high EE and a low EE parent, was tested psychophysiologically in their presence using an ABAC design. The patient demonstrated a significantly higher amount of spontaneous activity in skin conductance level when the high EE parent was present. The high EE parent also demonstrated a greater perceived inability to cope, and a higher level of personal distress.

An instrument for assessing and evaluating what relatives know about schizophrenia was evaluated as both a pre- and a post-test for an educational programme. The Knowledge About Schizophrenia Interview (KASI) places emphasis on the functional value of the reported knowledge rather than on the recall of information; it is quick, easy to administer, can be rated reliably, and has face-validity for the relative. The educational programme increased scores from pre-test to a post-test one week after the programme. Relatives with high criticism ratings on the Camberwell Family Interview had lower scores at both tests. Relatives of less chronic patients showed lower scores at pre-test and acquired significantly more information from the programme, while relatives of more chronic patients were less influenced by the information sessions.

There has recently been an increased interest in providing relatives of schizophrenic patients with information about the illness and how to manage the patient at home, due partly to the development of psychosocial intervention programmes (which frequently include an educational component) and a consumer demand for such information in an era of community care. Studies which describe the effects of such educational programmes are reviewed, and two different models of information acquisition are contrasted. These models have different implications, in terms of outcome measures, on how educational programmes should be evaluated. Guidelines are offered for practitioners wishing to give information to relatives.

Recent interest in the way social factors influence the course of schizophrenia has led to attempts to monitor and manipulate these factors. The work on the Expressed Emotion of the relative has been especially influential in this area. A number of studies have now been conducted in which a psychosocial intervention has been employed in an attempt to prevent relapse after discharge from hospital. These studies are reviewed with an emphasis on their methodological adequacy and on the nature of the intervention used. Recent studies have demonstrated a positive result for psychosocial interventions used in combination with neuroleptic medication. However, analysis of these studies does not allow us to conclude that we can identify the 'active ingredients' in these psychosocial treatment regimes. Although there is cause for optimism, further investigation is required.

The relapse and readmission rates of schizophrenic patients who participated in a controlled trial of a nine-month behavioural family intervention trial based on the EE status of their relatives are presented at two years. The patients who received the behavioural family intervention had lower rates of relapse and readmission than patients from high-EE homes who had received a short educational programme or routine treatment. The relapse rate of the behavioural family intervention group (33%) was the same as that of the low-EE group (33%), and significantly lower than that of the non-intervention high-EE group (59%).

Electrodermal activity and self-report of affect were recorded from schizophrenic patients with their relative absent and present, at index admission and on two subsequent occasions after discharge. It was hypothesised that it would be possible to discriminate at index admission patients who relapsed in the subsequent 2-year period from those who remained well, and that these differences would be stable over time and independent of illness episode. The former hypothesis was supported in part, but not the second. The results did not support electrodermal hyperactivity as a stable, enduring vulnerability marker.