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Background Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem – the self-evaluation of appearance – in relation to symptom and psychological correlates in patients with current persecutory delusions. Methods One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population. Results Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = −0.55, p < 0.001), negative self-beliefs (r = −0.52, p < 0.001), paranoia (r = −0.25, p = 0.006) and hallucinations (r = −0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001). Conclusions Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD.A qualitative study using constructivist grounded theory methodology.We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space.Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.

Live performances are immersive shared experiences, traditionally taking place in designated, carefully designed physical spaces such as theatres or concert halls. As it is becoming increasingly common for audiences to experience this type of content remotely using digital technology, it is crucial to reflect on the design of digital experiences and the technology used to deliver them. This research is guided by the question: How can the design of streaming technologies support artists in creating immersive and engaging audience experiences? A series of audience studies, which took place as cultural organisations were forced to adapt and deliver their content remotely due to the COVID19 global pandemic, highlighted problems with existing streaming solutions and informed a set of design recommendations for audience experience and research.

Anticipation of pleasure – a key aspect of hedonic experience - is a motivating factor for engaging in activities. Low levels of anticipatory pleasure and activity are found in individuals with psychosis. Cognitive factors (e.g., working memory and IQ) have been a focus of explanation for anticipation of pleasure in psychosis. However, cognitive factors do not fully account for such difficulties. It is plausible that emotional factors (e.g., depression, self-beliefs) also contribute. We examined anticipatory pleasure in relation to cognitive and emotional processes in patients with current psychosis. 128 patients with persecutory delusions in the context of non-affective psychosis completed assessments of anticipatory pleasure, cognitive functioning, emotional processes, and activity. Lower anticipatory pleasure was significantly associated with depression, insomnia, negative-self beliefs, suicidal ideation, poorer psychological wellbeing, and paranoia-related avoidance. There were no significant associations with working memory, physical activity, or meaningful activity. Emotional factors may play a more significant role than cognitive difficulties in the experience of anhedonia in psychosis. However, the cross-sectional design precludes causal inferences. Future research should examine whether, for example, improving self-concept or reducing paranoia-related avoidance leads to improvement in anticipatory pleasure in patients with psychosis.

Background There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. Aims To systematically assess the occurrence of voice content regarding appearance and identify correlates. Method Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. Results Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was ‘the voices tell me that I am ugly’ (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was ‘I look as nice as other people’ (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. Conclusions Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect – and subsequently reinforce – negative beliefs about one's appearance, low self-esteem, worry and paranoia. Declaration of interest None.

Background The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. Aims To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset. Method A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. Results Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. Conclusions Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. Declaration of interest None.

Background To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions. Methods 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed. Results The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. Conclusions Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

ObjectivesAnxiety and depression are common and deleterious comorbidities in people living with dementia (PLWD). Cognitive behavioural therapy (CBT) is one of the few promising treatments; however, it is unclear whether PLWD have the necessary prerequisites to engage in this. Having an understanding of cognitive mediation, that a thought mediates the relationship between an antecedent event and its emotional consequence, is key for engaging with CBT and is also a critical component of emotion regulation. There are no measures of this construct validated for PLWD. This study aims to adapt and validate an existing measure for this population. A secondary aim is to assess its applicability in older adults (OA) without a recognised neurocognitive impairment.MethodsA measure of cognitive mediation was adapted via expert and service user consultation for use in PLWD. A total of 102 PLWD and 77 OA without neurocognitive impairments completed the adapted measure along with two measures of emotion recognition and reasoning. Factor structure was examined separately in both samples, and the measure reduced, with convergent validity assessed.ResultsA final measure of 10 items (named the CM‐Dem) was subject to factor analysis yielding a single factor solution. The measure showed good psychometric properties in PLWD, including good model fit, high internal consistency, inter‐rater reliability, and moderate convergent validity with related constructs. In contrast, poor validity was found in OA, especially a lack of convergent validity.ConclusionsThe CM‐Dem has clinical and research utility as a measure of cognitive mediation in PLWD, but less so in OA.

The ongoing interdisciplinary research between the fields of theatre and neuroscience provides a fascinating and fruitful area of study and experimentation for artists and scientists alike; here Clelia Falletti, Gabriele Sofia and Victor Jacono have collected contributions with an international range, from neuroscientists, theatre scholars and practitioners, to give as full a picture as possible of a realm of exploration which is still undergoing rapid change and development. Falletti, Sofia and Jacono are theatre scholars who share a two-fold interest in neuroscience: firstly, this interest stems from their consideration that the discipline of theatre pertains 'to the vast territory of the "human sciences"' (p. xv), and secondly, it relates to their belief, which I share, that theatre scholars should not limit themselves to literary interpretations, but take an interdisciplinary perspective drawing on humanities, sciences and practice-based approaches in order to fully understand the complexity of the relationship between actor and audience.

Background: Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences. A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences. However, the effects of psychological intervention for improving sleep have not been evaluated in young people at ultra-high risk of psychosis. Improving sleep might prevent later transition to a mental health disorder. Aims: To assess the feasibility and acceptability of an intervention targeting sleep disturbance in young people at ultra-high risk of psychosis. Method: Patients were sought from NHS mental health services. Twelve young people at ultra-high risk of psychosis with sleep problems were offered an eight-session adapted CBT intervention for sleep problems. The core treatment techniques were stimulus control, circadian realignment, and regulating day-time activity. Participants were assessed before and after treatment and at a one month follow-up. Results: All eligible patients referred to the study agreed to take part. Eleven patients completed the intervention, and one patient withdrew after two sessions. Of those who completed treatment, the attendance rate was 89% and an average of 7.6 sessions (SD = 0.5) were attended. There were large effect size improvements in sleep. Post-treatment, six patients fell below the recommended cut-off for clinical insomnia. There were also improvements in negative affect and psychotic experiences. Conclusion: This uncontrolled feasibility study indicates that treating sleep problems in young people at ultra-high of psychosis is feasible, acceptable, and may be associated with clinical benefits.

The present research explored the ability of children with ADHD to distinguish between sarcasm and sincerity. Twenty-two children with a clinical diagnosis of ADHD were compared with 22 age and verbal IQ matched typically developing children using the Social Inference–Minimal Test from The Awareness of Social Inference Test (TASIT, McDonald, Flanagan, & Rollins, 2002). This test assesses an individual’s ability to interpret naturalistic social interactions containing sincerity, simple sarcasm and paradoxical sarcasm. Children with ADHD demonstrated specific deficits in comprehending paradoxical sarcasm and they performed significantly less accurately than the typically developing children. While there were no significant differences between the children with ADHD and the typically developing children in their ability to comprehend sarcasm based on the speaker’s intentions and beliefs, the children with ADHD were found to be significantly less accurate when basing their decision on the feelings of the speaker, but also on what the speaker had said. Results are discussed in light of difficulties in their understanding of complex cues of social interactions, and non-literal language being symptomatic of children with a clinical diagnosis of ADHD. The importance of pragmatic language skills in their ability to detect social and emotional information is highlighted.