Intervening early in the course of psychotic illness (e.g. schizophrenia) may significantly improve prospects for the recovery, both in medical and psychosocial terms, of the individuals who experience these conditions. Engaging such individuals in care, however, remains a challenge. One barrier to engagement is lack of insight, or the low illness awareness that is considered to be a typical characteristic of people who experience psychotic illnesses, particularly in their early phases. The dominant view of this phenomenon is that it is primarily related to the illness itself and thus is biologically based. There is reason to believe, however, that understanding the psychosis experience is also an interpretive process, and that the meaning of this experience for the individual arises out of dialogue between the person, mental health professionals and significant others. There is also reason to believe that the relationship between insight and recovery may not be as straightforward as presumed. While the dominant view sees insight as a crucial condition for recovery, emerging evidence suggests that insight once gained may lead to depression and demoralization. Insight thus may be understood as an interpretive, dialogical process that is fundamentally narrative in nature, the consequences of which may be divergent. Using qualitative methods (constructivist grounded theory complemented by narrative analysis), the present study sought to understand the process by which insight developed in early psychosis, and sought to explore the relationship between insight and the early stages of illness management and recovery, as reflected by the written and oral accounts of twelve individuals who were within the first three years of illness. Overall, the results suggest that insight development in early psychosis can be conceptualized as the process of coming to an acceptable, adaptive explanation. More specifically, the results first of all suggest that insight development involves finding or negotiating an account of illness that fits or can be accommodated with the individual’s own story of the psychosis experience. The process also involves finding an account of illness and its treatment that can be envisioned as a helpful rather than disruptive aspect of the individual’s future biography.

The discovery that it is possible to identify an individual before the onset of first episode psychosis and that treatment may prevent or delay onset have led to a proliferation of early intervention clinics designed to intervene before symptoms of psychosis have fully appeared. Early intervention has generated considerable debate, given the risks associated with intervening and that the majority of those identified will never develop full-blown psychosis. Despite potential stigmatizing effects, little is known about young people’s views regarding the favourable and/or adverse consequences of early intervention. This research examines the experiences and meaning of illness in young people identified as being at ultra high risk for psychosis and participating in a psychological intervention program. Specifically, the study uses photo elicitation to explore how participants construct and interpret their experiences, and the impact an at risk label has on their sense of self, identity, and social relationships. Five young people were invited to photograph their daily experiences at home, at school, and in the community. The participants and I then analyzed the photographs together in a photo elicitation interview. I further analyzed the visual and textual data from an interactionist perspective, exploring the concept of stigma and its relationship to young people’s experiences. Visual and narrative data revealed that young people reject their at risk status and redefine their experiences to fit with more acceptable and familiar notions of health. Participants are conscious of the stigma associated with psychosis and actively undertake strategies of resistance to avoid stigmatization and uphold a normal self conception and social impression. Photo elicitation provided insight and understanding into the experiences of young people at risk for psychosis that were not available through more traditional methods. The results from this study support the call for a reconsideration of the psychosis risk paradigm. There is a need to increase awareness about the power of diagnostic information and the labeling process. Non-specialized settings such as schools and community health centres may offer more appropriate environments for mental health monitoring and intervention.

The discovery that it is possible to identify an individual before the onset of first episode psychosis and that treatment may prevent or delay onset have led to a proliferation of early intervention clinics designed to intervene before symptoms of psychosis have fully appeared. Early intervention has generated considerable debate, given the risks associated with intervening and that the majority of those identified will never develop full-blown psychosis. Despite potential stigmatizing effects, little is known about young people’s views regarding the favourable and/or adverse consequences of early intervention. This research examines the experiences and meaning of illness in young people identified as being at ultra high risk for psychosis and participating in a psychological intervention program. Specifically, the study uses photo elicitation to explore how participants construct and interpret their experiences, and the impact an at risk label has on their sense of self, identity, and social relationships. Five young people were invited to photograph their daily experiences at home, at school, and in the community. The participants and I then analyzed the photographs together in a photo elicitation interview. I further analyzed the visual and textual data from an interactionist perspective, exploring the concept of stigma and its relationship to young people’s experiences. Visual and narrative data revealed that young people reject their at risk status and redefine their experiences to fit with more acceptable and familiar notions of health. Participants are conscious of the stigma associated with psychosis and actively undertake strategies of resistance to avoid stigmatization and uphold a normal self conception and social impression. Photo elicitation provided insight and understanding into the experiences of young people at risk for psychosis that were not available through more traditional methods. The results from this study support the call for a reconsideration of the psychosis risk paradigm. There is a need to increase awareness about the power of diagnostic information and the labeling process. Non-specialized settings such as schools and community health centres may offer more appropriate environments for mental health monitoring and intervention.

Intervening early in the course of psychotic illness (e.g. schizophrenia) may significantly improve prospects for the recovery, both in medical and psychosocial terms, of the individuals who experience these conditions. Engaging such individuals in care, however, remains a challenge. One barrier to engagement is lack of insight, or the low illness awareness that is considered to be a typical characteristic of people who experience psychotic illnesses, particularly in their early phases. The dominant view of this phenomenon is that it is primarily related to the illness itself and thus is biologically based. There is reason to believe, however, that understanding the psychosis experience is also an interpretive process, and that the meaning of this experience for the individual arises out of dialogue between the person, mental health professionals and significant others. There is also reason to believe that the relationship between insight and recovery may not be as straightforward as presumed. While the dominant view sees insight as a crucial condition for recovery, emerging evidence suggests that insight once gained may lead to depression and demoralization. Insight thus may be understood as an interpretive, dialogical process that is fundamentally narrative in nature, the consequences of which may be divergent. Using qualitative methods (constructivist grounded theory complemented by narrative analysis), the present study sought to understand the process by which insight developed in early psychosis, and sought to explore the relationship between insight and the early stages of illness management and recovery, as reflected by the written and oral accounts of twelve individuals who were within the first three years of illness. Overall, the results suggest that insight development in early psychosis can be conceptualized as the process of coming to an acceptable, adaptive explanation. More specifically, the results first of all suggest that insight development involves finding or negotiating an account of illness that fits or can be accommodated with the individual’s own story of the psychosis experience. The process also involves finding an account of illness and its treatment that can be envisioned as a helpful rather than disruptive aspect of the individual’s future biography.

Intervening early in the course of psychotic illness (e.g. schizophrenia) may significantly improve prospects for the recovery, both in medical and psychosocial terms, of the individuals who experience these conditions. Engaging such individuals in care, however, remains a challenge. One barrier to engagement is lack of insight, or the low illness awareness that is considered to be a typical characteristic of people who experience psychotic illnesses, particularly in their early phases. The dominant view of this phenomenon is that it is primarily related to the illness itself and thus is biologically based. There is reason to believe, however, that understanding the psychosis experience is also an interpretive process, and that the meaning of this experience for the individual arises out of dialogue between the person, mental health professionals and significant others. There is also reason to believe that the relationship between insight and recovery may not be as straightforward as presumed. While the dominant view sees insight as a crucial condition for recovery, emerging evidence suggests that insight once gained may lead to depression and demoralization. Insight thus may be understood as an interpretive, dialogical process that is fundamentally narrative in nature, the consequences of which may be divergent. Using qualitative methods (constructivist grounded theory complemented by narrative analysis), the present study sought to understand the process by which insight developed in early psychosis, and sought to explore the relationship between insight and the early stages of illness management and recovery, as reflected by the written and oral accounts of twelve individuals who were within the first three years of illness. Overall, the results suggest that insight development in early psychosis can be conceptualized as the process of coming to an acceptable, adaptive explanation. More specifically, the results first of all suggest that insight development involves finding or negotiating an account of illness that fits or can be accommodated with the individual’s own story of the psychosis experience. The process also involves finding an account of illness and its treatment that can be envisioned as a helpful rather than disruptive aspect of the individual’s future biography. / Graduate and Postdoctoral Studies / Graduate

Negative symptoms emerge early in the course of psychosis and are one of the best indicators of clinical outcomes; thus, the accurate, identification of these symptoms is paramount to early intervention efforts. Negative symptoms are typically assessed via self-report questionnaire or interviewer rated semi-structured interviews. However, the degree of concordance between self and interviewer report has been demonstrated to be low, approximately 50%. Therefore, it is important to identify the degree of discordance within each negative symptom domain (anhedonia, alogia, blunted affect, asociality, and amotivation) as well as to identify potential contributors to this lack of concordance. The present study examined each of the five negative symptom domains in regard to self and interviewer rating concordance in a sample (N = 70) that consists of a full range of negative symptoms and psychotic-like experiences (PLEs). Results indicated that self and interviewer report of negative symptom domains were inconsistently correlated. Dimensionally, asociality and avolition were the most concordant domains and alogia and anhedonia were more discordant. Although self and interviewer report scores of blunted affect did not significantly differ, each score may be capturing separate aspects of this experience. Participant drug use frequency was found to significantly impact rater responding on blunted affect, participant emotional clarity significantly impacted rater responding on alogia, participant clinical high risk (CHR) status impacted rater responding on consummatory anhedonia, and participant anxiety impacted rater responding on anticipatory anhedonia. This study identifies factors that underlie negative symptom rating discordance, which may help improve treatment intervention for those experiencing this critical phase of the disorder, and improve our ability to accurately monitor these symptoms in individuals with psychosis spectrum disorders. / Psychology

Indiana University-Purdue University Indianapolis (IUPUI) / Aim: Early psychosis has been identified as period during which rapid identification and treatment can lead to significant improvement in clinical and functional outcomes. Despite increased research, no studies have examined early psychosis in Veteran populations. It is unknown whether Veterans differ from non-Veterans at this stage of the disorder, and if the treatments offered to non-Veterans are appropriate to implement in Veteran Affairs Medical Centers. Given differences that appear between Veterans and non-Veterans in chronic psychosis, additional work is necessary to determine the best way to approach specialized treatment for Veterans experiencing early psychosis. Methods: The current study is a secondary analysis of assessment batteries collected at a community-based early intervention program and at a local Veteran Affairs Medical Center. Assessment results were compared for Veterans’ and non-Veterans’ background characteristics, symptoms, and neurocognitive deficits. Results: Significant differences were found between the two samples on age of illness onset, marital status, education level, positive symptoms of psychosis, and neurocognitive functioning. Logistic regression analyses identified age of onset as a potential underlying factor. Conclusions: While some aspects of illness presentation appear similar between Veterans and non-Veterans, there are important differences between these populations. Pre-existing treatment interventions, such as Social Skills Training, cognitive remediation approaches and cognitive behavior therapy for psychosis may be appropriate to implement with Veterans. Others– such as family based interventions or supported employment services – may need to be tailored to maximize the benefit for Veterans.

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Cette thèse est divisée en trois parties principales, ayant toutes trait à la régulation des émotions ou à l'efficacité des interventions issues de la troisième vague des thérapies cognitives comportementales, en particulier chez les personnes ayant des symptômes psychotiques. La thèse est composée d'un chapitre de livre rédigé en francais, de quatre articles rédigés en anglais (introduction, deux méta-analyses et une étude pilote) et d’une discussion générale rédigée en anglais. L'introduction, déjà publiée sous le format d’un chapitre de livre (et d’un article) constitue un examen exhaustif de la littérature portant sur la régulation des émotions dans la schizophrénie et dans les autres troubles psychotiques. Les individus présentant une schizophrénie présentent des dérégulations, indépendantes l’une de l’autre, dans les trois domaines distincts suivants: l’expression des émotions, le traitement des emotions, et l’expérience émotionnelle. Cette première partie de la thèse recommande fortement l'intégration des stratégies de régulation des émotions, notamment celles de la troisième vague des thérapies cognitives comportementales telles que la pleine conscience, l'acceptation et la compassion, dans le traitement des personnes souffrant de psychose. Dans la deuxième partie de la thèse, deux méta-analyses examinant l'efficacité des stratégies de la troisième vague des traitements cognitifs comportementaux dans la régulation des émotions sont présentées. La première méta-analyse vise à examiner l'efficacité de la thérapie basée sur la pleine conscience pour tous les troubles psychologiques ainsi que pour les conditions médicales. La deuxième méta-analyse porte plus spécifiquement sur l'efficacité des stratégies de la troisième vague pour la psychose. Les résultats des deux méta-analyses démontrent des tailles d'effet entre modérées et larges, avec un effet plus marqué sur les symptômes affectifs, notamment l'anxiété, la dépression et la détresse. En outre, les stratégies étudiées (la pleine conscience, l'acceptation et la compassion) sont des fortes modératrices positives de l'efficacité des traitements. Ces résultats suggèrent que ces stratégies sont efficaces dans la régulation des émotions, du moins lorsqu'elles sont mesurées au sein de grands bassins de participants, y compris les personnes souffrant de psychose. La troisième partie de la thèse implique le développement et la validation préliminaire d'une nouvelle intervention de groupe pour des individus en début de psychose à l'aide d'une combinaison de stratégies d'acceptation, de compassion et de la pleine conscience. Douze individus ont participé à cette étude pilote. Les résultats démontrent la faisabilité et l'acceptabilité du traitement. Des améliorations significatives dans la régulation des émotions et dans les symptômes affectifs sont observées, et sont potentiellement liées à l'intervention. Globalement, la thèse offre un soutien empirique du rôle de la régulation émotionnelle dans le traitement des personnes atteintes de troubles psychotiques. Plus de recherches sont nécessaires pour valider l'efficacité du nouveau traitement. / This thesis is divided into three main parts, all pertaining to emotional regulation or to the efficacy of third wave cognitive behavioral treatments particularly in individuals having experienced psychotic symptoms. The thesis consists of one book chapter published in French, four articles published in English (i.e., introduction, deux meta-analyses and a clinical pilot study), and a general discussion. The introduction already published as an article (and as book chapter) involves a comprehensive review of the literature on emotion regulation in schizophrenia and other psychotic disorders. Individuals with schizophrenia and other psychotic disorders tend to show emotional dysregulations at the experiential, expressive, and processing levels. This first part strongly recommends integrating emotion regulation strategies, namely third wave cognitive behavioral strategies such as mindfulness, acceptance and compassion in the treatment of individuals with psychosis. In the second part of the thesis, two meta-analyses reviewing the effectiveness of these third wave cognitive behavioral strategies in regulating emotions are presented. The first investigates the effectiveness of mindfulness-based therapy across all psychological disorders and medical conditions. The second meta-analysis focuses more specifically on the effectiveness of mindfulness interventions for psychosis. The results from both meta-analyses show moderate to large effect sizes, with higher ones for affective symptoms, especially anxiety, depression and distress. Furthermore, the investigated strategies (i.e., mindfulness, acceptance and compassion) are strong positive moderators of the treatments’ effectiveness. These results suggest that these strategies are effective in regulating emotions, at least when measured in large pools of participants, including individuals with psychosis. The third part of the thesis involves the development and preliminary validation of a new group intervention for early psychosis using a combination of acceptance, compassion and mindfulness. Twelve individuals participated in this pilot study. Results indicated the feasibility and acceptability of the treatment, with improvements in emotion regulation and affective symptoms observed, and potentially linked to the intervention. The thesis overall empirically supports the important role of emotional regulation in treating individuals with psychosis. More research is warranted pertaining to the effectiveness of the new developed treatment.