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The Cognitive Model of Voices in Psychosis: an Ecological Validation of the Social Ranking Perspective

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The Cognitive Model of Voices in Psychosis: an Ecological Validation of the Social Ranking Perspective View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Birmingham Research Archive, E-theses Repository THE COGNITIVE MODEL OF VOICES IN PSYCHOSIS: AN ECOLOGICAL VALIDATION OF THE SOCIAL RANKING PERSPECTIVE Thesis submitted to the University of Birmingham for the Degree of Doctor of Philosophy BY LIAM ANDREW GILLIES School of Psychology University of Birmingham United Kingdom B15 2TT January 2012 University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. Abstract Influential cognitive models of distressing symptoms in psychosis have been informed by evolutionary-based Social Ranking Theory. Social ranking theory views the formation and maintenance of symptoms as being significantly defined by ‘social mentalities’ that are operational during everyday social processes, such as when we compare ourselves to others. One framework of psychotic symptoms which has incorporated this social evolutionary perspective is the cognitive model of voices. The introduction of this thesis gives an overview of the nature of psychosis, and argues affective dysfunction and emotional factors are now included as a dimension of psychosis. It also draws attention to auditory hallucinations and persecutory beliefs and models of these symptoms are outlined. The cognitive model of voices is described and beliefs about the nature of voices, including their supposed omnipotence and power, are argued to be the critical determinants of affective and behavioural outcomes in voice hearers. For persecutory delusions, the deservedness of persecution is highlighted as a pertinent construct. The evolutionary basis of social defeat and rank is also outlined. Particular attention is drawn to the Involuntary Defeat Strategy (IDS) which is argued to automatically escalate when an individual encounters defeat and they perceive their social status to be lowered. The IDS is argued to be a dynamic mechanism, which may be attenuated when defeat is accepted. The current thesis is based on the rationale that the IDS is implemented in psychotic onset, affective dysfunction arising from the experience of psychosis, positive symptomology and relapse. Specifically, it argues that the specific nature of the IDS within the cognitive model of voices remains underdeveloped: there is a paucity of behavioural and ecologically valid support for the role of the core elements of the IDS contributing to beliefs and behavioural outcomes in relation to voices. 2 The empirical section of the thesis (chapters 4-6) contains four empirical studies, which aim to operationalise and test the main social evolutionary aspects of the cognitive model of voices in new ways. Section one of chapter four presents an analogue study with twenty five undergraduate students and members of the general population, which aimed to test the reliability and validity of the Ethological Coding System for Clinical Interview (ECSI) for assessment of key behavioural components of the IDS during social interaction. This was within the context of an interview paradigm which requires participants to talk about a neutral subject, after which they are asked to disclose shameful experiences and behavioural changes are coded. As predicted, increases in a core IDS behaviour was significantly related to shame and low social rank. Participants with lower social rank also displayed a larger activation of this key IDS behaviour when talking about shame. This result is argued to provide partial ecological support for the IDS as being activated when shame cognitions are online; being particularly active when social rank is seen as low and vulnerable to attack from others. Informed by the analogue study, section two of chapter four details a clinical study which applied the ECSI to assessment of the IDS in a sample of twenty four voice hearers. Participants with psychosis were videotaped during an interview paradigm which required them to talk about a neutral topic (e.g. daily life), after which they were ‘shame challenged’ through being asked to talk about their voices. The results indicated that belief in the omnipotence of voices was the best predictor of increases in aspects of IDS behaviour when participants were asked to talk about voices. It is argued that this study may provide behavioural support for the role of an active IDS in participants who believe their voices to be greatly omnipotent, and when these social mentalities are online. It is argued that the experience of living with highly omnipotent voices may prime the IDS over time, whereby the IDS remains escalated by the individual’s own beliefs and subordinate social schema. 3 The third research study detailed in chapter five builds on the first two studies, by aiming to assess important elements of the IDS in the longitudinal and ecologically valid context of the individual’s day to day experience (.i.e during one week of daily life). This was achieved by use of the Experimental Sampling Method (ESM) with forty participants with psychosis. The results suggested that social and voice subordination experienced during daily life predicted active elements of the IDS (.e.g. feelings of defeat, entrapment and shame). These elements of the IDS were also found to predict daily levels of positive and negative affect. It is argued that these results may partially support the view that the IDS and beliefs in power and omnipotence of voices are not independent. Moreover, it is argued that this work provides the first demonstration of the governance of daily positive and negative affect by the IDS in participants with psychosis. Chapter six describes a fourth empirical study with forty participants with psychosis, which aimed to assess deservedness of persecution framed within the context of the cognitive model of voices. Voice hearers high in deservedness may believe their voices to be incredibly powerful and omnipotent, and therefore more likely to acquiesce and comply to their wishes. The results were mixed: whilst compliance did not show any link with deservedness, participants high in deservedness had greater beliefs in the omnipotent and powerful nature of voices. It is argued that this indicates that the deservedness framework may be useful as a way of understanding relationships with hallucinations. In the final chapter seven, the main findings are summarised and implications for the model and clinical treatment of psychotic symptoms are explored. It is argued that the role of an active IDS could potentially be incorporated into the cognitive model of voices as a governor of voice beliefs and daily affect. As such, therapeutic interventions that aim to reduce the IDS may infer a similar decrease in the omnipotent and powerful nature of voices. This may be potentially achieved through the acceptance of defeat and a focus on more realistic goals. 4 Current psychological therapies which may help facilitate this are suggested. Moreover, it is argued that feelings of deservedness could potentially infer vulnerability for voices to become construed as powerful and omnipotent. The limitations of the work are also discussed and future research directions proposed. 5 Table of Contents Abstract ......................................................................................................................................... 2 Acknowledgements ....................................................................................................................... 9 Glossary ....................................................................................................................................... 10 Chapter 1 I: Psychosis Conceptualised: Definitions and Symptoms ........................................................... 11 II: Models and Treatment of Positive Symptoms ........................................................................ 25 Chapter 2 I: Darwin & Psychopathology: Natural Selection, Social Rank and Attachment ......................... 40 II: The Involuntary Defeat Strategy ............................................................................................ 50 Chapter 3 I: The Rationale for the Assessment of the Involuntary Defeat Strategy in Psychosis ............... 65 II: Social Behaviour in Psychosis .................................................................................................. 76 Chapter 4 EMPIRICAL STUDY 1: Assessment of Involuntary Defeat Strategy Behaviour using the Ethological Coding System for Clinical Interview: An Analogue Study ....................................... 81 EMPIRICAL STUDY 2: The Role of the Involuntary Defeat Strategy in the Cognitive Model of Voices in Psychosis .................................................................................................................... 103 Chapter 5 EMPIRICAL STUDY 3: The Daily Dynamics of the Involuntary Defeat Strategy and its role within the Cognitive Model of Voices: An Experience Sampling Study ............................................... 122 Chapter 6 EMPIRICAL
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