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The Nature of Schizotypal Symptoms and Social Recovery in Psychosis

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The Nature of Schizotypal Symptoms and Social Recovery in Psychosis The Nature of Schizotypal Symptoms and Social Recovery in Psychosis Joanne Michelle Hodgekins Thesis submitted for the degree of Doctor of Philosophy University of East Anglia School of Medicine, Health Policy and Practice March 2009 © This copy of this thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that no quotation from the thesis, nor any information derived therefrom, may be published without the author’s prior, written consent. ABSTRACT Schizotypy is traditionally conceptualised as a personality trait reflecting vulnerability to the development of psychosis. This thesis introduces the concept of schizotypal symptoms as state phenomena, related to both the development of psychotic symptoms, and to long-term recovery from the disorder. It is argued that schizotypal symptoms may be at the core of psychosis, occurring both prior to onset and following the remission of an acute psychotic episode. Schizotypal symptoms may therefore provide a bridge for the symptom-disability gap which has long been established in psychosis. The first study in this thesis reports on the psychometric properties of the Schizotypal Symptoms Inventory (SSI), a modified schizotypy assessment tool designed to measure current low-level positive psychotic symptoms in clinical and non-clinical populations. Levels of schizotypal symptoms are then compared in clinical and non-clinical samples. Following this, differential relationships between schizotypal symptom types and emotional, psychological, and neuropsychological variables are investigated. Schizotypal symptoms are then examined in relation to existing psychosis outcomes, before being integrated into a dimensional model of recovery. The final study of this thesis investigates the role of schizotypal symptoms as mediators of social recovery from psychosis, in the context of a randomised controlled trial. The findings of this thesis suggest that social anxiety schizotypal symptoms are highly prevalent in individuals recovering from acute psychosis. Moreover, differential relationships exist between schizotypal symptom types and emotional, psychological, and neuropsychological variables. Anomalous experiences are associated with a visual processing perceptual anomaly, whereas social anxiety and paranoid schizotypal symptoms are associated with emotional processing. Differential relationships also exist between schizotypal symptom types and recovery dimensions. Social anxiety mediates social recovery from psychosis, whereas anomalous experiences are associated with positive symptoms. Paranoid schizotypal symptoms are associated with both symptomatic and social recovery. These findings are combined in a psychological model of recovery in the discussion chapter. ii TABLE OF CONTENTS LIST OF TABLES x LIST OF FIGURES xiii ACKNOWLEDGEMENTS xiv CHAPTER ONE: INTRODUCTION 1 1.1 GENERAL OVERVIEW..................................................................................1 1.2 DEFINITION OF PSYCHOSIS .......................................................................2 1.2.1 Diagnostic Approach.................................................................................3 1.2.2 Single Symptom Approach.......................................................................9 1.2.3 Recovery from Psychosis........................................................................13 1.3 DEFINITION OF SCHIZOTYPY ..................................................................20 1.3.1 Epidemiology of Schizotypy...................................................................23 1.3.2 Aetiology of Schizotypy .........................................................................23 1.3.3 Types of Schizotypal Symptoms.............................................................24 1.3.4 Schizotypy and the Development of Psychosis ......................................26 1.3.5 Trait Schizotypy vs. State Schizotypal Symptoms .................................27 1.4 THE RELATIONSHIP BETWEEN SCHIZOTYPAL SYMPTOMS AND PSYCHOSIS ...............................................................................................................29 1.4.1 The Continuum Hypothesis of Psychosis ...............................................29 1.4.2 The Importance of Assessing Schizotypal Symptoms in Psychosis: Indictors of Recovery..............................................................................................32 1.5 SUMMARY AND AIMS OF THESIS...........................................................34 CHAPTER TWO: STUDY ONE: DEVELOPMENT AND PSYCHOMETRIC PROPERTIES OF THE SCHIZOTYPAL SYMPTOMS INVENTORY (SSI) 36 2.1 RATIONALE AND CONTEXT FOR THE STUDY.....................................36 2.2 REVIEW OF MEASURES TO ASSESS SCHIZOTYPY AND LOW-LEVEL PSYCHOTIC SYMPTOMS .......................................................................................37 iii 2.2.1 Measures Designed to Assess Borderline Conditions.............................37 2.2.2 Measures Designed to Assess Personality Types Related to Psychosis .38 2.2.3 Measures Designed to Assess Schizotypal Personality Traits ................39 2.2.4 Measures Designed to Assess Prodromal Psychotic Symptoms.............47 2.2.5 Summary of Review................................................................................60 2.3 STUDY AIMS AND RESEARCH QUESTIONS..........................................62 2.4 METHODOLOGY..........................................................................................63 2.4.1 Design .....................................................................................................63 2.4.2 Participants..............................................................................................63 2.4.3 Ethical Considerations............................................................................66 2.4.4 Measures .................................................................................................68 2.4.5 Procedure ................................................................................................70 2.4.6 Data Analysis Plan..................................................................................72 2.5 RESULTS .......................................................................................................73 2.5.1 Descriptive Data......................................................................................74 2.5.2 Comparison of SSI Scores in Clinical and Non-Clinical Samples .........75 2.5.3 Psychometric Analysis of the SSI...........................................................76 2.5.4 Factor Structure of the SSI......................................................................77 2.5.5 Descriptive Statistics of Factors..............................................................85 2.5.6 Correlations between Different Factors ..................................................86 2.5.7 Creation of the Brief SSI.........................................................................87 2.5.8 Descriptive Data for the Brief SSI ..........................................................91 2.5.9 Endorsement Frequencies.......................................................................93 2.5.10 Psychometric Analysis of the Brief SSI..................................................95 2.5.11 Distributions of Trait and State Symptom Counts ..................................97 2.6 DISCUSSION ...............................................................................................103 2.6.1 Summary and Discussion of the Psychometric Properties of the SSI...103 iv 2.6.2 Clinical Implications of Findings..........................................................105 2.6.3 Relevance to the Literature and Theoretical Significance of the SSI ...106 2.6.4 Weaknesses of the Current Study .........................................................107 2.6.5 Summary ...............................................................................................108 CHAPTER THREE: STUDY TWO: THE MCCOLLOUGH EFFECT AND POSITIVE SCHIZOTYPAL SYMPTOMS IN PSYCHOSIS 110 3.1 RATIONALE AND CONTEXT FOR THE STUDY...................................110 3.1.1 Aims of the Study .................................................................................114 3.2 RESEARCH HYPOTHESES.......................................................................115 3.3 METHODOLOGY........................................................................................115 3.3.1 Design ...................................................................................................115 3.3.2 Participants............................................................................................116 3.3.3 Measures and Materials.........................................................................116 3.3.4 Procedure ..............................................................................................120 3.3.5 Data Analysis Plan................................................................................120 3.4 RESULTS .....................................................................................................120 3.4.1 Descriptive Data....................................................................................120 3.4.2 Measuring the ME in a Sample with Psychosis....................................122 3.4.3 ME and Medication Effects ..................................................................122 3.4.4 Relationships with Other Variables ......................................................122
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