Psychological treatment and facial affect recognition in individuals with psychosis

Although Facial affect recognition (FAR), is associated with a lower level of functioning in individuals with Schizophrenia (SZ), it is unclear if the deficit is present in individuals with first episode psychosis (FEP) and if FAR is associated with symptoms of psychosis. Study I was a cross-sectional study, aiming to investigate 1) the presence of FAR in FEP and 2) if FAR was associated with symptoms of psychosis. A total of n=67 participants with FEP and n=51 controls were included. Results showed that participants with FEP had significantly more impaired general (p<0.001) and negative (p<0.001) FAR compared to controls. Anger and disgust drove the reported differences between groups in general and in negative affects. By contrast, the FAR of positive emotions was preserved. Further, symptoms of psychosis were not significantly associated with FAR. To conclude, impaired FAR was present early in the psychotic process but was not associated with symptoms of psychosis.

Psychotherapy is a recommended adjunctive treatment to antipsychotic medication and a psychotherapeutic method, Acceptance and commitment therapy for psychosis (ACTp), has shown promising results, but more research is needed, both in the group- and inpatient setting.

Study II was a feasibility pilot randomized controlled trial aiming to develop and evaluate group-ACTp (G-ACTp) for outpatients. Participants attending clinics for individuals with FEP were allocated to G-ACTp (=8) or individual CBTp (n=6). A total of 18 sessions were given in both treatments. Session attendance varied and the patients comprehended G-ACTp well but performed behavior change to a lesser degree. Participants struggled to fill out selfassessment questionnaires and recruitment was challenging. An exploratory analysis compared G-ACTp to CBTp and indicated that participants in CBTp may have performed significantly more homework. There was also an indication that participants in both groups might have significantly decreased their impairment and that the CBTp group also might have improved significantly in valued living. However, the limitations in this study are large and the results can only be seen as a hypothesis that needs to be further investigated in larger future RCTs. To conclude, participants needed support to attend treatment, perform behavior change, and fill out self-assessment forms. Recruitment was challenging and the results from the comparison,s between G-ACTp and CBTp as well as within both treatments should be interpreted with caution because of the small sample size.

Study III was a single case study developing and evaluating ACTp in the inpatient setting. A total of n=12 inpatients with symptoms of psychosis were included and given up to 10 daily sessions of ACTp. Daily measures during baseline and treatment, as well as pre-post treatment, were calculated. Recruiting and conducting ACTp in inpatient wards was feasible and the treated individuals found the therapy quite acceptable. Yet, a majority of the participants were unable to complete all ACTp sessions because of discharge. However, depression, health-related quality of life, and anxiety significantly improved in around 6/12 participants. To conclude, it was feasible to give ACTp in the inpatient setting, and participants improved during treatment. However, a shorter treatment manual could have been more feasible in the inpatient setting. Moreover, since no control-group was used it is uncertain if improvements were due to ACTp or standard treatment. Therefore, the results are preliminary and need to be further investigated in future RCTs.

To broaden the limited access to psychotherapy, frontline staff treating individuals with psychosis could be trained to give brief psychotherapeutic techniques. However, it is unclear how inpatient staff perceive the training and application of ACTp. Study IV was a qualitative study aiming to explore how frontline inpatient staff experience conversations with psychotic inpatients as well as training and applying the ACTp in these conversations. A total of n=16/31 frontline staff members were interviewed after having received up to 9 hours of training and subsequent supervision in ACTp. The semi-structured interviews (30-50 min) were analyzed according to Thematic analysis. Results showed that participants used several skills to build relationships with patients. Participants also valued the ACTp training and learned new skills. However, they struggled to learn the techniques and perceived a lack of fit between ACTp, the patients, and the inpatient setting. Finally, patient-related factors also affected motivation to train and use ACTp. To conclude, it was feasible to train the inpatient staff. Although there was some benefit of the training, the staff learned only parts of the ACT techniques and found it challenging to use them with inpatients.

List of scientific papers

I. Larsson, C*., Lee, M*., Lundgren, T., Erhardt, S., Sellgren, C. M., Cervenka, S., Borg, J., Bölte, S., & Fatouros-Bergman, H. (2022). Facial affect recognition in first-episode psychosis is impaired but not associated with psychotic symptoms. Heliyon, 8(9), e10424–e10424. *Authors contributed equally
https://doi.org/10.1016/j.heliyon.2022.e10424

II. Larsson, C., Parling, T., Sahin, K., Jacobsson, A., Scott, M., Kaldo, V., Lundgren, T., Fatouros-Bergman, H. Feasibility of Group Acceptance and Commitment Therapy for Psychosis -a Pilot Study. [Manuscript]

III. Larsson, C., Fatouros-Bergman, H., Isaksson, A., Johansson, M., Kaldo, V., Parling, T., & Lundgren, T. (2022). Acceptance and Commitment Therapy for inpatients with psychosis –an acceptability and feasibility single case AB designed study. Journal of Contextual Behavioral Science, 25, 44–60.
https://doi.org/10.1016/j.jcbs.2022.05.008

IV. Larsson, C., Parling, T., Reinebo, G., Sjödin, M., Hedström, R., Kaldo, V., Lundgren, T., Fatouros-Bergman, H. Implementing ACTp Techniques for Inpatients with Psychosis -A Qualitative Study of the Experiences of Frontline Staff. [Submitted]