Methodrosenbolton.com/backup/chapter 6 study current.doc · Web viewRobson Self Concept Questionnaire (Robson, 1989) 6 Illness Perception Questionnaire (IPQ; Weinman et al., 1996)

6.1 INTRODUCTION 3

6.2 AIMS 3

6.3 QUESTIONS 3

6.4 METHOD 4

6.4.1 Participants 4

6.4.2 Measures 5Beck Anxiety Inventory (BAI; Beck, Epstein, Brown and Steer, 1988) 5Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock and Erbaugh, 1961) 6Robson Self Concept Questionnaire (Robson, 1989) 6Illness Perception Questionnaire (IPQ; Weinman et al., 1996) 6Personal Beliefs about Illness Questionnaire (PBIQ; Birchwood et al, 1993) 8Distress Rating 9

6.4.3 Casenote Information 9

6.4.4 Procedure 9Recruitment 9Completing the questionnaires 10Analyses 10

6.5 RESULTS 11

6.5.1 Description of the Sample: Information at Time of Questionnaire Completion 11Sociodemographic information 11Clinical information 12

6.5.2 Information at Start of Illness 13Sociodemographic and clinical information 13

6.5.3 Reliability of Scales 13Reliability of the IPQ 13Reliability of the PBIQ 14

6.5.4 Distress and Self-esteem Scores 15

6.5.5 Illness Perception Measures 16

6.5.6 Association Between Measures 18Distress Measures 18Illness Perception Measures: IPQ 19Illness Perception Measures: PBIQ scales 21Illness Perception Measures: Relationship between IPQ scales and PBIQ scales 22

6.6 DISCUSSION 24

6.6.1 What are the rates of anxiety, depression and self-esteem? 24

6.6.2 How do people with psychosis view their illness? 25

Chapter 6 – Illness Appraisals in Psychosis 1

6.6.3 How do the illness appraisal measures relate to each other? 27

6.6.4 Conclusions 28


CHAPTER 6. INVESTIGATION OF ILLNESS APPRAISALS IN

PSYCHOSIS: DESCRIPTION OF THE SAMPLE AND QUESTIONNAIRE

RESPONSES

6.1 INTRODUCTION

Investigation into factors associated with a single episode of illness detailed in

chapters three and four found that no factors at onset differentiated the group of

people with a single episode without residual symptoms from those with repeated

episodes without residual symptoms apart from a trend for insight to be better in the

single episode group. As outlined in the discussion section of chapter four, this raises

the possibility that psychological factors may play a part in outcome. The role of

illness appraisals in psychosis is described in the literature review in chapter five

which demonstrates that how a person thinks about their illness may contribute to

outcome in terms of symptoms and distress. As a result, it was decided to investigate

illness appraisals and distress in a heterogeneous group of individuals with psychosis.

6.2 AIMS

The principal aim of the study was to explore the relationship between illness

appraisal variables and distress. Three aspects of distress were examined: anxiety,

depression and low self-esteem. The results of this study are presented over two

chapters. The first of these (chapter six) is a description of the sample and their

responses on the measures, while the next chapter (chapter seven) is an investigation

of the association of illness appraisals and distress. As the results to be reported in

this chapter are exploratory and descriptive, no specific hypotheses have been made

and research questions are posed instead.

6.3 QUESTIONS

The following research questions are investigated.

1. What are the rates of anxiety, depression and self-esteem?


Many of the studies outlined in chapter five have investigated rates of

comorbid depression. It would be of interest to determine the rates of all three

distress measures in one sample and to determine whether this sample is

consistent with other cross-sectional samples of people with schizophrenia. In

addition, it would be informative to investigate the associations between these

measures of distress.

2. How do people with psychosis view their illness?

The literature review in chapter five describes some relationships between

illness perceptions and distress. However, this research is still in its infancy

and little is known about the particular illness beliefs held by people with

psychosis. It would be interesting, for example, to have a better

understanding of which causal beliefs are endorsed by people with psychosis,

and to determine which illness appraisals occur in a large sample of people

with schizophrenia or schizophrenia-related disorders.

3. How do the illness appraisal measures relate to each other?

No study to date has used measures of illness representation described by the

Self-Regulation Model (Leventhal et al., 1980) alongside measures from

psychological approaches to psychosis (in this case, the Personal Beliefs about

Illness Questionnaire; Birchwood et al., 1993). It is of interest to examine

how the measures relate to one another.

6.4 METHOD

6.4.1 Participants

Broad criteria for inclusion into the study were established in order to include people

with a range of distress associated with their illness and a range of symptom

presentations and outcomes. Participants were required to have a primary case-note

diagnosis of a functional psychosis, according to International Classification of

Diseases-10 (F20 – schizophrenia; F25 – schizoaffective disorder; F22 – delusional

disorder; F23.8 – brief psychotic disorder; F29 – psychotic disorder, not otherwise

specified, ICD-10; World Health Organisation, 1992) or to have had symptoms


consistent with the above in the absence of a written diagnosis. Illness length could

be of any duration and there was no requirement for individuals to be experiencing

current psychotic symptoms. In order to ensure participants could understand the

information sheet and the questionnaires, it was requested that people with very low

intellect or poor understanding of English be excluded from consideration for the

study. It was not essential for individuals to be able to read fluently or to write as the

questionnaires could, if needed, be read to them.

Staff in two mental health trusts suggested the names of four-hundred and seven

people over the course of the study and attempts were made to contact all of these

individuals. Sixty-one were unsuitable for the study and it was not possible to trace

13 people. Three hundred and thirty-three participants were potentially suitable, of

whom 159 refused to take part. One hundred and seventy-four individuals, therefore,

participated in the study (52.3% of those who were potentially suitable). All

participants were in current contact with psychiatric services; 119 were known to

Oxfordshire Mental Healthcare NHS Trust and 55 to North East London Mental

Health NHS Trust. Participants were asked to attempt to complete the whole package

of questionnaires. Two individuals, both from Oxfordshire, changed their minds

about completing the study after giving consent and were excluded from the total.

6.4.2 Measures

The package of questionnaires incorporated the following self-report measures:

Beck Anxiety Inventory (BAI; Beck, Epstein, Brown and Steer, 1988)

This is a 21 item checklist of symptoms of anxiety widely used in both clinical

practice and research. The individual is asked to indicate how much they have been

bothered by the symptoms in the last week, choosing from four options ranging from

“Not at all” to “Severely, I could barely stand it”. These are scored 0-3 resulting in a

total BAI score of 0-63, with high scores indicating higher anxiety. The scale has

good internal reliability and test-retest consistency (Beck et al., 1988)


Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock and Erbaugh, 1961)

This is the most widely used self-report measure of depression, with items relating to

physiological, cognitive and behavioural symptoms of depression. For each of the 21

items, the individual is asked to choose one statement which best describes how they

have been feeling in the last week from a group of four of increasing severity. The

items are scored 0-3 resulting in a total BDI score of 0-63 with high scores indicating

more severe depression. The scale has good test-retest reliability (Beck et al., 1988)

and high levels of internal consistency (e.g. Strober et al., 1981).

Robson Self Concept Questionnaire (Robson, 1989)

This is a 30-item questionnaire for assessment of self-esteem with good reliability

and validity. Defining self-esteem as a composite and not single entity, the scale

assesses seven components of self-esteem: subjective sense of significance;

worthiness; appearance and social acceptability, competence, resilience and

determination; control over personal destiny and the value of existence. The

individual is asked to indicate how much they agree or disagree with each statement,

according to how they typically feel. The answers are scored on a scale of 0-7 and a

total score is calculated. A high score represents high self-esteem, with 140 being

considered the “normal” mean with a standard deviation of 20 (Romans et al., 1996;

Robson, 1989). This measure has been used previously in studies with people with

psychosis (e.g. Close and Garety, 1998; Freeman et al., 1998) and correlates highly

with Rosenberg’s (1965) measure of self-esteem (Robson, 1989).

Illness Perception Questionnaire (IPQ; Weinman et al., 1996)

Having found that the five components of illness representation described by

Leventhal’s self-regulation model (Leventhal et al., 1984) are valid and consistent

across a range of different clinical conditions (Skelton and Croyle, 1991), the IPQ

was developed to assess each of these cognitive representations. The measure

consists of five subscales covering themes of illness identity (ideas about the labels

for the symptoms of illness), cause (ideas about the likely causes of illness), time-line

(the likely duration of illness and whether acute, chronic or episodic), consequences

(beliefs about the illness severity and effect on physical, social and psychological

functioning) and cure/control (beliefs about the extent to which the illness is


amenable to improvement). The questionnaire shows good internal consistency and

re-test reliability (Weinman et al., 1996), and has been used in a wide variety of

conditions including heart disease (e.g. Cooper et al., 1999), diabetes (Griva et al.,

2000) and in carers of people with major health problems (e.g. Heijmans et al., 1999).

The identity subscale comprises a list of core symptom items that the person is

required to rate for frequency on a four point scale ranging from “All of the time” to

“Never” according to how often the individual experiences the symptom as part of his

or her illness. This can be scored 0-3 to give a frequency of symptoms, or rated 0 or

1 to give a total number of symptoms. The other subscales are rated on a five-point

scale ranging from “Strongly Disagree” to “Strongly Agree”, scored 1 to 5. After

reverse-scoring the appropriate items, scores for the time-line, consequences and

cure/control scales can be achieved by summing the totals. Time-line consists of

three items, giving a score of 3-15. The consequences scale comprises seven items

giving a score of 7-35, and cure-control scale consists of six items, giving a total

score of 6-30. The cause scale consists of eleven items which should not be

aggregated as each item refers to a specific causal belief. It may, however, be

appropriate to combine items to consider particular factors such as internal or

external causes (Weinman et al., 1996).

As the IPQ was designed for a physical health environment, the identity section of the

original did not include symptoms relating to the acute exacerbation of a psychotic

disorder. The original symptom list

“incorporated twelve common symptoms from other

symptom checklists… This core list of items may be added

to by researchers to tailor the scale to specific illnesses”

(Weinman et al., 1996, p.433)

The identity section of the IPQ used in this study was developed by Weinman and

Garety (reported in Bucher, 1998, unpublished BSc thesis) to include core symptoms

of a psychotic disorder as well as most general non-psychotic symptoms. In addition,

the IPQ was originally developed for a physical health environment and refers

throughout to “illness”, thus suggesting a medical model. It is quite likely that some

individuals with a mental health problem will not perceive their difficulties as

representing an illness, and so the questions were changed throughout to state


“problems/illness” (Weinman et al, personal communication). Use of this amended

questionnaire with people with psychosis has been validated by a number of further

studies (Jolley, Garety and Bucher, in preparation; Watson et al, in preparation). A

different revised version of the IPQ (IPQ-R; Moss-Morris et al., 2002) with an

extended identity section has been used by Lobban and colleagues in individuals with

schizophrenia (Lobban, Barrowclough and Jones, 2003) and in carers of individuals

with psychosis (Barrowclough et al., 2002).

A copy of the IPQ can be found in appendix XX.

Personal Beliefs about Illness Questionnaire (PBIQ; Birchwood et al, 1993)

This is a 16-item measure consisting of 5 subscales designed to assess how much

individuals with a diagnosis of psychosis believe certain social and scientific

statements about mental illness. Birchwood et al. (1993) describe:

“Belief in ‘self as illness’ assesses the extent to which

subjects believe that the origins of their illness lies in their

personality or psyche and includes four questions; ‘control

over illness’ [later renamed “entrapment”] includes four

questions and assesses the extent to which subjects feel they

have control over their illness; ‘stigma’ [later renamed “self

humiliation and shame”] includes three questions assessing

whether subjects believe their illness is a social judgement

upon them; ‘social containment’ [later renamed “social

humiliation”] assesses subjects’ belief in social segregation

and control of the mentally ill and includes two questions;

and finally ‘expectations’ [later renamed “loss”] assesses

whether they feel the illness affects their capacity for

independence.” (Birchwood et al., 1993, p.389).

Each question is rated on a four-point scale, with low scores indicating more positive

attitudes towards the self and psychosis, meaning low awareness of stigma, higher

control over illness and positive views of self-efficacy. A copy of the PBIQ can be

seen in appendix XX.


The scales were described to have reasonable internal consistency and good test-

retest reliability (Birchwood et al., 1993).

6.4.3 Casenote Information

Casenotes were examined after completion of the questionnaires for those who

consented. Three people (1.7%) refused consent to look at their notes, and notes for

one person were missing in their entirety.

In order to enable testing of hypotheses arising from the first study (reported in

chapter 4), information was sought both for first contact with a psychotic illness and

at time of questionnaire completion. Information at first contact with mental health

serves with a psychotic disorder was gathered, where possible, on the same variables

as in the first study, with the exception of durations of untreated psychosis and

prodrome and presence of an identifiable trigger to illness due to the inadequacy of

information on this.

6.4.4 Procedure

Recruitment

Potential participants were identified by care-coordinators in Community Mental

Health Teams and Rehabilitation Services across Oxfordshire Mental Healthcare

NHS Trust and North East London Mental Health NHS Trust, after appropriate

ethical approval had been granted. Once individuals meeting the diagnostic criteria

had been identified by the care-coordinators, there were various ways of proceeding.

Some individuals were invited to take part in the study by letter from the author

including an information sheet, response sheet and stamped, self-addressed envelope.

Some were contacted by telephone, and those in inpatient units were contacted in

person. In some cases the individuals were asked by their care-coordinators either to

take part or for permission for the author to contact them.

Completing the questionnaires

Having expressed an interest to take part in the study, telephone contact was usually

made with the participants at which time it was decided whether to meet to fill in the


questionnaires, or to do it by post. In a small number of cases (n=15, 8.7%), the care-

coordinator competed the questionnaires with the participant, without any contact

from the author. If the person chose to complete the questionnaires by post, issues of

consent were discussed on the telephone and they signed the consent form at the time

of completing the questionnaire. If meeting, consent was discussed in person prior to

the completion of the questionnaires. 23 (13.4%) opted to complete the

questionnaires by post while the remaining participants (n=134, 77.9%) met with the

author either at their home or in a Mental Health setting.

Participants in North East London Mental Health NHS Trust (NELMHT) received

£10 for taking part in the study. This was as a result of two main factors: the

recruitment in NELMHT being alongside recruitment for another study for which

people were being paid, and to aid the rate of recruitment.

Analyses

Descriptive information was generated by SPSS version 11.0 (SPSS Inc, 2001).

In order to investigate the relationship between the questionnaire measures,

correlations were conducted between the variables using SPSS. Depending on the

distribution of the data, Pearson’s Product Moment correlations or Spearman’s rho

correlations were calculated, all with two-tailed significance.

Missing data were treated in two ways. When missing from the casenote information

it was left as missing. When questionnaire information was missing for the items on

scales or subscales, scores were prorated when appropriate to do so. For scales with

three items, information had to be present for two in order to prorate. For scales with

more items, at least 75% of the items were required to be endorsed.

It should be noted that a number of correlations were conducted resulting in the

potential for Type I error: finding something to be of significance when it was not.

Significance levels were not adjusted for multiple testing.

All analyses were conducted using SPSS version 11.0.


6.5 RESULTS

Descriptive information about the sample is presented first, followed by issues of

reliability of the scales and details of the responses on the measures. Finally,

analyses investigating the correlations between the illness perception and distress

measures are presented.

6.5.1 Description of the Sample: Information at Time of Questionnaire

Completion

Sociodemographic information

Of the 172 participants who completed the study, 117 (68.0%) were male and 55

(32.0%) were female. The mean age at the time of completing the questionnaire was

41.7 years (SD=12.0). Twenty-one (27.3%) were inpatients with an acute episode of

psychotic illness when seen, 127 (74.3%) were living independently, 36 (21.2%)

were living in supported accommodation and 8 (4.7%) were staying in a

rehabilitation unit. Twenty-six (15.3%) were married, 116 (68.2%) were single, 24

(14.1%) were divorced or separated and 4 (2.4%) had been widowed. Twenty

(12.1%) were employed, 136 (82.4%) were unemployed, 3 (1.8%) were students and

6 (3.6%) were doing voluntary work.

For the 164 individuals for whom premorbid adjustment information was available,

143 (87.2%) had no premorbid adjustment difficulties, 9 (5.5%) had some degree of

difficulty and 12 (7.3%) had marked difficulties. Information on educational

attainment was available for 129 (75.0%) of the sample. Of these, 42 (32.6%) had no

qualifications, 47 (36.4%) had passed ‘O’Levels or equivalent, 22 (17.1%) had

passed ‘A’Levels and 18 (14.0%) had gained a degree or higher degree by the time of

the questionnaire completion.

Seventy-three (50.7%) had no family history of mental illness recorded in the

casenotes, 15 (10.4%) had a history of psychosis, 41 (28.5%) had a history of anxiety

or depression. Fifteen (10.4%) had a family history of psychiatric illness, the

diagnosis of which was either unknown or inconclusive, for example “mother had a

breakdown”.


Clinical information

Of the total sample of 172, date of onset was available for 164. This sample had a

mean of 14.4 years since first onset of psychotic illness (SD=10.9, n=164) with a

range of 0 to 38 years. They had had a mean of 3.3 admissions since the start of

illness (SD=3.1, n=158) of which 1.2 (SD=1.7, n=111) had been in the last 6 years.

Four (2.4%) were in their first episode of illness, 113 (72.4%, n=156) had a history

over 6 years’ duration. Schizophrenia was the most common diagnosis with 102

(61.4%) having this casenote diagnosis. The remaining 64 for whom information

was available had diagnoses of schizoaffective disorder (n=36, 21.7%), psychotic

episode (n=22, 13.3%) or had no psychotic diagnosis, but had experienced symptoms

consistent with such a disorder (n=6, 3.6%). Of the 165 cases for whom information

was available, 157 (95.2%) were prescribed an antipsychotic medication at the time

of meeting. Fifty-seven (36.5%, n=156) had been admitted under Mental Health Act

section at least once during the course of their illness while 14 (8.9%, n=158) had

never been admitted. Examination of the casenotes for the 172 participants found

them to have the following patterns of illness course (shown in Table X).

Fifty-five (33.1%, n=166) had a history of self-harm reported in the notes and 43

(25.0%, n=168) were reported to have current drug or alcohol abuse.

Table X. Pattern of illness course at time of questionnaire completion Frequency (N) Percent

Repeated episodes no persistent residual symptoms

83 48.3

Repeated episodes with persistent residual symptoms

64 37.2

Single episode no persistent residual symptoms 7 4.1

Single episode with persistent residual symptoms 9 5.2

Seen in first episode 4 2.3

Unable to determine 5 2.9

Total 172


6.5.2 Information at Start of Illness

Sociodemographic and clinical information

The mean age at first illness presentation was 27.3 years (SD=8.5, n=164). Marital

status was different from that at questionnaire completion, with 123 (75.9%) being

single, 29 (17.9%) married and 10 (6.2%) divorced or separated. Forty-five (34.6%)

were employed at the start of their illness, 69 (53.1%) were unemployed and 16

(12.3%) were in full time education.

6.5.3 Reliability of Scales

Reliability of the IPQ

On the recommendation of J. Weinman and supported by recent analysis of the IPQ

(Moss-Morris et al., 2002), tests of internal reliability were conducted on the IPQ.

Timeline had a high internal reliability coefficient (Cronbach’s alpha=0.87, N=172)

and was therefore kept in its original state. Consequences had an internal reliability

of 0.60, improving to 0.66 with the deletion of item 17 (n=166; “My current

problems/illness have become easier to live with”). Cure/Control had a Cronbach’s

alpha of 0.57 (n=165), improving to 0.66 with the deletion of items 25 (“My

treatment will be effective in curing my current problems/illness”) and 26 (“Recovery

from my current problems/illness is largely dependent on chance or fate”). In order

to maximise the internal consistency of the scales, the item-deleted scales were used

for analyses. Comparison of the descriptives for these scales is given below. In

future the revised item-deleted scales will be referred to as “Consequences” and

“Cure/Control”.

Table X. Internal reliability of IPQ Consequences and Cure/Control Scales

Variable Number of items

Total N Mean SD

IPQ Consequences with item 17 7 172 25.1 4.3

IPQ Consequences without item 17 6 172 22.7 4.1

IPQ Cure/Control with items 25 and 26 6 172 20.0 4.1

IPQ Cure/Control without items 25 and 26 4 171 13.4 3.3


In addition, in accordance with the statement of Weinman et al. (1996) that it may be

appropriate to combine causal items to look at factors such as internal and external

causes, exploratory factor analyses were conducted. Five factors were suggested:

germ/virus, diet and pollution; personality and own behaviour; state of mind, stress

and others; poor medical care; heredity and chance. The scales suggested by the

factor analyses, had low internal reliability (Cronbach’s alpha <0.6) and one factor

had only one item. In view of this it was decided to use the causal items of the IPQ

singly. In accordance with the suggestion by Weinman (2004, personal

communication) that it was sensible to “concentrate on those items where there was a

reasonable spread of agreement/disagreement in the sample”, the causal items of

germ/virus and pollution were excluded from the analyses in view of their very low

endorsement (less than 10%).

Reliability of the PBIQ

As checks for reliability were made for the IPQ, it was decided that similar checks

should be made for the internal reliability of the PBIQ scales. The original internal

reliability of the scales is shown below (Birchwood et al., 1993) alongside those of

the present study.

Table X. Internal reliability of PBIQ scales

In the current study, the social humiliation and self humiliation subscales had

unacceptably low Cronbach’s alphas; social humiliation was notably low at 0.04.

The social humiliation subscale consists of the two items “Because of my illness, I

have to rely on psychiatric services” and “Society needs to keep people with my

illness apart from everyone else”. In this population there was no association

between the two items, with 127 people (74.3%) agreeing with the first statement and

only 19 (11.2%) agreeing with the second.

Chapter 6 – Illness Appraisals in Psychosis

Entrapment Self humiliation

Self as illness

Social humiliation

Loss

Number of items 4 3 4 2 3

Birchwood et al. Cronbach’s alpha 0.64 0.61 0.71 0.51 0.58

Current study: Cronbach’s alpha 0.74 0.42 0.56 0.04 0.61

14

In view of some of the low Cronbach’s alpha scores in this study, a factor analysis

was conducted to determine whether a different arrangement of the items would

produce more coherent subscales for this population. Factor analysis produced five

factors with the same number of items in the scales as the original questionnaire.

Internal reliability of these items had a range of Cronbach’s alphas from 0.54 to 0.71.

While this was a better range of reliability than that of the original scales for this

sample, the groupings of items were difficult to identify as meaningful entities. For

example, “I am fundamentally normal, my illness is unlike any other” was put

together with “I find it difficult to cope with my current symptoms” as one factor. In

addition, reorganising the items would make it difficult to compare the results of the

current study with others. Similarly, although treating all 16 items of the

questionnaire as one scale had an excellent internal reliability Cronbach’s alpha of

0.83, it was felt that this would be difficult to interpret meaningfully. For this reason

it was decided to retain the original subscales, but as the original scales had a range of

internal consistency scores from 0.71 to a lowest Cronbach’s alpha of 0.51, it was

decided to use 0.5 as the minimum acceptable limit. As a result, analyses were

limited to the subscales of Entrapment, Self as illness and Loss.

6.5.4 Distress and Self-esteem Scores

The means, standard deviations and quartiles for the measures of anxiety, depression

and self-esteem are displayed in Table X.

Table X. Scores on distress items

Variable Total N Range Mean SD Median Quartiles25% 75%

Beck Anxiety Inventory 172 0-53 14.0 10.5 11.0 6.0 20.0

Beck Depression Inventory 172 0-50 16.5 11.3 13.5 7.3 23.0

Robson SCQ 172 38-210 114.8 32.7 113.0 97.0 134.0

The mean scores of the BDI and BAI suggest the population suffered from mild-

moderate anxiety and depression. The mean score on the Robson SCQ is over one

standard deviation lower than the mean of Robson’s non-clinical group (1989),

suggesting lowered self-esteem in the current sample. The standard deviation of 32.7

is greater than that in Robson’s (1989) sample of 20. According to the original cut-


offs for depression (Beck et al., 1961), 56 (32.6%) people were in the normal range

for depression, 50 (29.1%) suffered mild-moderate depression, 43 (25.0%) suffered

moderate-severe depression and 23 (13.4%) suffered with severe depression. Using

the norms for anxiety (Beck et al., 1988), 74 (43%) scored in the normal range for

anxiety, 46 (26.7%) scored in the mild-moderate range, 34 (19.8%) scored in the

moderate-severe range and 18 (10.5%) scored in the severe range.

Using Birchwood and colleagues’ cut-off of 15 or above on the BDI to suggest at

least mild depression, 83 people (48.3%) suffered from depression. Using 15 or

above for anxiety, 67 people (39.0%) suffered from anxiety.

6.5.5 Illness Perception Measures

The scores on IPQ scales and PBIQ scales are detailed separately below. The

responses on the cause subscale of the IPQ are displayed in Table X, showing the

pattern of agreement with each of the possible cause items. Details of the other IPQ

subscales are shown in Table X. As can be seen, the identity section of the IPQ was

limited to psychotic symptoms. This was in order not to overlap with more general

symptoms such as lack of concentration which may be assessed by the measures of

anxiety and depression. The individual components of the Identity scale are outlined

in Table X.

PBIQ scores are shown in Table X.

Table X. IPQ Cause items

Variable Total N

Mean SD Agree (%) Neither agree nor disagree (%)

Disagree (%)

IPQ Cause: state of mind 171 3.7 1.2 126 (73.7) 13 (7.6) 32 (18.7)

IPQ Cause: heredity 171 2.8 1.3 56 (32.7) 41 (24.0) 74 (43.3)

IPQ Cause: chance 171 3.1 1.4 78 (45.6) 25 (14.6) 68 (39.8)

IPQ Cause: personality 172 3.4 1.3 102 (59.3) 24 (14.0) 46 (26.7)

IPQ Cause: stress 172 4.0 1.1 140 (81.4) 12 (7.0) 20 (11.6)

IPQ Cause: poor medical care 172 2.4 1.3 39 (22.7) 32 (18.6) 101 (58.7)

IPQ Cause: diet 172 2.1 1.2 30 (17.4) 20 (11.6) 122 (70.7)

IPQ Cause: germ/virus 172 1.8 1.0 15 (8.7) 21 (12.2) 136 (79.1)

IPQ Cause: pollution 171 1.8 1.0 12 (7.0) 21 (12.3) 138 (80.7)


IPQ Cause: own behaviour 172 2.9 1.2 64 (37.2) 33 (19.2) 75 (43.6)

IPQ Cause: others 170 3.4 1.3 91 (53.5) 34 (20.0) 45 (26.5)

As illustrated above, particular patterns emerge for the appraisal of cause in

psychosis. Fewer than 10% agreed with the statements that their illness was caused

by a germ/virus or pollution, with around 80% disagreeing, indicating that these

causes are not perceived to be relevant for people with psychosis. Stress was

endorsed strongly by the sample (81.4%) as was state of mind (73.7%) and

disagreement with the statement that diet was a cause (70.7%). Own behaviour as a

cause of illness showed a spread of agreement with 37.2% agreeing and 43.6%

disagreeing and chance showed a similar spread of agreement (45.6% versus 39.8%).

Heredity had the highest percentage of people answering that they did not know

(24.0%). Others and personality showed similar patterns of agreement with one

another, with the majority of people agreeing, while the majority of the participants

(58.7%) disagreed that poor medical care contributed to their illness. Interestingly,

however, 22.7% felt that poor medical care did play a part.

Table X. IPQ scales: Identity, Timeline, Consequences and Cure/ControlVariable Total N Mean SD Median Quartiles

25% 75%IPQ Identity / Frequency of psychotic symptoms 167 5.3 4.3 5.0 2.0 8.0

IPQ Timeline 172 10.9 3.2 11.5 9.0 13.8

IPQ Consequences 172 22.7 4.1 23.0 20.0 26.0

IPQ Cure/Control 172 13.4 3.3 14.0 12.0 16.0

Table X indicates that the group endorsed low rates of positive symptomatology,

given the possible range of scores of 0-18 and that 75% of the sample had scores of 8

or below. Timeline had a range of scores of 3-15, suggesting that the sample

perceived a long duration of illness. Similarly, scores on the Consequences scale

suggest the sample generally perceived negative consequences of illness and scores

of appraisal of control over illness suggest the sample held low beliefs in its

controllability.

Table X. Individual components of Identity scale


Symptom N Range Mean SD Endorsed (%)

Hearing voices 172 0-3 0.91 1.07 51.7

Feeling controlled by others 171 0-3 0.96 1.02 57.3

Seeing images 172 0-3 0.55 0.82 36.6

Having paranoid thoughts 172 0-3 1.10 1.01 64.5

Holding beliefs not shared by others 167 0-3 1.14 1.08 64.7

Feeling that my mind is being controlled 172 0-3 0.74 0.98 44.2

Although the sample reported low frequency of symptoms, Table X indicates that a

substantial percentage of the sample reported positive symptoms at least

“occasionally”, with half the sample reporting auditory hallucinations and 65 percent

reporting paranoid thoughts.

Table X. PBIQ scalesVariable Total N Mean SD Median Quartiles

25% 75%

PBIQ Entrapment 170 10.0 2.8 10.0 8 12.0

PBIQ Self as illness 171 9.7 2.5 10.0 8.0 11.0

PBIQ Loss 171 7.6 2.1 8.0 6.0 9.0

The PBIQ scale scores outlined in Table X indicates that Entrapment is evenly

distributed with the mean and median being equivalent to the actual mean of the

scale. Self as illness is similarly distributed, as is PBIQ Loss.

6.5.6 Association Between Measures

Distress Measures

Using Pearson’s Product Moment Correlation, all three distress measures were

significantly correlated with each other. Anxiety and depression had a correlation

coefficient of 0.61 (N=172, p<.001, two-tailed test), while anxiety was negatively

correlated with self-esteem (r= -0.46, N=172, p<.001). Depression and self-esteem

were negatively correlated (r= -0.74, N=172, p<.001). Increased anxiety was

associated with increased depression and that high self-esteem was associated with


lower anxiety and depression. The correlation between anxiety and self-esteem

shows a medium effect size while the correlations between depression and anxiety

and depression and self-esteem show large effect sizes (Cohen, 1988, cited in Clark-

Carter, 1997).

Illness Perception Measures: IPQ

Cause subscale: As the cause items were to be assessed individually, and the factor

analyses of the items have already been reported, correlations between the cause

subscale items were not conducted.

Timeline, Consequences, Cure/Control and Identity subscales: The IPQ subscales of

Timeline, Consequences, Cure/control and Identity (frequency of psychotic

symptoms) all showed significant correlations with one another. These are shown in

Table X. The strongest effect is that shown by timeline and consequences, indicating

that the longer the perceived duration of illness, the greater the perceived

consequences of illness. Greater perceived cure/control was associated with shorter

perceived duration of illness and fewer negative consequences. Greater number of

symptoms was found to be related to longer perceived duration of illness, greater

perceived consequences and lower sense of cure/control. The actual duration of

illness was also examined for correlations with the IPQ, including IPQ Timeline,

which had no relationship (r=0.08). None of the subscales was related to actual

length of illness.

Table X. Correlations between IPQ scales

IPQ timeline IPQ consequences

IPQ cure/control

IPQ identity

IPQ Consequences

Pearson Correlation 0.40**

Sig. (2-tailed) <0.001

N 172

IPQ Cure/Control

Pearson Correlation -0.25** -0.17*

Sig. (2-tailed) 0.001 0.025

N 171 171

IPQ Identity Pearson Correlation 0.26** 0.31** -0.34**


Sig. (2-tailed) 0.001 <0.001 <0.001

N 167 167 166

Years since illness start

Pearson Correlation 0.08 -0.02 -0.13 0.01

Sig. (2-tailed) 0.305 0.814 0.100 0.857

N 164 164 163 159

** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).

The IPQ cause scales and the IPQ Consequences, Cure/control, Timeline and Identity

scales show the associations below (Table X). As can be seen, a number of the

variables are significantly correlated with each other, mainly showing small effect

sizes. Of interest, IPQ identity was associated with agreeing with own behaviour and

state of mind as playing a part in causing illness, while the causes of illness

personality, stress, state of mind and others were all associated with greater perceived

consequences of illness. Heredity and others were both associated with greater

timeline, while diet was found to be associated with lower reported consequences of

illness.

Table X. Correlation coefficients IPQ subscales (Spearman’s rho)

IPQ identity IPQ timeline

IPQ consequences

IPQ cure/control

IPQ cause: diet Correlation Coefficient 0.14 0.05 -0.17* -0.02

Sig. (2-tailed) 0.065 0.479 0.027 0.769N 167 172 172 171

IPQ cause: heredity

Correlation Coefficient 0.10 0.24** 0.08 <0.01

Sig. (2-tailed) 0.214 0.002 0.315 0.961N 167 171 171 170

IPQ cause: chance

Correlation Coefficient 0.08 0.00 -0.02 -0.01

Sig. (2-tailed) 0.299 0.998 0.777 0.944N 166 171 171 170

IPQ cause: personality

Correlation Coefficient 0.17* 0.13 0.20** 0.12

Sig. (2-tailed) 0.026 0.093 0.008 0.109N 167 172 172 171

IPQ cause: stress Correlation Coefficient -0.03 0.05 0.25** 0.14

Sig. (2-tailed) 0.724 0.507 0.001 0.076N 167 172 172 171

IPQ cause: own behaviour

Correlation Coefficient 0.22** -0.09 -0.02 0.09

Sig. (2-tailed) 0.004 0.223 0.835 0.265


N 167 172 172 171IPQ cause: others Correlation

Coefficient 0.15 0.18* 0.30** 0.01

Sig. (2-tailed) 0.059 0.021 <0.001 0.849N 165 170 170 169

IPQ cause: poor medical care

Correlation Coefficient 0.01 -0.09 0.06 -0.11

Sig. (2-tailed) 0.896 0.234 0.462 0.164N 167 172 172 171

IPQ cause: state of mind

Correlation Coefficient 0.17* 0.06 0.32** 0.06

Sig. (2-tailed) 0.024 0.406 <0.001 0.423N 167 171 171 170


Illness Perception Measures: PBIQ scales

The three subscales of the PBIQ were significantly correlated with each other as

shown in Table X. Entrapment showed a moderate association with Self as illness

and a large association with Loss. Loss and Self as illness were also significantly

correlated with one another, showing a medium effect size.


Illness Perception Measures: Relationship between IPQ scales and PBIQ scales

The pattern of association between the IPQ and PBIQ are in Tables X and X. As can

be seen in the first table (Table X), all of the illness perception subscales from the

IPQ and PBIQ are significantly correlated with each other, in the expected direction.

For example, higher scores on PBIQ entrapment are associated with lower perceived

Chapter 6 – Illness Appraisals in Psychosis

PBIQ entrapment

PBIQ self as illness

PBIQ loss

PBIQ Self as illness Pearson Correlation 0.46**

Sig. (2-tailed) <0.001N 170

PBIQ Loss Pearson Correlation 0.55** 0.40**

Sig. (2-tailed) <0.001 <0.001N 170 171

Years since illness began

Pearson Correlation -0.04 0.10 0.18*

Sig. (2-tailed) 0.645 0.224 0.019N 162 163 163

21

IPQ cure/control, longer timeline and greater perceived consequences. In addition,

greater scores on PBIQ entrapment were associated with higher IPQ identity

indicating that greater symptom frequency correlated with greater perceived

entrapment. PBIQ loss was significantly related to longer perceived duration of

illness, greater frequency of symptom, poorer sense of cure/control and greater

perceived negative consequences of illness.

Table X. Correlations between IPQ scales and PBIQ scales

IPQ timeline

IPQ consequences

IPQ cure/control

IPQ identity

PBIQ entrapment Pearson Correlation 0.25** 0.37** -0.49** 0.41**

Sig. (2-tailed) 0.001 <0.001 <0.001 <0.001N 170 170 169 165


Pearson Correlation 0.35** 0.32** -0.34** 0.42**

Sig. (2-tailed) <0.001 <0.001 <0.001 <0.001N 171 171 170 166

PBIQ loss Pearson Correlation 0.43** 0.33** -0.42** 0.35**

Sig. (2-tailed) <0.001 <0.001 <0.001 <0.001N 171 171 170 166


Looking at the PBIQ and its association with the cause section of the IPQ reveals a

number of significant correlations all showing small effect sizes. Greater agreement

with heredity as a cause of illness was associated with greater loss (PBIQ loss), while

the belief that others caused the individual’s illness was associated with greater PBIQ

entrapment and PBIQ loss. PBIQ loss was also found to be associated with poor

medical care as a cause of illness, and belief that diet was a cause. PBIQ self as

illness was associated with seeing one’s personality as a cause of illness, as was

believing one’s state of mind to be a causative factor.

Table X Correlation coefficients between PBIQ subscales and IPQ identity

(Spearman’s rho)

PBIQ entrapment


PBIQ loss

IPQ cause: diet Correlation Coefficient 0.20** 0.16* 0.15*Sig. (2-tailed) 0.008 0.035 0.050N 170 171 171

IPQ cause: heredity Correlation Coefficient 0.07 0.08 0.16*Sig. (2-tailed) 0.366 0.304 0.033N 169 170 170


IPQ cause: chance Correlation Coefficient 0.06 0.08 0.15*Sig. (2-tailed) 0.415 0.319 0.046N 169 170 170

IPQ cause: personality Correlation Coefficient 0.01 0.28** 0.15*Sig. (2-tailed) 0.878 <0.001 0.049N 170 171 171

IPQ cause: stress Correlation Coefficient -0.05 <0.01 -0.06Sig. (2-tailed) 0.545 0.965 0.431N 170 171 171

IPQ cause: own behaviour Correlation Coefficient -0.07 0.13 0.01

Sig. (2-tailed) 0.374 0.088 0.894N 170 171 171

IPQ cause: others Correlation Coefficient 0.17* 0.12 0.19*Sig. (2-tailed) 0.028 0.131 0.016N 168 169 169

IPQ cause: poor medical care Correlation Coefficient 0.07 -0.02 0.16*

Sig. (2-tailed) 0.372 0.818 0.037N 170 171 171

IPQ cause: state of mind Correlation Coefficient 0.07 0.20** 0.14

Sig. (2-tailed) 0.346 0.009 0.060N 169 170 170


6.6 DISCUSSION

6.6.1 What are the rates of anxiety, depression and self-esteem?

In this sample of people with a mean duration of illness of over 14 years, the mean

scores on the measures of anxiety and depression suggest mild comorbid anxiety and

depression. Using the cut-off suggested by Birchwood and colleagues of 15 points or

above (Birchwood and colleagues, 1993, 1997, 1998, 2000) for depression, 48%

suffer with depression. Applying this criterion to anxiety identifies 39% as suffering

from anxiety. The rate of depression is comparable to that of Birchwood and

Chadwick (1997) who found 53% to suffer from depression according to their

criterion, and van der Gaag et al. (2003) who report depression in 55%. The mean

score on the BDI of 16.5 in this population are slightly lower than in the Birchwood

and Chadwick 1997 study, although higher than the Birchwood and colleagues’ 1993

and 1998 studies.


Both anxiety and depression scores are lower in this population than those of those of

Freeman et al. (1998) and Freeman and Garety (1999), although Barrowclough et al.

(2003), report their sample of 59 people with similar diagnoses to have an identical

mean BDI score of xx.

The self-esteem mean scores in this population of 114 are just over one standard

deviation lower than the normal mean of 140. This is half to one standard deviation

higher than self-esteem scores measured with the Robson SCQ reported by Freeman

et al. (1998) and the initial assessment scores of Hall and Tarrier (2003).

This population appears therefore to be suffering with mild to moderate depression

and anxiety and lower than normal self-esteem. Given the population consisted

mainly of outpatients known to mental health teams, principally people who were

considered amenable to be approached to talk about their mental health difficulties, it

is understandable that the group were not as distressed as samples in acute episodes

of symptomatic presentation or who had chronic persistent positive symptoms.

Nevertheless, the rates of significant clinical distress were considerable. The fact that

48% were classified as suffering from depression is consistent with the findings of

high-rates of co-morbidity of depression in people with schizophrenia or

schizophrenia-related disorders. While fewer people suffered with anxiety, and the

mean scores on the BAI were lower than that of depression, it was still a considerable

problem for some, with a range of anxiety scores of 0-53 and 25% scoring above 20.

The distress scores correlated highly with one another, particularly that of self-esteem

and depression which is to be expected given that a negative attitude towards the self

is a central to depression (Robson, 1988).

6.6.2 How do people with psychosis view their illness?

Responses to the Cause Scale of the IPQ, shows that people did not attribute their

mental health problems to environmental causes. Instead, high rates of endorsement

were found for the role of stress and state of mind, with over 70% in agreement. This

suggests good understanding of their illness. In addition, personality and others were

endorsed by a small majority of people. This is slightly contradictory but suggests

that people rated a number of factors as having caused their difficulties, consistent

with multi-factorial models of the onset of psychosis (e.g. Garety et al. 2001). Of


interest, but difficult to interpret, is the finding that a sizeable minority (22.7%) rated

their problems as having been caused by poor medical care.

The pattern of endorsement described is very similar to the responses reported by a

sample of people with depression reported by Moss-Morris and Petrie (1996, reported

in Moss-Morris, 1997) who also found stress to be the most endorsed cause, followed

by the concepts relating to the self such as metal attitude and emotional state. In this

study, “the self” would include state of mind and personality which were endorsed by

73% and 59% of people and were the most endorsed after stress.

High percentages of the sample endorsed the presence of positive symptoms

(Identity), suggesting good awareness of their illness and willingness to report. This

is consistent with a recent report by Liraud et al. (2004) who found people with

psychosis to be accurate in their self-report of psychological symptoms. The least

endorsed symptom was that of visual hallucinations, with is consistent with rates of

visual hallucinations reported in the clinical literature (15-30%; Sartorius et al.,

1986).

All the subscales of the IPQ were correlated with one another. The strongest

correlation was found between negative consequences of illness and perceived long

duration. Interestingly, this was independent of actual duration of illness as no

association was found between actual duration of illness and any of the subscales of

the IPQ. The weakest, although significant, correlation was found between less

perceived cure/control over illness and negative consequences. Identity, or frequency

of psychotic symptoms correlated at a similar level with all three scales. These

patterns of relationship are consistent with the literature from physical illness studies,

with Hagger and Orbell (2003) also finding in their meta-analysis of 45 studies the

strongest correlation to be between the consequences and timeline scales. All

correlation coefficients in this study are larger than the mean correlation coefficients

corrected for measurement error reported by Hagger and Orbell.

With regard to the relationship between the cause items and other IPQ subscales, no

significant correlations were found between the Cure/Control subscale and any of the

cause items. Consequences showed a negative correlation with diet, such that

appraisal of illness as having been caused by diet was associated with less severe

negative consequences of illness. Greater negative consequences were perceived by


people who saw their illness as being caused by their personality, stress, their state of

mind and others. Interestingly, longer Timeline was perceived by people who

perceived a hereditary cause of their illness. Longer Timeline also showed an

association with “others”, while Identity showed associations with own behaviour,

personality and state of mind.

It would appear that these findings raise the possibility of locus of control playing a

part in people’s appraisal, in that if one perceives the cause to be external (others or

heredity) the timeline is perceived to be longer. Others as a cause of illness (i.e. an

external cause) was also associated with greater negative consequences. In contrast,

greater frequency of symptoms (Identity) and negative consequences are largely

associated with causes originating from the self, although the locus of control of

stress is debatable. It is difficult to argue this with any degree of strength, however,

as locus of control was not assessed, and the analyses are correlational and do not

imply cause. In addition, it should be borne in mind that while significant, some of

these correlations are quite small, and they have not been corrected for multiple

testing. It could be, therefore, that some of the significant correlations are due to

chance.

All three PBIQ scales were significantly positively correlated with one another

indicating that negative views of illness (greater personal blame for the cause, lesser

degree of control and poor self-efficacy) are consistent across dimensions of illness.

Scores on the Loss subscale (including questions about poor work functioning and

self-efficacy) correlated with greater duration of illness, suggesting that aspects of an

individual’s illness history feed into their appraisal of illness.

6.6.3 How do the illness appraisal measures relate to each other?

Interestingly, the four IPQ scales (not including the individual Cause items) and the

PBIQ scales showed significant correlations with one another, suggesting a degree of

association between the scales. The highest correlation was found between IPQ

Cure/Control and PBIQ Entrapment of r=0.49. As Entrapment used to be titled

“Control” it appears these subscales are tapping similar constructs. However, in spite

of further correlations over 0.40 between PBIQ Entrapment and IPQ Identity and

PBIQ Loss and IPQ Cure/Control, the rest of the correlations are in the range of 0.25-


0.37, suggesting that the measures are associated with one another but not measuring

exactly the same concepts. In addition, there is no particular pattern of correlations

which you would expect if there was a congruence between the measures, suggesting

that while the scales are associated with one another, there is nothing to support that

any of the scales are directly comparable to each other.

With regard to the pattern of association between the PBIQ scales and the IPQ Cause

scale, a number of the items showed significant correlations with each other, all with

small effect sizes. It is difficult to interpret anything meaningful from these results

with no obvious patterns. None of the PBIQ scales shows the same pattern of results

as the IPQ scales, with a slightly lower range of correlation coefficients (0.15-0.28

versus 0.17-0.32.

6.6.4 Summary

The group selected for inclusion in this study were a group of 172 individuals with a

long history of illness (over 14 years). They were found to describe causes of their

illness broadly consistent with psychological models of psychosis, and reported high

levels of positive symptoms. They were similar to many cross-sectional samples in

terms of their age at time of questionnaire completion and gender ratio (e.g. Freeman

et al., 1998, Birchwood and Chadwick, 1997). They were less distressed than some

samples (e.g. Freeman et al. 1998), but more distressed than others (e.g. Birchwood et

al., 1993). A high percentage of the sample suffered from anxiety, depression and

low-self-esteem which is significant given the relatively stable but chronic

population.

The illness perception measures showed significant correlations with each other and

in the case of the IPQ these were consistent with the wider literature with a physical

illness with regard to their direction and effect sizes.

Some association was found between the two illness perception measures, but with

the exception of PBIQ Entrapment and IPQ Cure/Control, only moderate effect sizes

were shown, suggesting the measures are related but the concepts are not identical.


6.6.5 Conclusions


Documents

Methodrosenbolton.com/backup/chapter 6 study current.doc · Web viewRobson Self Concept Questionnaire (Robson, 1989) 6 Illness Perception Questionnaire (IPQ; Weinman et al., 1996)