Past exam of the developing new and effective psychological treatments for anxiety disorders and psychosis course of the University of Oxford / 2022 / 5

Recent innovations offered plausible routes to better outcomes for delusions by replacing a broad, undifferentiated treatment target with specific maintaining processes. Persistent persecutory beliefs may be supported by worry, poor sleep, felt vulnerability, low confidence, reasoning inflexibility and safety behaviors. Changing one of these may create opportunities for a person to reconsider threat without demanding immediate agreement that their belief is wrong. The promise is mechanistic and practical; it does not imply that all delusions share one cause or that every plausible target will improve clinical outcomes.

A contributory-causal approach begins by identifying a potentially modifiable process, experimentally changing it and examining consequences for the clinical problem. Worry is an example: repeated anticipation of danger can generate threatening explanations and keep them mentally available. In the Worry Intervention Trial, Daniel Freeman and colleagues randomised 150 patients with persistent persecutory delusions to six sessions targeting worry alongside standard care, or standard care alone. Worry and delusion outcomes improved, with gains followed to 24 weeks. Because therapist contact was not matched, the result supports the added intervention package more securely than an exclusively worry-mediated effect.^[ref]

Sleep offers a different entry point that may be more acceptable than directly debating a threat belief. The OASIS trial randomised 3755 university students with insomnia to digital CBT for sleep or usual practice. It produced a large sleep benefit and smaller changes in paranoia and hallucinatory experiences. This supports testing sleep as a contributory process, while the nonclinical student sample and usual-practice comparator prevent direct inference that the same intervention treats persistent delusions in patients with psychosis.^[ref]

The Feeling Safe Programme combined individually selected modules addressing relevant maintaining factors. Its 2021 trial allocated 130 patients with persistent persecutory delusions to Feeling Safe or same-therapist befriending, with usual care continuing. The six-month adjusted difference in delusional conviction favoured Feeling Safe by about 10.7 points on a 0–100 scale. A categorical recovery comparison was less precise and did not reach conventional significance. The positive continuous primary outcome therefore should not be restated as a definitively superior recovery rate.^[ref]

Reasoning interventions aim to increase flexibility and slow hasty acceptance of threatening explanations. Philippa Garety and colleagues' SlowMo combined eight face-to-face sessions, digital material and a mobile application. In the 361-person analysis, the primary total paranoia score at 24 weeks did not show a statistically significant advantage over usual care, although several secondary and earlier outcomes favoured the intervention. There was no significant effect on jumping to conclusions. This mixed pattern is particularly important: an engaging, mechanistically informed treatment can show promising signals without meeting its prespecified primary test.^[ref]

These approaches could improve outcomes for several reasons. Targeting common difficulties such as insomnia or worry can give treatment an understandable starting point. Personalised modules can concentrate time on processes actually present instead of requiring every patient to complete the same sequence. Concrete experiments may provide more persuasive evidence than verbal reassurance. Digital support can make an exercise accessible between appointments, while carefully designed measures can show whether the nominated process changed before the belief or distress changed.

However, a target can be associated with delusions without causing them. Poor sleep and worry may partly reflect a common adversity, or lessen when general distress improves. An intervention intended for one process can alter several others, making a statistical mediator an uncertain guide to the active ingredient. Even when a factor contributes causally, changing it may produce only modest benefit because other maintaining processes remain. Necessary theoretical precision includes specifying who has the target, how much it must change and which outcome should follow.

Outcome choice can make an innovation appear more or less successful. Conviction, preoccupation, distress, activity, quality of life and diagnostic status are related but distinct. Greater doubt about a threatening explanation may be valuable without elimination of the belief; conversely, a questionnaire change need not restore work or social participation. The difference between SlowMo's primary and secondary findings illustrates why the endpoint and assessment time should be specified in advance. Multiple favourable secondary results cannot simply replace an unsuccessful primary test.

Clinical heterogeneity also matters. A treatment developed for persistent persecutory delusions is not automatically established for every delusional theme, acute state or diagnostic group. Language requirements, willingness to attend research therapy and referral patterns select who enters a trial. Comorbid depression, cognitive difficulties, substance use or continuing victimisation may alter the usefulness of a module. An unusual belief should be assessed in its cultural and social context; a psychological account must not assume that all reported threats are unreal.

Innovations can fail at implementation even when the trial mechanism is sound. Skilled research therapists, close supervision and protected time may be unavailable in routine services. A mobile application can increase opportunity for practice but also introduce access, privacy or comprehension barriers. Adding modules can increase burden, dilute effective content or delay the experiment that matters most. Patients may prefer a different target from the one selected by a questionnaire. Acceptability, fidelity, reach and cost therefore need direct measurement alongside symptom outcomes.

A strong next study would compare an adapted innovation with a credible active treatment in several services, with adequate power and blinded assessment. Prespecify primary conviction or distress outcomes, patient-prioritised functioning and longer-term maintenance. Measure candidate mechanisms repeatedly, recording which modules are actually received; module choice in a tailored treatment is not random and cannot itself identify the best component. A complementary factorial or sequentially randomised experiment could test specific additions while preserving adequate care for all participants.

By May 2022, the most convincing advance was the shift toward testable mechanisms and more rigorous, symptom-focused clinical comparisons. Worry, sleep, flexible reasoning and personalised threat-learning approaches offered reasons for optimism, with some positive clinical results and important null findings. Better outcomes would depend on genuine target engagement, adequate comparisons, generalisation and feasible delivery, rather than novelty, a digital format or a plausible causal diagram alone.