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Imogen H Bell

University of Melbourne, Centre for youth mental health, Post-Doc

Columbia University, Psychiatry, past intern

Swinburne University of Technology, Centre for Mental Health, past intern

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I am a researcher and psychologist based in Melbourne, Australia. My research focuses on advancing understanding and treatment of mental health difficulties using digital technologies, particularly smartphone apps, online therapies and virtual reality. Also interested in understanding the mechanisms of, and developing novel treatments for, unusual experiences such as hearing voices and psychosis.
Address: Melbourne, Victoria, Australia

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Alvaro sanchez lopez

Claire Stephens

Andrés Peña-Vargas

Nicholas Moberly

University of Exeter

Katherine Montero

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Papers by Imogen H Bell

The effect of psychological treatment on repetitive negative thinking in youth depression and anxiety: a meta-analysis and meta-regression

Psychological Medicine

Background Depression and anxiety are prevalent in youth populations and typically emerge during ... more Background Depression and anxiety are prevalent in youth populations and typically emerge during adolescence. Repetitive negative thinking (RNT) is a putative transdiagnostic mechanism with consistent associations with depression and anxiety. Targeting transdiagnostic processes like RNT for youth depression and anxiety may offer more targeted, personalised and effective treatment. Methods A meta-analysis was conducted to examine the effect of psychological treatments on RNT, depression and anxiety symptoms in young people with depression or anxiety, and a meta-regression to examine relationships between outcomes. Results Twenty-eight randomised controlled trials examining 17 different psychological interventions were included. Effect sizes were small to moderate across all outcomes (Hedge's g depression = −0.47, CI −0.77 to −0.17; anxiety = −0.42, CI −0.65 to −0.20; RNT = −0.45, CI −0.67 to −0.23). RNT-focused and non-RNT focused approaches had comparable effects; however, those...

Ownership, usage and interest in digital mental health technologies amongst clinicians and young people across a spectrum of clinical care needs (Preprint)

BACKGROUND There is currently an increased appetite and acceptance of technology-enabled mental h... more BACKGROUND There is currently an increased appetite and acceptance of technology-enabled mental health care. To adequately harness this opportunity, it is critical that the design and development of digital mental health technologies is informed by the needs and preferences of end-users. Despite young people and clinicians being predominant users of such technologies, little research has examined their perspectives on different digital mental health technologies. OBJECTIVE The current study aimed to (i) understand what technologies young people, both within youth mental health services and the general population, have access to and use in their everyday lives, and what applications of these technologies they were interested in to support their mental health; (ii) explore what technologies youth mental health clinicians currently used within their practice, and what applications of these technologies they were interested in to support their clients’ mental health. METHODS Youth menta...

The Therapeutic Use of Digital Technologies in Psychosis

Ownership and regular use of digital technologies such as smartphones is growing increasingly pre... more Ownership and regular use of digital technologies such as smartphones is growing increasingly prevalent in people experiencing severe mental illness such as psychosis. Mobile devices such as smartphones, computer-based applications, and online programs or websites have unique capabilities, which show promise for enhancing and supporting current psychological treatments for psychosis. Clinicians might soon be able to utilise these technologies to improve engagement and delivery of standard interventions, help clients self-manage their symptoms and monitor clinical changes outside of therapy sessions, and develop more tailored treatments using advanced methods of assessment. This chapter provides an overview of the current research in digital technologies for the psychological treatment of people with a psychotic disorder, including discussion of barriers and facilitators to engagement, limitations of the current literature, and the ethical implications of utilising these technologies...

Client experiences of blending a coping-focused therapy for auditory verbal hallucinations with smartphone-based ecological momentary assessment and intervention

Internet Interventions

This study explored participants' experiences of a novel intervention blending ecological momenta... more This study explored participants' experiences of a novel intervention blending ecological momentary assessment and intervention (EMA/I) digital technologies with four face-to-face therapy sessions to improve coping in people who experience persisting auditory verbal hallucinations (hear voices). A smartphone app was used to deliver prompts to facilitate both self-monitoring and self-management of voices. Analysis of data recorded by the app was also used in-session to develop an idiographic formulation of antecedents of and responses to voicehearing episodes. Semi-structured interviews were conducted with 12 participants who completed the blended therapy. A thematic approach was used to analyse the data, generating four main themes, with associated subthemes: (1) Therapy experience changed by digital technology; (2) Valuing face-to-face component; (3) Preference for different phases of the digital technology; (4) Not as bothered by voices. Key findings revealed that participants perceived EMA/I technology as helping capture their experience more accurately and communicate this more effectively to the therapist, which, in combination with coping prompts developed in-session, deepened the therapeutic relationship. These findings add to the emerging literature that shows blended therapy can play an important role in the treatment of people with psychosis, and suggest potential of EMA/I as a technology for other clinical populations.

Virtual reality as a clinical tool in mental health research and practice

Dialogues in Clinical Neuroscience

Virtual reality (VR) is a potentially powerful technology for enhancing assessment in mental heal... more Virtual reality (VR) is a potentially powerful technology for enhancing assessment in mental health. At any time or place, individuals can be transported into immersive and interactive virtual worlds that are fully controlled by the researcher or clinician. This capability is central to recent interest in how VR might be harnessed in both treatment and assessment of mental health conditions. The current review provides a summary of the advantages of using VR for assessment in mental health, focusing on increasing ecological validity of highly controlled environments, enhancing personalization and engagement, and capturing real-time, automated data in real-world contexts. Considerations for the implementation of VR in research and clinical settings are discussed, including current issues with cost and access, developing evidence base, technical challenges, and ethical implications. The opportunities and challenges of VR are important to understand as researchers and clinicians look t...

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

World Psychiatry

Implementation lessons from the transition to telehealth during COVID-19: a survey of clinicians and young people from youth mental health services

Psychiatry Research

Digital Technology to Enhance Clinical Care of Early Psychosis

Current Treatment Options in Psychiatry

A systematic review of task-based functional neuroimaging studies investigating language, semantic and executive processes in thought disorder

Neuroscience & Biobehavioral Reviews

The aim of the current systematic review was to synthesise the research that has investigated tho... more The aim of the current systematic review was to synthesise the research that has investigated thought disorder (TD) using task-based functional neuroimaging techniques to target executive, language, or semantic functions. Thirty-seven pertinent studies were identified from January 1990 to August 2016. Functional correlates of TD included the superior and middle temporal, fusiform, and inferior frontal gyri bilaterally, as well as the left and right cingulate cortex, the right caudate nucleus, and the cerebellum. TD-related increases and decreases in activation were both evident in most of these regions. However, the specificity of these correlates from general clinical and cognitive influences is unknown. The cortical regions implicated overlap with those thought to contribute to language and semantic systems. Cortico-striatal circuitry may also play a role in some aspects of TD through aberrant salience representation and inappropriate attentional prioritisation. To advance the field further, greater integration across structural, functional, and behavioural measures is required, in addition to non-unitary considerations of TD.

A systematic review of the structural neuroimaging correlates of thought disorder

Neuroscience & Biobehavioral Reviews

One clinical dimension often cited as a hallmark of schizophrenia is thought disorder (TD). The a... more One clinical dimension often cited as a hallmark of schizophrenia is thought disorder (TD). The aim of the current systematic review was to summarise our current understanding of the neurobiology of TD that has been investigated with structural neuroimaging techniques. Ninety-seven relevant studies were identified from January 1990 to August 2016, 26 of which had TD-motivated research questions or hypotheses. The remaining 71 studies conducted exploratory clinical analyses that included TD amongst a number of psychotic symptoms. These studies implicate the left superior temporal gyrus in TD. There was also evidence to suggest associations between TD and structural measures within the orbitofrontal cortex, cerebellum, nucleus accumbens, and amygdala-hippocampal region. However, there is a dearth of structural neuroimaging research driven by TD-motivated hypotheses. Furthermore, few studies have explored specific TD symptoms or subgroups, or surface-based morphometric measures of cortical structure, despite theoretical and practical reasons for doing so. It is hoped that the current review will assist in the augmentation of diverse hypothesis-driven research into the aetiology of TD.

Optokinetic nystagmus confirms multistable rivalry between four discrete overlapping motion stimuli

Frontiers in Human Neuroscience, 2015

Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations

Schizophrenia Bulletin

The field of digital mental health is rapidly expanding with digital tools being used in assessme... more The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention, and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular synergies between the phenomenon of hallucinations and digital tools that are being developed. Highlighted uses include monitoring and managing intermittently occurring hallucinations in daily life; therapeutic applications of audio and video media including virtual and augmented reality; targeting verbal aspects of hallucinations; and using avatars to represent hallucinatory voices. Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice. Implementation may benefit from identifying how to market resources to the broad range of populations who experience hallucinations and identifying sustainable funding models. It is envisaged that digital tools will contribute to improved self-management and service provision for people experiencing hallucinations.

Smartphone-based ecological momentary assessment and intervention in a blended coping-focused therapy for distressing voices: Development and case illustration

Internet Interventions , 2018

Common approaches to the psychological treatment of distressing voice hearing experiences, such a... more Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate therapeutic settings to the context of daily life. Two promising technologies include ecological momentary assessment and intervention (EMA/I), which may offer a means of advanced assessment and support in daily life, and inform the tailoring of interventions to suit individual needs. In this study, a highly novel intervention approach was developed involving four face-to-face sessions with a psychologist blended with EMA/I between sessions in order to improve coping with distressing voice hearing experiences. The authors describe the background and development of this approach alongside a single case illustration, which supported feasibility and acceptability. This study details how digital technologies such as EMA/I may be used in future as clinical tools to enhance standard psychological treatments and clinical care of people with persisting and distressing experiences.

Pilot randomised controlled trial of a brief coping-focused intervention for hearing voices blended with smartphone-based ecological momentary assessment and intervention (SAVVy): Feasibility, acceptability and preliminary clinical outcomes

Schizophrenia Research , 2019

Background: Voice-hearing experiences can be distressing and impairing, and existing psychologica... more Background: Voice-hearing experiences can be distressing and impairing, and existing psychological treatments show modest effectiveness. Ecological momentary assessment and intervention (EMA/I) are two promising approaches which may be used as digital tools to support and enhance existing psychological therapies. The aim of this study was to investigate the potential clinical utility of smartphone-based EMA/I in a blended, coping focused therapy for voice-hearing experiences. Method: This pilot RCT focused on feasibility, acceptability and preliminary estimations of efficacy. Thirty-four participants with persisting and distressing voices were randomised to receive the four-session intervention alongside treatment-as-usual (TAU) or TAU-only. Results: Findings supported the feasibility and acceptability of the approach, with good engagement and satisfaction rates, and clinical outcomes showed the intervention holds promise for improving coping, overall severity of voices and to some degree their negative impact. Conclusion: This is the first examination of the use of EMA/I in a blended therapy for psychotic experiences, with findings suggesting these technologies show promise as clinical tools.

Smartphone-based ecological momentary assessment and intervention in a coping- focused intervention for hearing voices (SAVVy): study protocol for a pilot randomised controlled trial

by Imogen H Bell and Michelle H Lim

Background: Smartphone-based ecological momentary assessment and intervention (EMA/I) show promis... more Background: Smartphone-based ecological momentary assessment and intervention (EMA/I) show promise for enhancing psychological treatments for psychosis. EMA has the potential to improve assessment and formulation of experiences which fluctuate day-today , and EMI may be used to prompt use of therapeutic strategies in daily life. The current study is an examination of these capabilities in the context of a brief, coping-focused intervention for distressing voice hearing experiences.

Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders: A Systematic Review

by Imogen H Bell, Michelle H Lim, Susan Rossell, and Neil Thomas

Objective: Ecological momentary assessment (EMA) and ecological momentary intervention (EMI) are ... more Objective: Ecological momentary assessment (EMA) and ecological momentary intervention (EMI) are technologies used to track fluctuations in experiences and prompt behavioral responses within the context of a person's daily life. Most commonly delivered via smartphone, EMA and EMI have potential to provide simple, cost-effective, and userled treatment for psychotic disorders. This systematic review aimed to synthesize current research exploring the feasibility, acceptability, and clinical outcomes of EMA and EMI in the treatment of psychotic disorders.

The effect of psychological treatment on repetitive negative thinking in youth depression and anxiety: a meta-analysis and meta-regression

Psychological Medicine

Background Depression and anxiety are prevalent in youth populations and typically emerge during ... more Background Depression and anxiety are prevalent in youth populations and typically emerge during adolescence. Repetitive negative thinking (RNT) is a putative transdiagnostic mechanism with consistent associations with depression and anxiety. Targeting transdiagnostic processes like RNT for youth depression and anxiety may offer more targeted, personalised and effective treatment. Methods A meta-analysis was conducted to examine the effect of psychological treatments on RNT, depression and anxiety symptoms in young people with depression or anxiety, and a meta-regression to examine relationships between outcomes. Results Twenty-eight randomised controlled trials examining 17 different psychological interventions were included. Effect sizes were small to moderate across all outcomes (Hedge's g depression = −0.47, CI −0.77 to −0.17; anxiety = −0.42, CI −0.65 to −0.20; RNT = −0.45, CI −0.67 to −0.23). RNT-focused and non-RNT focused approaches had comparable effects; however, those...

Ownership, usage and interest in digital mental health technologies amongst clinicians and young people across a spectrum of clinical care needs (Preprint)

BACKGROUND There is currently an increased appetite and acceptance of technology-enabled mental h... more BACKGROUND There is currently an increased appetite and acceptance of technology-enabled mental health care. To adequately harness this opportunity, it is critical that the design and development of digital mental health technologies is informed by the needs and preferences of end-users. Despite young people and clinicians being predominant users of such technologies, little research has examined their perspectives on different digital mental health technologies. OBJECTIVE The current study aimed to (i) understand what technologies young people, both within youth mental health services and the general population, have access to and use in their everyday lives, and what applications of these technologies they were interested in to support their mental health; (ii) explore what technologies youth mental health clinicians currently used within their practice, and what applications of these technologies they were interested in to support their clients’ mental health. METHODS Youth menta...

The Therapeutic Use of Digital Technologies in Psychosis

Ownership and regular use of digital technologies such as smartphones is growing increasingly pre... more Ownership and regular use of digital technologies such as smartphones is growing increasingly prevalent in people experiencing severe mental illness such as psychosis. Mobile devices such as smartphones, computer-based applications, and online programs or websites have unique capabilities, which show promise for enhancing and supporting current psychological treatments for psychosis. Clinicians might soon be able to utilise these technologies to improve engagement and delivery of standard interventions, help clients self-manage their symptoms and monitor clinical changes outside of therapy sessions, and develop more tailored treatments using advanced methods of assessment. This chapter provides an overview of the current research in digital technologies for the psychological treatment of people with a psychotic disorder, including discussion of barriers and facilitators to engagement, limitations of the current literature, and the ethical implications of utilising these technologies...

Client experiences of blending a coping-focused therapy for auditory verbal hallucinations with smartphone-based ecological momentary assessment and intervention

Internet Interventions

This study explored participants' experiences of a novel intervention blending ecological momenta... more This study explored participants' experiences of a novel intervention blending ecological momentary assessment and intervention (EMA/I) digital technologies with four face-to-face therapy sessions to improve coping in people who experience persisting auditory verbal hallucinations (hear voices). A smartphone app was used to deliver prompts to facilitate both self-monitoring and self-management of voices. Analysis of data recorded by the app was also used in-session to develop an idiographic formulation of antecedents of and responses to voicehearing episodes. Semi-structured interviews were conducted with 12 participants who completed the blended therapy. A thematic approach was used to analyse the data, generating four main themes, with associated subthemes: (1) Therapy experience changed by digital technology; (2) Valuing face-to-face component; (3) Preference for different phases of the digital technology; (4) Not as bothered by voices. Key findings revealed that participants perceived EMA/I technology as helping capture their experience more accurately and communicate this more effectively to the therapist, which, in combination with coping prompts developed in-session, deepened the therapeutic relationship. These findings add to the emerging literature that shows blended therapy can play an important role in the treatment of people with psychosis, and suggest potential of EMA/I as a technology for other clinical populations.

Virtual reality as a clinical tool in mental health research and practice

Dialogues in Clinical Neuroscience

Virtual reality (VR) is a potentially powerful technology for enhancing assessment in mental heal... more Virtual reality (VR) is a potentially powerful technology for enhancing assessment in mental health. At any time or place, individuals can be transported into immersive and interactive virtual worlds that are fully controlled by the researcher or clinician. This capability is central to recent interest in how VR might be harnessed in both treatment and assessment of mental health conditions. The current review provides a summary of the advantages of using VR for assessment in mental health, focusing on increasing ecological validity of highly controlled environments, enhancing personalization and engagement, and capturing real-time, automated data in real-world contexts. Considerations for the implementation of VR in research and clinical settings are discussed, including current issues with cost and access, developing evidence base, technical challenges, and ethical implications. The opportunities and challenges of VR are important to understand as researchers and clinicians look t...

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

World Psychiatry

Implementation lessons from the transition to telehealth during COVID-19: a survey of clinicians and young people from youth mental health services

Psychiatry Research

Digital Technology to Enhance Clinical Care of Early Psychosis

Current Treatment Options in Psychiatry

A systematic review of task-based functional neuroimaging studies investigating language, semantic and executive processes in thought disorder

Neuroscience & Biobehavioral Reviews

The aim of the current systematic review was to synthesise the research that has investigated tho... more The aim of the current systematic review was to synthesise the research that has investigated thought disorder (TD) using task-based functional neuroimaging techniques to target executive, language, or semantic functions. Thirty-seven pertinent studies were identified from January 1990 to August 2016. Functional correlates of TD included the superior and middle temporal, fusiform, and inferior frontal gyri bilaterally, as well as the left and right cingulate cortex, the right caudate nucleus, and the cerebellum. TD-related increases and decreases in activation were both evident in most of these regions. However, the specificity of these correlates from general clinical and cognitive influences is unknown. The cortical regions implicated overlap with those thought to contribute to language and semantic systems. Cortico-striatal circuitry may also play a role in some aspects of TD through aberrant salience representation and inappropriate attentional prioritisation. To advance the field further, greater integration across structural, functional, and behavioural measures is required, in addition to non-unitary considerations of TD.

A systematic review of the structural neuroimaging correlates of thought disorder

Neuroscience & Biobehavioral Reviews

One clinical dimension often cited as a hallmark of schizophrenia is thought disorder (TD). The a... more One clinical dimension often cited as a hallmark of schizophrenia is thought disorder (TD). The aim of the current systematic review was to summarise our current understanding of the neurobiology of TD that has been investigated with structural neuroimaging techniques. Ninety-seven relevant studies were identified from January 1990 to August 2016, 26 of which had TD-motivated research questions or hypotheses. The remaining 71 studies conducted exploratory clinical analyses that included TD amongst a number of psychotic symptoms. These studies implicate the left superior temporal gyrus in TD. There was also evidence to suggest associations between TD and structural measures within the orbitofrontal cortex, cerebellum, nucleus accumbens, and amygdala-hippocampal region. However, there is a dearth of structural neuroimaging research driven by TD-motivated hypotheses. Furthermore, few studies have explored specific TD symptoms or subgroups, or surface-based morphometric measures of cortical structure, despite theoretical and practical reasons for doing so. It is hoped that the current review will assist in the augmentation of diverse hypothesis-driven research into the aetiology of TD.

Optokinetic nystagmus confirms multistable rivalry between four discrete overlapping motion stimuli

Frontiers in Human Neuroscience, 2015

Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations

Schizophrenia Bulletin

The field of digital mental health is rapidly expanding with digital tools being used in assessme... more The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention, and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular synergies between the phenomenon of hallucinations and digital tools that are being developed. Highlighted uses include monitoring and managing intermittently occurring hallucinations in daily life; therapeutic applications of audio and video media including virtual and augmented reality; targeting verbal aspects of hallucinations; and using avatars to represent hallucinatory voices. Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice. Implementation may benefit from identifying how to market resources to the broad range of populations who experience hallucinations and identifying sustainable funding models. It is envisaged that digital tools will contribute to improved self-management and service provision for people experiencing hallucinations.

Smartphone-based ecological momentary assessment and intervention in a blended coping-focused therapy for distressing voices: Development and case illustration

Internet Interventions , 2018

Common approaches to the psychological treatment of distressing voice hearing experiences, such a... more Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate therapeutic settings to the context of daily life. Two promising technologies include ecological momentary assessment and intervention (EMA/I), which may offer a means of advanced assessment and support in daily life, and inform the tailoring of interventions to suit individual needs. In this study, a highly novel intervention approach was developed involving four face-to-face sessions with a psychologist blended with EMA/I between sessions in order to improve coping with distressing voice hearing experiences. The authors describe the background and development of this approach alongside a single case illustration, which supported feasibility and acceptability. This study details how digital technologies such as EMA/I may be used in future as clinical tools to enhance standard psychological treatments and clinical care of people with persisting and distressing experiences.

Pilot randomised controlled trial of a brief coping-focused intervention for hearing voices blended with smartphone-based ecological momentary assessment and intervention (SAVVy): Feasibility, acceptability and preliminary clinical outcomes

Schizophrenia Research , 2019

Background: Voice-hearing experiences can be distressing and impairing, and existing psychologica... more Background: Voice-hearing experiences can be distressing and impairing, and existing psychological treatments show modest effectiveness. Ecological momentary assessment and intervention (EMA/I) are two promising approaches which may be used as digital tools to support and enhance existing psychological therapies. The aim of this study was to investigate the potential clinical utility of smartphone-based EMA/I in a blended, coping focused therapy for voice-hearing experiences. Method: This pilot RCT focused on feasibility, acceptability and preliminary estimations of efficacy. Thirty-four participants with persisting and distressing voices were randomised to receive the four-session intervention alongside treatment-as-usual (TAU) or TAU-only. Results: Findings supported the feasibility and acceptability of the approach, with good engagement and satisfaction rates, and clinical outcomes showed the intervention holds promise for improving coping, overall severity of voices and to some degree their negative impact. Conclusion: This is the first examination of the use of EMA/I in a blended therapy for psychotic experiences, with findings suggesting these technologies show promise as clinical tools.

Smartphone-based ecological momentary assessment and intervention in a coping- focused intervention for hearing voices (SAVVy): study protocol for a pilot randomised controlled trial

by Imogen H Bell and Michelle H Lim

Background: Smartphone-based ecological momentary assessment and intervention (EMA/I) show promis... more Background: Smartphone-based ecological momentary assessment and intervention (EMA/I) show promise for enhancing psychological treatments for psychosis. EMA has the potential to improve assessment and formulation of experiences which fluctuate day-today , and EMI may be used to prompt use of therapeutic strategies in daily life. The current study is an examination of these capabilities in the context of a brief, coping-focused intervention for distressing voice hearing experiences.

Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders: A Systematic Review

by Imogen H Bell, Michelle H Lim, Susan Rossell, and Neil Thomas

Objective: Ecological momentary assessment (EMA) and ecological momentary intervention (EMI) are ... more Objective: Ecological momentary assessment (EMA) and ecological momentary intervention (EMI) are technologies used to track fluctuations in experiences and prompt behavioral responses within the context of a person's daily life. Most commonly delivered via smartphone, EMA and EMI have potential to provide simple, cost-effective, and userled treatment for psychotic disorders. This systematic review aimed to synthesize current research exploring the feasibility, acceptability, and clinical outcomes of EMA and EMI in the treatment of psychotic disorders.