If it is absurd, then why do you do it? The richer the obsessional experience, the more compelling the compulsion

What Kurt Schneider Really Said and What the DSM Has Made of it in Its Different Editions: A Plea to Redefine Hallucinations in Schizophrenia

Kurt Schneider has played a leading role in shaping our current view of schizophrenia, placing certain manifestations of delusions and hallucinations at the center of the disorder, especially ideas of persecution and voice-hearing. The first part of this review summarizes Schneider's original ideas and then traces how the different editions of the DSM merged aspects of Kraepelin's, Bleuler's, and Schneider's historical concepts. Special attention is given to the transition from the DSM-IV to the DSM-5, which eliminated much of Schneider's original concept. In the second part of the article, we contrast the current definition of hallucination in the DSM-5 with that of Schneider. We present empirically derived arguments that favor a redefinition of hallucinations, much in accordance with Schneider's original ideas. We plea for a two-dimensional model of hallucinations that represents the degree of insight and perceptuality, ranging from thoughts with full "mineness" via perception-laden thoughts and intrusions (including "as if" experiences") to hallucinations. While we concur with the DSM-5 that cognitions that are indistinguishable from perceptions should be labeled as hallucinations, we suggest expanding the definition to internally generated sensory phenomena, including those with only partial resemblance to external perceptions, that the individual considers real and that may lie at the heart of a subsequent delusional superstructure.

Exploring aspects of self-reported emotional mental imagery in patients with bipolar disorder

BACKGROUND AND OBJECTIVES

CBT for patients with bipolar disorder has modest effects. Across disorders, mental imagery has been used to update CBT to increase effectiveness. In order to enhance CBT for bipolar disorder with imagery techniques, research is needed into emotional imagery quality and, related appraisals of imagery and their relationships with mood instability and subsequent behaviour in bipolar disorder.

METHODS

Patients with bipolar disorder (n = 106), unipolar depression (n = 51), creative imagery prone participants (n = 53) and participants without a history of a mood disorder (n = 135) completed the Dutch Imagery Survey (DImS), an online imagery survey, adapted from the Imagery Interview, assessing self-reported emotional imagery aspects. Imagery quality, appraisals and their self-perceived effects on emotion and behaviour were compared between groups. As unexpected differences within the bipolar group appeared, these were additionally explored.

RESULTS

Imagery appraisals but not imagery quality discriminated between the patient groups and non-patient groups Imagery was perceived as an emotional amplifier in all groups, but this was specifically apparent in bipolar manic and bipolar depressed groups. Only in the bipolar group imagery was experienced to amplify behavioural tendencies.

LIMITATIONS

Results need to be replicated using a larger sample of patients with BD who are currently manic or depressed.

CONCLUSIONS

Not only quality of imagery, but especially appraisals associated with imagery are differentiating between imagery prone people with and without mood disorder. Imagery amplifies emotion in all groups, but only in those patients with bipolar disorder currently manic or depressed did this influence behaviour.

Insight in obsessive-compulsive disorder: conception, clinical characteristics, neuroimaging, and treatment

Obsessive-compulsive disorder (OCD) is a chronic disabling disease with often unsatisfactory therapeutic outcomes. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has broadened the diagnostic criteria for OCD, acknowledging that some OCD patients may lack insight into their symptoms. Previous studies have demonstrated that insight can impact therapeutic efficacy and prognosis, underscoring its importance in the treatment of mental disorders, including OCD. In recent years, there has been a growing interest in understanding the influence of insight on mental disorders, leading to advancements in related research. However, to the best of our knowledge, there is dearth of comprehensive reviews on the topic of insight in OCD. In this review article, we aim to fill this gap by providing a concise overview of the concept of insight and its multifaceted role in clinical characteristics, neuroimaging mechanisms, and treatment for OCD.

Psychotic Vulnerability and its Associations with Clinical Characteristics in Adolescents with Obsessive-Compulsive Disorder

Compared to peers, children and adolescents with obsessive-compulsive disorder (OCD) are at increased risk of developing psychotic disorders. Yet very few studies have examined early indicators of psychosis in pediatric OCD. In the present study, 52 youth with a primary diagnosis of OCD (Mage = 15.66 [SD = 2.33], 59.6% girls) were interviewed using the Schizophrenia Proneness Instrument Child and Adolescent version (SPI-CY), which is a comprehensive clinical interview assessing both Cognitive-Perceptual basic symptoms (COPER) and high-risk criterion Cognitive Disturbances (COGDIS). Associations between COPER/COGDIS symptoms and demographic and clinical characteristics were examined. Findings showed that COPER or COGDIS symptoms were present in 44% of participants, with no significant difference between girls and boys. Psychotic vulnerability was associated with an earlier age of OCD onset, greater OCD severity, poorer insight, and more contamination/cleaning symptoms. Psychotic vulnerability was also strongly associated with worse psychosocial functioning. Findings suggest that early indicators of psychosis are frequent in pediatric OCD and associated with more severe OCD and poorer functioning. Research examining how psychotic vulnerability is associated with short- and long-term outcomes for youth with OCD is needed.

Understanding why people with OCD do what they do, and why other people get involved: supporting people with OCD and loved ones to move from safety-seeking behaviours to approach-supporting behaviours

The distress inherent in obsessive compulsive disorder (OCD) can often lead to partners, family members and friends becoming entangled with the OCD in terms of being drawn into performing certain behaviours to try and reduce the distress of their loved one. In the past this has often been referred to somewhat pejoratively as collusion, or more neutrally as accommodation. In this paper we emphasise that this is usually a natural human response to seeing a loved one in distress and wanting to help. This paper provides detailed clinical guidance on how to understand this involvement and how to include others in the treatment of OCD along with practical tips and hints around potential blocks that may require troubleshooting. It also details the relatively recently introduced concept of approach-supporting behaviours, and provides guidance on how to distinguish these from safety-seeking behaviours. The ‘special case’ of reassurance seeking is also discussed.

Key learning aims

(1)

Hallucinations and Delusions as Low-Quality Attributions: Influencing Factors and Proposal for Their Analysis

Hallucinations and delusions, in keeping with the distress accompanying them, are major features in the diagnosis of psychosis in international classifications. In spite of their human and clinical importance, the concepts are unclear. The distinction between hallucinations and delusions in terms of perception-thought is not precise enough, causing problems in analyzing the patient's words. Nor are the differentiations or variations within each precise enough. Continuing the long clinical tradition discussing the distinction between hallucinations and delusions while assuming their similarities, this study poses a concept integrating the two phenomena as attributions people make about themselves and their settings. Then the elements of any attribution can be used as guides for structuring significant literature on both, and reduce analytical ambiguity. Such attributions make more sense within the structure of two-way relationships with factors in a person's own framework and setting. This structure is described with its variables and relationships as a guide to assessment, follow-up, and intervention. Two checklists are provided for orientation.

Maladaptive Daydreaming and Obsessive-Compulsive Symptoms: A confirmatory and exploratory investigation of shared mechanisms

Maladaptive Daydreaming (MD) is a newly proposed mental disorder characterized by excessive, vivid fantasy activity impairing functioning. There is a high comorbidity of MD with Obsessive-Compulsive Spectrum Symptoms (OCSS), yet the mechanisms responsible for this relationship are still unclear. The present study set out to explore the relationship between MD and OCSS by: (1) examining dissociation, trauma, sense of control, and mind-wandering as potential mediators; (2) exploring whether MD is more strongly related to obsessions or compulsions; and (3) identifying patterns of specific obsessions and/or compulsions common in an MD sample. A group of 510 participants with self-identified MD completed a battery of online questionnaires. Dissociation and sense of control significantly mediated the MD-OCSS association. MD was moderately related to both obsessions and compulsions but was significantly more strongly related to the former. Frequently endorsed obsessions and compulsions among MD participants included checking and repetition compulsions, intrusive obsessions, and body-related obsessions and compulsions. We conclude that dissociative mechanisms, including dissociative absorption, play a major role in the relationship between MD and OCSS and may lead to consequent checking when transitioning back to reality, altered embodiment, intrusive images, and thoughts, and an impaired sense of mental control. Clinicians working with OCSS should be aware of the possible role of MD in the development or maintenance of symptoms. Future work should develop useful interventions for this type of shared psychopathology.

Four reasons why early detection centers for psychosis should be renamed and their treatment targets reconsidered: we should not catastrophize a future we can neither reliably predict nor change

Since the 1990s, facilities for individuals at putative risk for psychosis have mushroomed and within a very short time have become part of the standard psychiatric infrastructure in many countries. The idea of preventing a severe mental disorder before its exacerbation is laudable, and early data indeed strongly suggested that the sooner the intervention, the better the outcome. In this paper, the authors provide four reasons why they think that early detection or prodromal facilities should be renamed and their treatment targets reconsidered. First, the association between the duration of untreated psychosis and outcome is empirically established but has become increasingly weak over the years. Moreover, its applicability to those who are considered at risk remains elusive. Second, instruments designed to identify future psychosis are prone to many biases that are not yet sufficiently controlled. None of these instruments allows an even remotely precise prognosis. Third, the rate of transition to psychosis in at-risk patients is likely lower than initially thought, and evidence for the success of early intervention in preventing future psychosis is promising but still equivocal. Perhaps most importantly, the treatment is not hope-oriented. Patients are more or less told that schizophrenia is looming over them, which may stigmatize individuals who will never, in fact, develop psychosis. In addition self-stigma has been associated with suicidality and depression. The authors recommend that treatment of help-seeking individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized as it is only one of many possible outcomes, including full remission. Prodromal clinics should not be abolished but should be renamed and restructured. Such clinics exist, but the transformation process needs to be facilitated.

Level of Insight in Patients With Obsessive-Compulsive Disorder: An Exploratory Comparative Study Between Patients With "Good Insight" and "Poor Insight"

Introduction: Insight may be defined as the ability to perceive and evaluate external reality and to separate it from its subjective aspects. It also refers to the ability to self-assess difficulties and personal qualities. Insight may be a predictor of success in the treatment of obsessive-compulsive disorder (OCD), so that individuals with poor insight tend to become refractory to treatment. The objective of this study is to investigate factors associated with poor insight in individuals with OCD. Methods: This cross-sectional exploratory study used the Brown Belief Assessment Scale as a parameter for the creation of the comparison groups: individuals who obtained null scores (zero) composed the group with preserved or good insight (n = 148), and those with scores above the 75% percentile composed the group with poor insight (n = 124); those with intermediate scores were excluded. Sociodemographic characteristics and clinical and psychopathological aspects, intrinsic and extrinsic to the typical symptoms of OCD, were compared in a univariate analysis. A logistic regression was used to determine which factors associated with critical judgment remained significant. Results: Individuals in the poor insight group differed from those with good insight in regard to: more prevalent use of neuroleptics (p = 0.05); higher untreated time interval (p < 0.001); higher total Yale-Brown obsessive-compulsive scale score and the obsessions and compulsions factors (all factors with p < 0.001); higher dimensional Yale-Brown obsessive-compulsive scale total and dimensional scores (p from 0.04 to 0.001); higher prevalence of contamination/cleaning (p = 0.006) and hoarding (p < 0.001) symptoms dimensions; more prevalent sensory phenomena (p = 0.023); higher levels of depression (p = 0.007); and more prevalent comorbidity with bipolar affective disorder (p = 0.05) and post-traumatic stress disorder (PTSD) (p = 0.04). After analyzing the logistic regression, we conclude that the most important factors associated with poor insight are: the presence of any sensory phenomena (OR: 2.24), use of neuroleptics (OR: 1.66), and hoarding symptoms (OR: 1.15). Conclusion: The variability of insight in patients with OCD seems to be an important psychopathological characteristic in the differentiation of possible subtypes of OCD, since the poor insight is associated with sensory phenomena and greater use of neuroleptics, which makes it possible to conjecture the role of dopaminergic neurocircuits in the neurobiology of this disorder. In addition, there is also an association with the symptoms of hoarding content, admittedly one of the symptomatic contents with less response to conventional OCD treatments. Studies based on neurobiological aspects such as neuroimaging and neuropsychology may help to elucidate more consistently the role of insight in patients with OCD and the repercussions concerning available treatments.