Improving treatments for psychotic disorders: beyond cognitive behaviour therapy for psychosis

How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication?

BACKGROUND

Antipsychotic medications (APs) are used for people with psychosis diagnoses and, increasingly for other problems and groups.

AIMS

This study examines how APs are prescribed, from the perspective of recipients.

METHODS

757 people, from 30 countries, responded to questions about their experiences with APs, in an online survey.

RESULTS

Most (70%) were told nothing about adverse effects. Fewer than 2% recalled being told about the risks of diabetes, suicidality, sexual dysfunction, or reduced life span. None recalled being told about reduced brain volume or withdrawal effects. Only 28% recalled being offered other treatments; with only 14% offered talking therapies. 46% were not told how long to take the APs; and, of those who were told something, 48% were told to take them forever. Most respondents (76%) were not told how APs work. Only 19% were satisfied with the prescribing process, and only 25% reported a good, or very good, relationship with the prescriber. Information, satisfaction with the process, and the prescriber relationship were all positively related to three self-reported outcomes: reduction of problems the drugs were prescribed for, general helpfulness, and quality of life.

CONCLUSIONS

Steps need to be taken to ensure people prescribed antipsychotics are fully informed, especially about adverse effects and alternatives.

How does loneliness interact with positive, negative and depressive symptoms of psychosis? New insights from a longitudinal therapy process study

Cross-sectional research suggests an association between loneliness and psychotic symptoms, but the causal direction of this association is still unclear. Even though loneliness has been proposed as a potential treatment target to improve psychotherapy for psychosis, not much is known about its role in the treatment process. In this study, we re-analyzed data from a therapy process study to investigate the temporal dynamics between loneliness and psychotic symptoms throughout therapy and to explore whether state-of-the-art CBT for psychosis (CBTp) decreases loneliness. Over the course of up to 45 weekly sessions of CBTp, 57 patients reported their feelings of loneliness and current positive, negative and depressive symptom levels at each session. Multilevel regression revealed a reduction in all symptoms over time, but no reduction in loneliness. Time-lagged multilevel regression showed that loneliness predicted subsequent negative and depressive symptoms, whereas positive symptom levels predicted subsequent loneliness. Thus, changes in loneliness seem to be both cause and consequence of psychotic symptom changes. These findings highlight the importance of loneliness as a treatment target, particularly in patients with negative symptoms and depression. Future research should address loneliness-specific interventions as an augmentation of state-of-the-art CBTp.

Schizophrenia, the very idea: On self-disorder, hyperreflexivity, and the diagnostic concept

The purpose of the present article is to consider schizophrenia-the very idea-from the perspective of phenomenological psychopathology, with special attention to the problematic nature of the diagnostic concept as well as to the prospect and challenges inherent in focusing on subjective experience. First, we address historical and philosophical topics relevant to the legitimacy of diagnostic categorization-in general and regarding "schizophrenia" in particular. William James's pragmatist approach to categorization is discussed. Then we offer a version of the well-known basic-self or ipseity-disturbance model (IDM) of schizophrenia, but in a significantly revised form (IDMrevised). The revised model better acknowledges the diverse and even seemingly contradictory nature of schizophrenic symptoms while, at the same time, interpreting these in a more unitary fashion via the key concept of hyperreflexivity-a form of exaggerated self-awareness that tends to undermine normal world-directedness and the stability of self-experience. Particular attention is paid to forms of exaggerated "self-presence" that are sometimes neglected yet imbue classically schizophrenic experiences involving subjectivism or quasi-solipsism and/or all-inclusive or ontological forms of paranoia. We focus on the distinctively paradoxical nature of schizophrenic symptomatology. In concluding we consider precursors in the work of Klaus Conrad, Kimura Bin and Henri Grivois. Finally we defend the concept of schizophrenia by considering its distinctive way of altering certain core aspects of the human condition itself.

Self-Disorder in Schizophrenia: A Revised View (1. Comprehensive Review-Dualities of Self- and World-Experience)

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum disorders. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. The following 2 articles aim to provide further clarification of the nature of self-disorders in schizophrenia by offering a comprehensive review (article 1) and theoretical revision (article 2) of the currently most influential model of altered selfhood in schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). This article presents a state-of-the-art overview of the current self-disturbance model and critically assesses its descriptive adequacy with respect to the clinical variability and heterogeneity of the alterations in self- and world-awareness characteristic of schizophrenia. Special attention is paid to experiences of exaggerated basic self, increased "grip" or "hold" on the world, and paradoxical combinations. The next article proposes a theoretical revision of the self-disturbance model by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the phenomenologically heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline the implications of our revised model for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

Self-Disorder in Schizophrenia: A Revised View (2. Theoretical Revision-Hyperreflexivity)

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum conditions. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. This is the second of two articles that aim to clarify the nature of self-disorders in schizophrenia by considering the currently most influential, phenomenological model of schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). The previous paper (article 1) presented a state-of-the-art overview of this model and critically assessed its descriptive adequacy with respect to the clinical heterogeneity and variability of the alterations in self- and world-awareness characteristic of schizophrenia. This paper (article 2) proposes a theoretical revision by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline implications of our revised model (IDMrevised) for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

The self, neuroscience and psychosis study: Testing a neurophenomenological model of the onset of psychosis

AIM

Basic self disturbance is a putative core vulnerability marker of schizophrenia spectrum disorders. The primary aims of the Self, Neuroscience and Psychosis (SNAP) study are to: (1) empirically test a previously described neurophenomenological self-disturbance model of psychosis by examining the relationship between specific clinical, neurocognitive, and neurophysiological variables in UHR patients, and (2) develop a prediction model using these neurophenomenological disturbances for persistence or deterioration of UHR symptoms at 12-month follow-up.

METHODS

SNAP is a longitudinal observational study. Participants include 400 UHR individuals, 100 clinical controls with no attenuated psychotic symptoms, and 50 healthy controls. All participants complete baseline clinical and neurocognitive assessments and electroencephalography. The UHR sample are followed up for a total of 24 months, with clinical assessment completed every 6 months.

RESULTS

This paper presents the protocol of the SNAP study, including background rationale, aims and hypotheses, design, and assessment procedures.

CONCLUSIONS

The SNAP study will test whether neurophenomenological disturbances associated with basic self-disturbance predict persistence or intensification of UHR symptomatology over a 2-year follow up period, and how specific these disturbances are to a clinical population with attenuated psychotic symptoms. This may ultimately inform clinical care and pathoaetiological models of psychosis.

Schizophrenia in the mind, the brain and the body

The author describes three lines of research programs that have guided her goal of elucidating the etiology of schizophrenia: working memory and representational guidance of behavior, disrupted social cognition and bodily-self disturbances.

Personality traits and transition to psychosis one year after the first assessment

Introduction

Several studies have identified ultra-high-risk criteria that may characterize an at-risk mental state and predict the transition of psychotic evolution. Personality traits may play a crucial role in this process.

Aims

The current study aims to: (a) explore the evolution of an initial diagnosis over 12 months; (b) assess differences in social and occupational functioning; (c) identify common (trans-diagnostic) personality traits of psychotic risk.

Methods

The sample includes 97 (44 males and 53 females) young adults. They completed an assessment that consists of socio-demographic data, the Social and Occupational Functioning Scale, the Early Recognition Inventory-retrospective assessment onset of schizophrenia, and the Personality Inventory for DSM-5 (PID-5). According to the tests' assessment, the sample was divided into three different groups: Ultra-High Risk (UHR), At-Risk, and Not at risk. One year after the first evaluation, psychiatrists administered the QuickSCID-5 to verify the diagnostic trajectories of the sample.

Results

Overall, the most prevalent category diagnoses were anxiety/depression, personality disorders, and psychosis. Specifically, the most common diagnosis in the UHR group was psychosis. Moreover, in the UHR group, the social and occupational functioning score was the lowest. In terms of differences in PID-5 personality traits, the At-risk and UHR groups scored highest in detachment and disinhibition. No statistically significant differences were found between the groups for negative affectivity, antagonism, and psychoticism traits.

Conclusion

Results obtained by the current study should be considered an attempt to better understand the diagnostic trajectories and trans-diagnostic personality traits in a group of young help-seekers, specifically in UHR. Findings highlight both the importance of diagnosis and personality traits evaluation to customize a specific intervention based on the level of psychotic risk. Clinical suggestions are reported.

A network analysis of anxiety, depressive, and psychotic symptoms and functioning in children and adolescents at clinical high risk for psychosis

Objective

Youths at clinical high risk for psychosis (CHR-P) are characterized by a high prevalence of anxiety and depressive disorders. The present study aimed at developing and analyzing a network structure of CHR-P symptom domains (i.e., positive, negative, disorganization, and general subclinical psychotic symptoms), depressive and anxiety symptoms, and general functioning.

Methods

Network analysis was applied to data on 111 CHR-P children and adolescents (M age = 14.1), who were assessed using the Structured Interview for Prodromal Syndromes, the Children's Depression Inventory, the Children's Global Assessment Scale, and the Multidimensional Anxiety Scale for Children.

Results

In the network, negative and disorganization symptoms showed the strongest association (r = 0.71), and depressive and anxiety symptoms showed dense within-domain connections, with a main bridging role played by physical symptoms of anxiety. The positive symptom cluster was not associated with any other node. The network stability coefficient (CS) was slightly below 0.25, and observed correlations observed ranged from 0.35 to 0.71.

Conclusion

The lack of association between subclinical positive symptoms and other network variables confirmed the independent nature of subclinical positive symptoms from comorbid symptoms, which were found to play a central role in the analyzed network. Complex interventions should be developed to target positive and comorbid symptoms, prioritizing those with the most significant impact on functioning and the most relevance for the young individual, through a shared decision-making process. Importantly, the results suggest that negative and disorganization symptoms, as well as depressive and anxiety symptoms, may be targeted simultaneously.

Uncovering the realities of delusional experience in schizophrenia: a qualitative phenomenological study in Belgium

BACKGROUND

Delusions in schizophrenia are commonly approached as empirical false beliefs about everyday reality. Phenomenological accounts, by contrast, have suggested that delusions are more adequately understood as pertaining to a different kind of reality experience. How this alteration of reality experience should be characterised, which dimensions of experiential life are involved, and whether delusional reality might differ from standard reality in various ways is unclear and little is known about how patients with delusions value and relate to these experiential alterations. This study aimed to investigate the nature of delusional reality experience, and its subjective apprehension, in individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis.

METHODS

In this qualitative phenomenological study, we recruited individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis from two psychiatric-hospital services in Belgium using homogenous sampling. Criteria for participation were having undergone at least one psychotic episode with occurring delusional symptoms, present at least 1 year before participation, on the basis of clinical notes assessed by the attending psychiatrist; a schizophrenia-spectrum diagnosis, ascertained through clinical interview by the attending psychiatrist upon admission; being aged between 18 years and 65 years; and having the capacity to give informed consent. Exclusion criteria included worries concerning capacity to consent and risk of distress caused by participation. We did phenomenologically driven semi-structured interviews with the participants to explore the nature of delusional reality experience and their subjective valuation of these experiences. We used interpretative phenomenological analysis, a qualitative method tailored to the in-depth exploration of participants' first-person perspective, to analyse their accounts.

FINDINGS

Between March 2, 2020, and Sept 30, 2020, 18 adults (13 men and five women, aged 19-62 years) participated in the interview study. The findings suggest that delusions are often embedded in wide-ranging alterations of basic reality experience, involving quasi-ineffable atmospheric and ontological qualities that undermine participants' sense of the world as unambiguously real, fully present, and shared with others. We also found that delusional reality experience can differ from standard reality in various ways (ie, in a hypo-real and hyper-real form), across multiple dimensions (eg, meaningfulness, necessity and contingency, and detachment and engagement), and that participants are often implicitly or explicitly aware of the distinction between delusional and standard reality. Delusional experience can have an enduring value and meaning that is not fully captured by a strictly medical perspective.

INTERPRETATION

Increased awareness and recognition of the distinctive nature of delusional reality experience, in both clinical and research settings, can improve diagnostic accuracy, explanatory models, and therapeutic support for individuals with delusions whose lived realities are not always evident from an everyday perspective.

FUNDING

FWO Flanders.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

BACKGROUND

Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients.

METHODS

Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists' notes, and open interviews on a sub-group of patients were qualitatively analyzed.

RESULTS

Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone.

CONCLUSION

This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.