From social experience to illness experience: reviewing the psychological mechanisms linking psychosis with social context

Socio-Motor Improvisation in Schizophrenia: A Case-Control Study in a Sample of Stable Patients

Improvising is essential for human development and is one of the most important characteristics of being human. However, how mental illness affects improvisation remains largely unknown. In this study we focused on socio-motor improvisation in individuals with schizophrenia, one of the more debilitating mental disorder. This represents the ability to improvise gestures during an interaction to promote sustained communication and shared attention. Using a novel paradigm called the mirror game and recently introduced to study joint improvisation, we recorded hand motions of two people mirroring each other. Comparing Schizophrenia patients and healthy controls skills during the game, we found that improvisation was impaired in schizophrenia patients. Patients also exhibited significantly higher difficulties to being synchronized with someone they follow but not when they were leaders of the joint improvisation game. Considering the correlation between socio-motor synchronization and socio-motor improvisation, these results suggest that synchronization does not only promote affiliation but also improvisation, being therefore an interesting key factor to enhance social skills in a clinical context. Moreover, socio-motor improvisation abnormalities were not associated with executive functioning, one traditional underpinning of improvisation. Altogether, our results suggest that even if both mental illness and improvisation differ from normal thinking and behavior, they are not two sides of the same coin, providing a direct evidence that being able to improvise in individual situations is fundamentally different than being able to improvise in a social context.

Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition

Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored.

Social functioning and subclinical psychosis in adolescence: a longitudinal general adolescent population study

OBJECTIVES

To investigate the longitudinal relationship between subclinical psychotic symptoms and social functioning in a representative general population sample of adolescents.

METHOD

Data were derived from a routine general health screening of 1909 adolescents in a circumscribed region. Baseline measurement was in the second grade of secondary school (T0), and follow-up occurred approximately 2 years later (T1). Social functioning and subclinical psychotic symptoms of hallucinations and delusions were assessed at both time points.

RESULTS

Baseline (T0) social problems preceded follow-up (T1) subclinical delusions, but not T1 subclinical hallucinations. Similarly, T0 delusions preceded social problems at T1, but T0 hallucinations did not.

CONCLUSION

This longitudinal general population study demonstrated a bidirectional association between social problems and delusions, but found no link between social problems and hallucinations. This may reflect a downward negative spiral where delusional thoughts and social problems reinforce each other.

Prospective Validation of the Decalogue, a Set of Doctor-Patient Communication Recommendations to Improve Patient Illness Experience and Mood States within a Hospital Cardiologic Ambulatory Setting

Strategies to improve doctor-patient communication may have a beneficial impact on patient's illness experience and mood, with potential favorable clinical effects. We prospectively tested the psychometric and clinical validity of the Decalogue, a tool utilizing 10 communication recommendations for patients and physicians. The Decalogue was administered to 100 consecutive patients referred for a cardiologic consultation, whereas 49 patients served as controls. The POMS-2 questionnaire was used to measure the total mood disturbance at the end of the consultation. Structural equation modeling showed high internal consistency (Cronbach alpha 0.93), good test-retest reproducibility, and high validity of the psychometric construct (all > 0.80), suggesting a positive effect on patients' illness experience. The total mood disturbance was lower in the patients exposed to the Decalogue as compared to the controls (1.4 ± 12.1 versus 14.8 ± 27.6, p = 0.0010). In an additional questionnaire, patients in the Decalogue group showed a trend towards a better understanding of their state of health (p = 0.07). In a cardiologic ambulatory setting, the Decalogue shows good validity and reliability as a tool to improve patients' illness experience and could have a favorable impact on mood states. These effects might potentially improve patient engagement in care and adherence to therapy, as well as clinical outcome.

Social priming enhances interpersonal synchronization and feeling of connectedness towards schizophrenia patients

What leads healthy individuals to abnormal feelings of contact with schizophrenia patients remains obscure. Despite recent findings that human bonding is an interactive process influenced by coordination dynamics, the spatiotemporal organization of the bodily movements of schizophrenia patients when interacting with other people is poorly understood. Interpersonal motor coordination between dyads of patients (n = 45) or healthy controls (n = 45), and synchronization partners (n = 90), was assessed with a hand-held pendulum task following implicit exposure to pro-social, non-social, or anti-social primes. We evaluated the socio-motor competence and the feeling of connectedness between participants and their synchronization partners with a measure of motor coordination stability. Immediately after the coordination task, all participants were also asked to rate the likeableness of their interacting partner. Our results showed greater stability during interpersonal synchrony in schizophrenia patients who received pro-social priming, inducing in their synchronization partner greater feelings of connectedness towards patients. This greater feeling of connectedness was positively correlated with stronger motor synchronization between participants suggesting that motor coordination partly underlies patients' social interactions and feelings of contact with others. Pro-social priming can have a pervasive effect on abnormal social interactions in schizophrenia patients.

Association between Genetic Variation in the Oxytocin Receptor Gene and Emotional Withdrawal, but not between Oxytocin Pathway Genes and Diagnosis in Psychotic Disorders

Social dysfunction is common in patients with psychotic disorders. Oxytocin is a neuropeptide with a central role in social behavior. This study aims to explore the relationship between oxytocin pathway genes and symptoms related to social dysfunction in patients with psychotic disorders. We performed association analyses between four oxytocin pathway genes (OXT, OXTR, AVP, and CD38) and four areas of social behavior-related psychopathology as measured by Positive and Negative Syndrome Scale. For this purpose, we used both a polygenic risk score (PGRS) and single OXTR candidate single nucleotide polymorphism previously reported in the literature (rs53576, rs237902, and rs2254298). A total of 734 subjects with DSM-IV psychotic spectrum disorders and 420 healthy controls were included. Oxytocin pathway PGRSs were calculated based on the independent Psychiatric Genomics Consortium study sample. There was a significant association between symptom of Emotional Withdrawal and the previously reported OXTR risk allele A in rs53576. No significant associations between oxytocin pathway gene variants and a diagnosis of psychotic disorder were found. Our findings indicate that while oxytocin pathway genes do not appear to contribute to the susceptibility to psychotic disorders, variations in the OXTR gene might play a role in the development of impaired social behavior.

Prediction and prevention of psychosis: current progress and future tasks

Prevention of psychoses has been intensively investigated within the past two decades, and particularly, prediction has been much advanced. Depending on the applied risk indicators, current criteria are associated with average, yet significantly heterogeneous transition rates of ≥30 % within 3 years, further increasing with longer follow-up periods. Risk stratification offers a promising approach to advance current prediction as it can help to reduce heterogeneity of transition rates and to identify subgroups with specific needs and response patterns, enabling a targeted intervention. It may also be suitable to improve risk enrichment. Current results suggest the future implementation of multi-step risk algorithms combining sensitive risk detection by cognitive basic symptoms (COGDIS) and ultra-high-risk (UHR) criteria with additional individual risk estimation by a prognostic index that relies on further predictors such as additional clinical indicators, functional impairment, neurocognitive deficits, and EEG and structural MRI abnormalities, but also considers resilience factors. Simply combining COGDIS and UHR criteria in a second step of risk stratification produced already a 4-year hazard rate of 0.66. With regard to prevention, two recent meta-analyses demonstrated that preventive measures enable a reduction in 12-month transition rates by 54-56 % with most favorable numbers needed to treat of 9-10. Unfortunately, psychosocial functioning, another important target of preventive efforts, did not improve. However, these results are based on a relatively small number of trials; and more methodologically sound studies and a stronger consideration of individual profiles of clinical needs by modular intervention programs are required.

Cognitive remediation for individuals with psychosis in a supported education setting: a randomized controlled trial

Cognitive remediation (CR) has demonstrated good outcomes when paired with supported employment, however little is known about its effectiveness when integrated into a supported education program. This randomized controlled trial examined the effectiveness of integrating CR within a supported education program compared with supported education without CR. Thirty-seven students with psychosis were recruited into the study in the 2012 academic year. Academic functioning, cognition, self-esteem, and symptomatology were assessed at baseline, at 4months following the first academic term in which CR was provided, and at 8months assessing maintenance of gains. The treatment group demonstrated better retention in the academic program and a trend of improvement across a range of academic functional domains. While both treatment and control groups showed improvement in cognitive measures, the outcomes were not augmented by CR training. CR was also associated with significant and sustained improvements in self esteem. Further research, investigating specific intervention components is required to clarify the mixed findings regarding the effectiveness of CR in an education setting.

The role of gender in housing for individuals with severe mental illness: a qualitative study of the Canadian service context

OBJECTIVE

This study was undertaken to examine the role of gender as it relates to access to housing among individuals with severe mental illness (SMI) in Canada.

DESIGN

An exploratory, qualitative approach was used to assess the perspectives of Canadian housing experts. The focus of inquiry was on the role of gender and associated intersections (eg, ethnicity) in pathways to housing access and housing needs for individuals with SMI.

SETTING

A purposeful sampling strategy was undertaken to access respondents across all Canadian geographic regions, with diversity across settings (urban and rural) and service sectors (hospital based and community based).

PARTICIPANTS

-29 individuals (6 men and 23 women) considered to be experts in a housing service context as it pertains to SMI were recruited. On average, participants had worked for 15 years in services that specialised in the support and delivery of housing services to people with SMI.

MEASURES

Semistructured interviews with participants focused on the role gender plays in access to housing in their specific context. Barriers and facilitators were examined as were intersections with other relevant factors, such as ethnicity, poverty and parenthood. Quantitative ratings of housing accessibility as a function of gender were also collected.

RESULTS

Participants across geographic contexts described a lack of shelter facilities for women, leading to a reliance on exploitative circumstances. Other findings included a compounding of discrimination for ethnic minority women, the unique resource problems faced in rural contexts, and the difficulties that attend access to shelter and housing for parents with SMI.

CONCLUSIONS

These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender.