Response to psychotic experiences: Impact of personality traits on perceived levels of distress

BACKGROUND

This study examined the influence of personality traits on (subclinical) positive symptom distress in patients with a psychotic disorder, their unaffected siblings and healthy controls.

METHODS

Data were obtained from the Genetic Risk and Outcome of Psychosis study (GROUP), a Dutch longitudinal multicenter cohort study. Data from 140 patients, 216 unaffected siblings and 102 healthy controls was available for baseline levels of Five Factor Model personality traits and frequency and distress due to psychotic experiences three years later, assessed with the Community Assessment of Psychic Experience questionnaire. Main effects of all five personality traits on symptom distress were investigated as well as moderating effects of Neuroticism, Extraversion and Openness on positive symptom frequency and positive symptom distress. Age, gender, symptom frequency and IQ were controlled for.

RESULTS

In both patients and siblings, the observed main effects of Neuroticism and Openness on (subclinical) positive symptom distress three years later either lost significance or had a very small effect size when controlling for covariates, mainly due to the correction for the effect of positive symptoms on personality traits at baseline. In both groups, levels of Openness at baseline moderated the association between positive symptom frequency and positive symptom distress three years later, in the direction that higher levels of Openness were associated with weaker associations between positive symptom frequency and - distress, even when covariates were controlled for.

DISCUSSION

The level of Openness to Experiences influences the perceived distress from (subclinical) positive symptoms in both patients and siblings.

Antipsychotics and Identity: The Adverse Effect No One is Talking About

People who take antipsychotics, and people who are prescribed antipsychotics without taking them, experience effects which are not frequently discussed: effects on their identity and sense of self. Qualitative research indicates the relationship between taking APs and identity is multilayered, and changeable. Taking APs can restore people to their earlier, pre-symptom sense of self. Being prescribed and taking APs can also, on the other hand, be experienced as damaging, erasing and dulling people's sense of who they are. This complexity deserves exploration in clinical practice, which we believe is currently not done routinely. More work is needed to understand whether, and how, the relationship between identity and APs is being addressed. We outline the importance of having discussions in a clinical space around identity, and a sense of agency, on the grounds that true recovery-oriented care, which enacts shared decision-making principles, demands it. Further, we argue that it will allow for better therapeutic alliance and trust to be forged between clinician and client, ultimately leading to better care.

Financial dissatisfaction in people with psychotic disorders - A short report on its prevalence and correlates in a large naturalistic psychosis cohort

Psychotic disorders have a strong negative impact on multiple aspects of daily life, including people's financial situation. This exploratory study examines the level of financial dissatisfaction and its correlates in a large cohort of people with psychotic disorders. Data from the first assessments of people with psychotic disorders (n = 5271) who were included in the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS; 2006-2020), which is conducted in the northern Netherlands, were used. The Manchester Short Assessment of Quality of Life (MANSA) was used to measure financial dissatisfaction. In addition, sociodemographic and psychiatric characteristics, substance use and global and social functioning were assessed. One-fifth to one-third of people with psychotic disorders report financial dissatisfaction, fluctuating over the year in which they were assessed. These proportions are considerably higher than in the general population. Cannabis and other substance use were associated with higher levels of financial dissatisfaction (small to medium effect). The other significant associations showed (very) small effect sizes. Therefore, we conclude that financial dissatisfaction in people with psychotic disorders appears to be relatively independent of other demographic and psychiatric characteristics, and global and social functioning. These findings are an important first step for increasing knowledge on financial dissatisfaction among people with psychotic disorders. The findings can also contribute to raising awareness about the topic for healthcare professionals working in this field.

VR-SOAP, a modular virtual reality treatment for improving social activities and participation of young people with psychosis: a study protocol for a single-blind multi-centre randomized controlled trial

BACKGROUND

Young people with a psychotic disorder have the same social goals as their healthy peers, but their social networks are smaller, they participate less often in leisure activities and are less successful in work and education. Causes of these problems are multifaceted, but culminate in difficulties with interacting in daily life social situations. Current treatments have only moderate effects on social functioning and often target one specific domain. Virtual reality (VR) has the potential to improve the treatment of social interaction difficulties. We developed a modular VR treatment for social functioning and participation (VR-SOAP). In this study, the effect of this intervention will be investigated in a randomized controlled trial (RCT).

METHODS

A total of 116 participants (age 18-40) with a DSM-5 diagnosis of schizophrenia spectrum or other psychotic disorder and problems with social functioning will be recruited from mental healthcare institutes in the Netherlands. Participants will be randomized to the experimental condition (VR-SOAP) or active VR control condition (VRelax). VR-SOAP consists of 14 sessions and 5 modules addressing causes of impaired social functioning: four optional modules (1-4) and one fixed module (5). Vrelax consists of 14 sessions that entail psychoeducation, stress management, relaxation techniques, and the exploration of relaxing environments in VR. Primary outcomes are quantity and quality of social contacts, leisure activities and social participation, measured with the experience sampling method (ESM). Secondary outcomes are psychiatric symptoms, social behaviour, social cognition, self-esteem, self-stigma and paranoid thoughts. Treatment effects will be compared at pre-treatment (baseline), post-treatment and at 6-month follow-up.

DISCUSSION

If VR-SOAP proves to be effective, it provides therapists with a much-needed tool to improve social functioning of young adults with a psychotic disorder. Additionally, since the treatment consists of multiple modules targeting different transdiagnostic factors, this trial might provide input for new treatments to improve social functioning in a range of symptoms and disorders, e.g. mood, autism spectrum and anxiety disorders.

TRIAL REGISTRATION

On the 10th of November 2021, this trial was registered prospectively in the Dutch Trial Register as NL9784 .

Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) versus Virtual Reality Relaxation (VRelax) for People With a Psychotic Disorder: A Single-Blind Multicenter Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

Social cognition training (SCT), an intervention for social cognition and social functioning, might be improved by using virtual reality (VR), because VR may offer better opportunities to practice in a potentially more realistic environment. To date, no controlled studies have investigated VR-SCT. This study investigated a VR-SCT, "DiSCoVR". We hypothesized that DiSCoVR would improve social cognition and social functioning.

STUDY DESIGN

Participants were randomized to DiSCoVR (n = 41) or VR relaxation ('VRelax', n = 40), an active control condition, and completed 16 twice-weekly sessions. Three assessments (baseline, posttreatment, and 3-month follow-up) were performed by blinded assessors. The primary outcome was social cognition (emotion perception and theory of mind). Secondary outcomes included social functioning (measured with an interview and experience sampling), psychiatric symptoms, information processing, and self-esteem. Data were analyzed using mixed-models regression analysis. Treatment effects were evaluated by the time by condition interaction terms.

STUDY RESULTS

No significant time by condition interactions were found for any of the outcome variables, indicating an absence of treatment effects. Between-group effect sizes ranged from negligible to moderate (Cohen's d < |0.53|). Main effects of time were found for several outcomes.

CONCLUSIONS

These results suggest that DiSCoVR was not effective, possibly because of inadequate simulation of emotional expressions in VR. This lack of efficacy may indicate that current SCT protocols are relatively unsuitable for improving social functioning. Previous studies showed small to moderate effects on higher order social cognition, but the SCT approach may need critical reevaluation, as it may not sufficiently lead to functional improvement.

Personality traits in psychotic illness and their clinical correlates: A systematic review

This systematic review focuses on personality traits according to both the Five Factor Model and Cloninger Psychobiological Model in relation to treatment related outcome variables across all stages of clinical psychotic illness. Search of Pubmed and Psychinfo databases led to final inclusion of 65 studies, which were ranked on quality and analyzed according to the associations between personality and outcome. Main findings are that higher levels of Harm Avoidance and Neuroticism are associated with higher symptom levels, tendency towards passive coping, greater self-stigma, lower quality of life, and Harm Avoidance to higher suicidality. Higher levels of Extraversion and higher levels of Self-Directedness are associated with more preference for active coping, more intrinsic motivation and higher self-esteem. Higher Novelty Seeking is related to more substance use and aggression, in men specifically. On outcome of trauma, care consumption and duration of untreated illness no consistent associations with personality traits were found. Combined evidence from both personality models however reveals a consistent pattern of personality traits related to clinical outcome in psychotic disorder, which is discussed in a dimensional manner.

Communicating diagnoses to individuals with a first episode psychosis: A qualitative study of individuals perspectives

BACKGROUND

Receiving the label of a psychotic disorder influences self-perception and may result in negative outcomes such as self-stigma and decreased self-esteem. The way the diagnosis is communicated to individuals may affect these outcomes.

AIMS

This study aims to explore the experiences and needs of individuals after a first episode of psychosis with regard to the way in which information about diagnosis, treatment options and prognosis is communicated with them.

DESIGN AND METHODS

A descriptive interpretative phenomenological approach was used. Fifteen individuals who experienced a first episode of psychosis participated in individual semi-structured open-ended interviews on their experiences and needs regarding the process of providing information about diagnosis, treatment options and prognosis. Inductive thematic analysis was used to analyze the interviews.

RESULTS

Four recurring themes where identified (1) timing (when); (2) content (what); and (3) the way information is provided (how). Individuals also reported that the provided information could elicit an emotional reaction, for which they would require specific attention, therefore the fourth theme is (4) reactions and feelings.

CONCLUSION

This study provides new insights into the experiences and specific information needed by individuals with a first episode of psychosis. Results suggest that individuals have different needs regarding the type of (what), how and when to receive information about diagnosis and treatment options. This requires a tailor-made process of communicating diagnosis. A guideline on when, how and what to inform, as well as providing personalized written information regarding the diagnosis and treatment options, is recommended.

Determinants of Quality of Life and Treatment Satisfaction During Long-Term Involuntary In-patient Treatment of Dual-Diagnosis Patients

INTRODUCTION

Treatment resistance and disengagement from mental health services are major obstacles in the treatment of dual diagnosis patients with Severe Mental Illness. The patients in this study were admitted to a long-term involuntary treatment facility.

AIM OF THE STUDY

To study which patient experiences and perceptions are related to the outcome measures Subjective Quality of Life (SQOL) and Treatment Satisfaction (TS) during the long-term involuntary treatment.

METHODS

Patients were invited for an interview by an independent researcher, which included self-report questionnaires. The structured interviews included self-assessing Helping Alliance, Insight, Attitude toward involuntary admission, Perceived coercion and Perceived benefit were studied as determinants of SQOL and TS. The relationship between the determinants and the outcomes were analyzed by linear regression analysis.

RESULTS

Patient reported outcomes from dual diagnosis patients in a long-term treatment facility, showed that most of the patients, in spite of the involuntary character of the treatment, were satisfied with the treatment. With respect to the determinants of SQOL and TS the perceptions that "My opinion is taken into account" and "Perceived benefits of the treatment" are strong predictors of both the outcomes.

CONCLUSIONS

The current study shows that the most important aspects for treatment satisfaction and quality of life of dual-diagnosis patients admitted involuntary to long-term treatment, are being listened to (being taken seriously) and experiencing improvements during treatment. These qualities reflect the goals of Shared Decision Making and Perceived Procedural Justice in treatment. The study also corroborates earlier findings that even when treated involuntarily, patients might not hold particular negative views regarding their treatment.

Yoga-Based Group Intervention for In-patients With Schizophrenia Spectrum Disorders-A Qualitative Approach

Background: Yoga may pose a promising complementary therapy in the multimodal treatment of in-patients with schizophrenia spectrum disorders (SSD). However, to date, no studies have qualitatively examined in-patients' with SSD experiences of Yoga as well as their perceptions of its limitations and benefits as a treatment component. This qualitative study aimed to explore for the first time the mechanisms and processes of Yoga-based Group Intervention (YoGI) for in-patients with SSD in Germany by asking for their subjective experiences. Findings could serve as a preliminary basis for developing an effective and evidence-based YoGI manual tailored to this patient group. Materials and Methods: In total, 25 semi-structured interviews were conducted directly after YoGI, for which responses were either noted down by hand or audio-recorded. The interview guide was pilot-tested and consisted of 14 questions to explore the personal articulated experiences of participation in YoGI from in-patients with SSD. Positive, negative, depressive, and anxiety symptoms were assessed during a diagnostic interview and through questionnaires. The interview data was transcribed, coded by two independent researchers, and analysed using an inductive thematic approach. The research team collaboratively discussed emerging categories to reduce redundancy and form meaningful themes and subthemes. Results: The analysis revealed seven main themes. YoGI was perceived as feasible and focusing on individual adaptation, captured by the theme inclusivity. Nevertheless, participants encountered challenges; thus, physical limitations need to be considered. While practising together, participants experienced interconnectedness and developed a mindful stance as they accepted their limitations and adapted exercises with self-compassion. Patients described that following the flow of the asanas required physical persistence, which ultimately led many participants to experience confidence and relaxation. YoGI affected symptom representation as heightened awareness led participants to notice impeding as well as improved symptoms. Conclusion: YoGI showed various promising effects on in-patients with SSD. Future research should examine to what extent these effects can be sustained and how the mindful approach during YoGI can be transferred to areas outside the Yoga class. Furthermore, a randomised controlled trial could investigate the effectiveness of a manualised YoGI.

Improving cognition in severe mental illness by combining cognitive remediation and transcranial direct current stimulation: study protocol for a pragmatic randomized controlled pilot trial (HEADDSET)

Background

A fundamental challenge for many people with severe mental illness (SMI) is how to deal with cognitive impairments. Cognitive impairments are common in this population and limit daily functioning. Moreover, neural plasticity in people with SMI appears to be reduced, a factor that might hinder newly learned cognitive skills to sustain. The objective of this pilot trial is to investigate the effects of cognitive remediation (CR) on cognitive and daily functioning in people dependent on residential settings. In addition, transcranial direct current stimulation (tDCS) is used to promote neural plasticity. It is expected that the addition of tDCS can enhance learning and will result in longer-lasting improvements in cognitive and daily functioning.

Methods

This is a pragmatic, triple-blinded, randomized, sham-controlled, pilot trial following a non-concurrent multiple baseline design with the participants serving as their own control. We will compare (1) CR to treatment as usual, (2) active/sham tDCS+CR to treatment as usual, and (3) active tDCS+CR to sham tDCS+CR. Clinical relevance, feasibility, and acceptability of the use of CR and tDCS will be evaluated. We will recruit 26 service users aged 18 years or older, with a SMI and dependent on residential facilities. After a 16-week waiting period (treatment as usual), which will serve as a within-subject control condition, participants will be randomized to 16 weeks of twice weekly CR combined with active (N = 13) or sham tDCS (N = 13). Cognitive, functional, and clinical outcome assessments will be performed at baseline, after the control (waiting) period, directly after treatment, and 6-months post-treatment.

Discussion

The addition of cognitive interventions to treatment as usual may lead to long-lasting improvements in the cognitive and daily functioning of service users dependent on residential facilities. This pilot trial will evaluate whether CR on its own or in combination with tDCS can be a clinically relevant addition to further enhance recovery. In case the results indicate that cognitive performance can be improved with CR, and whether or not tDCS will lead to additional improvement, this pilot trial will be extended to a large randomized multicenter study.

Trial registration

Dutch Trial Registry NL7954. Prospectively registered on August 12, 2019.

The association of cannabis use with quality of life and psychosocial functioning in psychosis

BACKGROUND

Cannabis use is highly prevalent among people with a psychotic disorder. They often report sociality, coping with unpleasant affect and having positive experiences as important reasons for cannabis use, suggesting that cannabis improves their quality of life (QoL) and psychosocial functioning. However, based on previous studies we hypothesize that cannabis use is negatively associated with long-term subjective QoL and psychosocial functioning in people with a psychotic disorder.

METHODS

We included 2994 people with a psychotic disorder (36.4% female), mean age 44.4 (SD 11.9), mean illness duration 17.2 years (SD 11.1), who participated in two yearly routine outcome assessments between 2014 and 2018 (interval 9-15 months) from the naturalistic PHAMOUS cohort study. Linear regression analyses were used to examine whether first assessment cannabis use was associated with QoL (ManSA) and psychosocial functioning (HoNOS). Changes in outcomes between assessments were analyzed with AN(C)OVA, to examine differences between continuers (n = 255), discontinuers (n = 85), starters (n = 83) and non-users (n = 2571).

RESULTS

At first assessment, 11.4% was using cannabis. They had lower QoL (B = -2.93, p < 0.001) and worse psychosocial functioning (B = 1.03, p = 0.002) than non-users. After one year, changes in QoL and psychosocial functioning were not significantly different between continuers, starters, discontinuers and non-users.

CONCLUSIONS

Cannabis users were less satisfied with their family relations and financial situation and showed more aggressive and disruptive behavior and self-harm than non-users. These differences are likely the result of patients having used cannabis for many years. Starting or discontinuing cannabis did not lead to changes in QoL and psychosocial functioning within one year.

Empathy and Its Relationship With Social Functioning in Individuals at Ultra-High Risk for Psychosis

Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosis. There is some evidence that empathy is also impaired in this phase and that these impairments may underlie difficulties in social functioning. The main aim of this study was to investigate whether cognitive and affective empathy are lower in people in the UHR phase of psychosis in comparison to healthy controls, and whether possible impairments have the same magnitude as in people with schizophrenia. A second aim was to examine whether there is a relationship between empathy and social functioning in individuals in the UHR phase. Method: Forty-three individuals at UHR for psychosis, 92 people with a schizophrenia spectrum disorder, and 49 persons without a psychiatric disorder completed the Interpersonal Reactivity Index (IRI), Questionnaire of Cognitive and Affective Empathy (QCAE), and Faux Pas as instruments to measure empathy. The Time Use survey was used to measure social functioning. MAN(C)OVA was used to analyse differences between groups on empathy and social functioning, and correlations were calculated between empathy measures and social functioning for each group. Results: The UHR group presented significantly lower levels of self-reported cognitive empathy than the healthy controls, but not compared to patients with SSD, while performance-based cognitive empathy was unimpaired in the UHR group. On the affective measures, we found that people with UHR and patients with SSD had significantly higher levels of self-reported distress in interpersonal settings compared to healthy controls. In the UHR group, perspective-taking was negatively associated with time spent on structured social activities. In the SSD group, we found that structured social activities were positively associated with perspective-taking and negatively associated with personal distress in interactions with others. Lastly, in people without mental illness, social activities were positively associated with performance-based perspective-taking. Conclusion: Impairments in subjective cognitive empathy appear to be present in the UHR phase, suggesting that difficulties in interpreting the thoughts and feelings of others precede the onset of psychotic disorders. This can inform future interventions in the UHR phase.

[Are conspiracy theorists psychotic? A comparison between conspiracy theories and paranoid delusions]

BACKGROUND

Conspiracy theories are popular during the COVID-19 pandemic. Conspiratorial thinking is characterised by the strong conviction that a certain situation that one sees as unjust is the result of a deliberate conspiracy of a group of people with bad intentions. Conspiratorial thinking appears to have many similarities with paranoid delusions.

AIM

To explore the nature, consequences, and social-psychological dimensions of conspiratorial thinking, and describe similarities and differences with paranoid delusions.

METHOD

Critically assessing relevant literature about conspiratorial thinking and paranoid delusions.

RESULTS

Conspiratorial thinking meets epistemic, existential, and social needs. It provides clarity in uncertain times and connection with an in-group of like-minded people. Both conspiratorial thinking and paranoid delusions involve an unjust, persistent, and sometimes bizarre conviction. Unlike conspiracy theorists, people with a paranoid delusion are almost always the only target of the presumed conspiracy, and they usually stand alone in their conviction. Furthermore, conspiracy theories are not based as much on unusual experiences of their inner self, reality, or interpersonal contacts. CONCLUSIONS Conspirational thinking is common in uncertain circumstances. It gives grip, certainty, moral superiority and social support. Extreme conspirational thinking seems to fit current psychiatric definitions of paranoid delusions, but there are also important differences. To make a distinction with regard to conspiratorial thinking, deepening of conventional definitions of delusions is required. Instead of the strong focus on the erroneous content of delusions, more attention should be given to the underlying idiosyncratic, changed way of experiencing reality.

Targeting Personal Recovery of People With Complex Mental Health Needs: The Development of a Psychosocial Intervention Through User-Centered Design

Long-term admissions in psychiatric facilities often result in a gradual erosion of the identity of people diagnosed with severe mental illnesses (SMIs) into merely "patient." Moreover, experiences of loss often reduced people's sense of purpose. Although regaining a multidimensional identity and a sense of purpose are essential for personal recovery, few interventions specifically address this, while at the same time take people's often considerable cognitive and communicative disabilities into consideration. This study describes the development process of a new intervention through user-centered design (UCD). UCD is an iterative process in which a product (in this case, an intervention) is developed in close cooperation with future users, such that the final product matches their needs. The design process included three phases: an analysis, design, and evaluation phase. In the analysis phase, the "problem" was defined, users' needs were identified, and design criteria were established. In the design phase, the collected information served as input to create a testable prototype using a process of design and redesign, in close collaboration with service users and other stakeholders. This resulted in an intervention entitled "This is Me" (TiM) in which service users, together with a self-chosen teammate, actively engage in new experiences on which they are prompted to reflect. Finally, in the evaluation phase, TiM was implemented and evaluated in a real-life setting. In a small feasibility pilot, we found indications that some people indeed demonstrated increased reflection on their identity during the intervention. Furthermore, TiM seemed to benefit the relationship between the service users and the mental health professionals with whom they underwent the experiences. The pilot also revealed some aspects of the (implementation of) TiM that can be improved. Overall, we conclude that UCD is a useful method for the development of a new psychosocial intervention. The method additionally increased our knowledge about necessary factors in targeting personal recovery for people with complex mental health needs. Moreover, we conclude that TiM is a promising tool for supporting people with SMI in redeveloping a multidimensional identity and a renewed sense of purpose.

Parental Efficacy Moderates the Association Between Empathy and Burden Among Parents of Children Admitted to a Psychiatric Ward

Empathy is considered a positive aspect of caregiving, although in certain circumstances, being empathic might increase the burden of caregivers. The current study assessed the associations between empathy, parental efficacy, and family burden among parents of children who were hospitalized in a psychiatric unit. Specifically, we examined whether the association between empathy and family burden was moderated by the parents' sense of self-efficacy. Seventy parents of children with psychiatric disorders, hospitalized in an inpatient psychiatric unit, filled out questionnaires of empathy, parental efficacy, and family burden. Results supported a moderating role of parental efficacy between empathy and family burden (interaction effect: β = -1.72, p = .0406). Specifically, empathy was positively related to family burden among parents with low self-efficacy (conditional effect = 0.70, p = .032) and negatively related to family burden among parents with high self-efficacy (conditional effect = -0.39, p = N.S). Implications for practice include the importance of self-efficacy and address the possible negative implications of empathy among parents of children treated in a psychiatric hospital.

Evaluation of an Adaptive Implementation Program for Cognitive Adaptation Training for People With Severe Mental Illness: Protocol for a Randomized Controlled Trial

BACKGROUND

Cognitive Adaptation Training is a psychosocial intervention that focuses on reducing the negative effects of cognitive disorders, especially executive functions such as planning and targeted action. International research has shown that Cognitive Adaptation Training enhances multiple aspects of daily functioning in people with severe mental illnesses. Despite this evidence, implementation of the intervention into routine care remains a challenge.

OBJECTIVE

In this implementation research, a newly developed implementation program based on previous experience and scientific literature, is tested. The primary aim of this research is to assess the effectiveness of the implementation program. The secondary aim of this study is to evaluate the factors that impede or facilitate the implementation of Cognitive Adaptation Training.

METHODS

To test the effectiveness of the implementation program, a multicenter cluster randomized controlled trial was conducted comparing the implementation program to a single training program in four mental health institutions in The Netherlands. Focus groups, semistructured interviews, and questionnaires were used at multiple levels of service delivery (service user, professional, team, organization) to identify factors that may hamper or facilitate implementation. The RE-AIM framework was applied to measure the implementation effectiveness. Following this framework, the primary outcomes were Reach, Intervention Effectiveness, Adoption, Implementation, and Maintenance. These are assessed before, during, and after implementation. The research had a total duration of 14 months, with a follow-up measurement at 14 months. Data will be analyzed using multilevel modeling.

RESULTS

The study was funded in April 2018. Data collection occurred between November 2018 and January 2020. In total, 21 teams of 4 mental health institutions agreed to participate. Data analysis is ongoing and results are expected to be published in December 2020.

CONCLUSIONS

This implementation research may provide important information about the implementation of psychosocial interventions in practice and may result in a program that is useful for Cognitive Adaptation Training, and possibly for psychosocial interventions in general.

TRIAL REGISTRATION

The Netherlands Trial Register (NL7989); https://www.trialregister.nl/trial/7989.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17412.

Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) for People With a Psychotic Disorder: Single-Group Feasibility and Acceptability Study

BACKGROUND

People with a psychotic disorder commonly experience problems in social cognition and functioning. Social cognition training (SCT) improves social cognition, but may inadequately simulate real-life social interactions. Virtual reality (VR) provides a realistic, interactive, customizable, and controllable training environment, which could facilitate the application of skills in daily life.

OBJECTIVE

We developed a 16-session immersive VR SCT (Dynamic Interactive Social Cognition Training in Virtual Reality [DiSCoVR]) and conducted a single-group feasibility pilot study.

METHODS

A total of 22 people with a psychotic disorder and reported problems in social cognition participated. Feasibility and acceptability were assessed using a survey for participants and therapists, and by examining relevant parameters (eg, dropouts). We analyzed preliminary treatment effects on social cognition, neurocognition, and psychiatric symptoms.

RESULTS

A total of 17 participants completed the study. Participants enjoyed DiSCoVR (mean 7.25, SD 2.05; range 3-10), thought it was useful for daily social activities (mean 7.00, SD 2.05; range 3-10), and enjoyed the combination of VR and a therapist (mean 7.85, SD 2.11; range 3-10). The most frequently mentioned strength of DiSCoVR was the opportunity to practice with personalized social situations (14/20, 70%). A significant improvement of emotion perception was observed (Ekman 60 Faces; t₁₆=-4.79, P<.001, d=-0.67), but no significant change was found in other measures of social cognition, neurocognition, psychiatric symptoms, or self-esteem.

CONCLUSIONS

DiSCoVR was feasible and acceptable to participants and therapists, and may improve emotion perception.

Insight, personality, and symptoms among individuals with psychosis: Cross-sectional and longitudinal relationships

BACKGROUND

Reports on the relationship between clinical insight and psychotic symptoms have shown inconsistent results, and the association between clinical insight and personality has rarely been addressed. The aim of this study was to examine whether personality is correlated cross-sectionally with insight level, and longitudinally with change in insight, beyond symptoms.

METHODS

Participants were a sub-sample of the Dutch Genetic Risk and Outcome of Psychosis (GROUP) project. Two hundred and eleven participants diagnosed with non-affective psychotic disorders took part in the cross-sectional part of the study, of whom 136 took part in the three-year follow-up assessment. They were administered with self-report Birchwood insight scale and NEO-Five Factor Inventory, and clinicians assessed them according to PANSS and CDS symptoms scales.

RESULTS

Cross-sectional analysis showed baseline self-report insight was positively related to neuroticism and agreeableness and negatively related to extraversion. Longitudinal analysis showed change in level of self-reported insight was predicted by baseline-insight and change in symptoms of disorganization. Personality factors did not predict insight change (as measured either by self-report or by clinician assessment).

DISCUSSION

The cross-sectional findings showed self-report insight (as opposed to clinician-rated) is associated with personality traits, suggesting negative affect is related to higher level of insight and that having insight may be influenced by the wish to comply with views of professionals, or a tendency to cover up problems. The longitudinal findings imply that not personality but change in severity of symptoms of disorganization, and possibly other variables, predicts change in insight.

Brain areas associated with clinical and cognitive insight in psychotic disorders: A systematic review and meta-analysis

In the past years, ample interest in brain abnormalities related to clinical and cognitive insight in psychosis has contributed several neuroimaging studies to the literature. In the current study, published findings on the neural substrates of clinical and cognitive insight in psychosis are integrated by performing a systematic review and meta-analysis. Coordinate-based meta-analyses were performed with the parametric coordinate-based meta-analysis approach, non-coordinate based meta-analyses were conducted with the metafor package in R. Papers that could not be included in the meta-analyses were systematically reviewed. Thirty-seven studies were retrieved, of which 21 studies were included in meta-analyses. Poorer clinical insight was related to smaller whole brain gray and white matter volume and gray matter volume of the frontal gyri. Cognitive insight was predominantly positively associated with structure and function of the hippocampus and ventrolateral prefrontal cortex. Impaired clinical insight is not associated with abnormalities of isolated brain regions, but with spatially diffuse global and frontal abnormalities suggesting it might rely on a range of cognitive and self-evaluative processes. Cognitive insight is associated with specific areas and appears to rely more on retrieving and integrating self-related information.

A qualitative evaluation of the effects of Metacognitive Reflection and Insight Therapy: 'Living more consciously'

OBJECTIVES

Extensive research showed that one of the major difficulties that people with schizophrenia spectrum disorders are struggling with involves their ability to reflect on their own and others' mental activities, also defined as metacognition. Several new psychotherapies have been developed to assist patients (re)gain metacognitive capacity, including Metacognitive Reflection and Insight Therapy (MERIT). The current study investigated the client's subjective experience of psychotherapy, to determine whether service users found MERIT effective and whether these gains align with quantitative findings, which processes they considered responsible for these benefits, in which ways participants found MERIT similar or different from other interventions, and whether they experienced non-desirable factors and outcomes.

DESIGN

All participants who had participated in a randomized controlled trial investigating the efficacy of MERIT were offered a structured post-therapy interview by an independent assessor. Fourteen out of 18 (77%) participants, all of whom had completed therapy, responded.

RESULTS

Most participants (10/14) indicated that they had experienced the therapy as beneficial to their recovery, and in general contributed to their understanding of their own thinking, which maps closely onto the quantitative findings reported elsewhere. They mainly attributed these changes to their own active role in therapy, the intervention letting them vent and self-express, and forming an alliance with the therapist.

CONCLUSIONS

Participants reports of change map closely onto the quantitative findings from the randomized controlled trial. Findings are discussed in the frameworks of the metacognitive model of psychosis and the integrative intersubjective model of psychotherapy for psychosis emphasizing the role of the clients as active agent of change.

PRACTITIONER POINTS

The use of a systematic, qualitative interview at the conclusion of therapy may yield important information regarding process and outcome. Analysis of the interview revealed that clients' perceptions regarding change within themselves closely maps onto quantitative findings. MERIT may not be the appropriate intervention for all clients; some may prefer a more solution-oriented approach such as CBTp or Metacognition-Oriented Social Skills training. Self-expressing with a trained clinician may be therapeutic in itself.

Clinical effects and treatment outcomes of long-term compulsory in-patient treatment of treatment-resistant patients with severe mental illness and substance-use disorder

BACKGROUND

The treatment of homeless dual-diagnosis patients (i.e., those with severe mental illness and substance-use disorder) is difficult and often fails. For patients in the Netherlands who had not responded to earlier voluntary and compulsory treatment, a new treatment facility - Sustainable Residence (SuRe) - was developed to offer long-term compulsory in-patient treatment.

AIM OF THE STUDY

To study patterns of changes in clinical and functional outcomes during treatment at SuRe and how these relate to eventual treatment outcome.

METHODS

On the basis of the intensity of care needed after four years, three groups of patients were distinguished (total n = 165): those discharged to a less restrictive and less supportive setting (n = 70, 42%), those still hospitalized at SuRe at the end of the four-year study period (n = 69, 42%) and those referred to a more appropriate setting (n = 26, 16%). Random coefficient analysis was used to examine differences between groups regarding changes in clinical and functional outcomes during treatment. During treatment, outcomes were monitored using Routine Outcome Assessment.

RESULTS

All three groups made small but significant improvements on global psychosocial functioning, distress and therapeutic alliance (effect sizes (ES) 0.11 to 0.16 per year). Patients who were discharged to a less restrictive setting showed small to moderate improvement in risk to self and others, psychiatric symptoms, and skills for daily living (ES 0.19-0.33 per year and 0.42-0.73 for their mean 2.2-year treatment period). Patients remaining at SuRe showed a small increase in risk to self (ES 0.20 per year; 0.80 for their treatment period of four years or more). Oppositional behaviour was consistently greater in referred patients than in the other groups (ES 0.74-0.75).

CONCLUSION

Long-term compulsory treatment appeared to have helped improve clinical and functional outcomes in a substantial proportion (42%) of previously severely dysfunctional, treatment-resistant dual-diagnosis patients, who could then be discharged to a less restrictive and less supportive environment. However, risk-to-self increased in a similar proportion. A smaller number of patients (16%) showed marked oppositional behaviour and needed a higher level of care and protection in another facility.

Measuring empathy in schizophrenia: The Empathic Accuracy Task and its correlation with other empathy measures

INTRODUCTION

Empathy is an interpersonal process impaired in schizophrenia. Past studies have mainly used questionnaires or performance-based tasks with static cues to measure cognitive and affective empathy. We used the Empathic Accuracy Task (EAT) designed to capture dynamic aspects of empathy by using videoclips in which perceivers continuously judge emotionally charged stories. We compared individuals with schizophrenia with a healthy comparison group and assessed correlations among EAT and three other commonly used empathy measures.

METHOD

Patients (n = 92) and a healthy comparison group (n = 42) matched for age, gender and education completed the EAT, the Interpersonal Reactivity Index, Questionnaire of Cognitive and Affective Empathy and Faux Pas. Differences between groups were analyzed and correlations were calculated between empathy measurement instruments.

RESULTS

The groups differed in EAT performance, with the comparison group outperforming patients. A moderating effect was found for emotional expressivity of the target: while both patients and the comparison group scored low when judging targets with low expressivity, the comparison group performed better than patients with more expressive targets. Though there were also group differences on the empathy questionnaires, EAT performance did not correlate with questionnaire scores.

CONCLUSIONS

Individuals with schizophrenia benefit less from the emotional expressivity of other people than the comparison group, which contributes to their impaired empathic accuracy. The lack of correlation between the EAT and the questionnaires suggests a distinction between self-report empathy and actual empathy performance. To explore empathic difficulties in real life, it is important to use instruments that take the interpersonal perspective into account.

Social cognitive group treatment for impaired insight in psychosis: A multicenter randomized controlled trial

PURPOSE

The majority of people with schizophrenia has impaired insight, which is related to a poorer outcome. In this study, we evaluate a new psychosocial intervention 'REFLEX' aimed at improving insight in people with schizophrenia. REFLEX focuses on targeting stigma-sensitivity, perspective taking and self-reflection in people with schizophrenia and low insight. Primary objective is to improve insight and subsequently to improve functional outcome and symptoms.

METHOD

A total of 121 people diagnosed with schizophrenia according to DSM IV criteria with impaired insight was included in 2012-2015 from seven sites in a multicenter randomized controlled trial. REFLEX was compared to an active control condition consisting of group-wise simplified cognitive remediation training. Primary outcome of the study were the preconditions of insight: internalized stigma, self-reflection, mental flexibility and perspective taking. Clinical insight and cognitive insight were secondary outcomes.

RESULTS

Although perspective taking, self-reflection, mental flexibility and stigma sensitivity remained unchanged after the intervention, results showed a significant improvement of clinical insight in both conditions directly after treatment (SAI-E Rater, p < .001, PANSS G12, p < .005) and at follow-up (SAI-E Rater, p < .01, SAI-E interview, p < .001, PANSS G12, p < .0001). Improvement of clinical insight directly after treatment was larger in the REFLEX condition (SAI-E Rater, p < .05). Other outcomes (self-esteem, quality of life and depression) remained unchanged.

CONCLUSION

Though insight improved in both conditions, REFLEX was not superior to simplified drill-and-practice cognitive remediation training. Nevertheless, this study indicates that structured interventions can significantly improve insight. Further research on the underlying mechanisms of both conditions is needed, as insight is unlikely to improve spontaneously in chronic patients.

Illness representations among parents of children and adults with serious mental disorders: A systematic review and theoretical model

OBJECTIVE

Cognitive representations of an illness have an important impact on psychological outcomes. The current systematic review explored 1) the characteristics of illness representations held by parents of children and adults with serious mental illness (SMI), and 2) the associations of these representations with both parents' and patients' psychological outcomes.

METHOD

PSYINFO and PUBMED were screened for eligible studies published between January 2000 and August 2018. Selection was based on PRISMA guidelines. Reference lists of these papers were checked for additional references. Two independent coders extracted all relevant data.

RESULTS

The search resulted in 31 relevant studies, which were divided, by type of methodology, into three sections: quantitative, qualitative, and mixed quantitative-qualitative. In each section, findings were divided in accordance with the two research questions.

CONCLUSION

Parents struggle to make meaning of their child's illness, often holding stigmatizing ideas about the illness and blaming themselves for its existence. More longitudinal studies that include both of the child's parents, as well as interventional studies, are needed to expand our knowledge of ways to help parents construct more beneficial representations of their children's illnesses.

Individualized Prediction of Transition to Psychosis in 1,676 Individuals at Clinical High Risk: Development and Validation of a Multivariable Prediction Model Based on Individual Patient Data Meta-Analysis

Background: The Clinical High Risk state for Psychosis (CHR-P) has become the cornerstone of modern preventive psychiatry. The next stage of clinical advancements rests on the ability to formulate a more accurate prognostic estimate at the individual subject level. Individual Participant Data Meta-Analyses (IPD-MA) are robust evidence synthesis methods that can also offer powerful approaches to the development and validation of personalized prognostic models. The aim of the study was to develop and validate an individualized, clinically based prognostic model for forecasting transition to psychosis from a CHR-P stage. Methods: A literature search was performed between January 30, 2016, and February 6, 2016, consulting PubMed, Psychinfo, Picarta, Embase, and ISI Web of Science, using search terms ("ultra high risk" OR "clinical high risk" OR "at risk mental state") AND [(conver* OR transition* OR onset OR emerg* OR develop*) AND psychosis] for both longitudinal and intervention CHR-P studies. Clinical knowledge was used to a priori select predictors: age, gender, CHR-P subgroup, the severity of attenuated positive psychotic symptoms, the severity of attenuated negative psychotic symptoms, and level of functioning at baseline. The model, thus, developed was validated with an extended form of internal validation. Results: Fifteen of the 43 studies identified agreed to share IPD, for a total sample size of 1,676. There was a high level of heterogeneity between the CHR-P studies with regard to inclusion criteria, type of assessment instruments, transition criteria, preventive treatment offered. The internally validated prognostic performance of the model was higher than chance but only moderate [Harrell's C-statistic 0.655, 95% confidence interval (CIs), 0.627-0.682]. Conclusion: This is the first IPD-MA conducted in the largest samples of CHR-P ever collected to date. An individualized prognostic model based on clinical predictors available in clinical routine was developed and internally validated, reaching only moderate prognostic performance. Although personalized risk prediction is of great value in the clinical practice, future developments are essential, including the refinement of the prognostic model and its external validation. However, because of the current high diagnostic, prognostic, and therapeutic heterogeneity of CHR-P studies, IPD-MAs in this population may have an limited intrinsic power to deliver robust prognostic models.

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

BACKGROUND

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

METHODS

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

RESULTS

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

CONCLUSIONS

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

Cognitive-behavior therapy for children and adolescents with anxiety disorders: A meta-analysis of secondary outcomes

Anxiety-focused cognitive-behavioral therapy (CBT) effectively reduces anxiety in children and adolescents. An important remaining question is to what extent anxiety-focused CBT also affects broader outcome domains. Additionally, it remains unclear whether parental involvement in treatment may have impact on domains other than anxiety. A meta-analysis (n_studies = 42, n_participants = 3239) of the effects of CBT and the moderating role of parental involvement was conducted on the following major secondary outcomes: depressive symptoms, externalizing behaviors, general functioning, and social competence. Randomized controlled trials were included when having a waitlist or active control condition, a youth sample (aged<19) with a primary anxiety disorder diagnosis receiving anxiety-focused CBT and reported secondary outcomes. Controlled effect sizes (Cohen's d) were calculated employing random effect models. CBT had a large effect on general functioning (-1.25[-1.59;0.90], n_studies = 17), a small to moderate effect on depressive symptoms (-0.31[-0.41;-0.22], n_studies = 31) and a small effect on externalizing behaviors (-0.23[-0.38;-0.09], n_studies = 12) from pre-to post-treatment. Effects remained or even further improved at follow-up. Social competence only improved at follow-up (n_studies = 6). Concluding, anxiety-focused CBT has a positive effect on broader outcome domains than just anxiety. Higher parental involvement seemed to have beneficial effects at follow-up, with improvements in general functioning and comorbid symptoms.

Neural correlates of exercise training in individuals with schizophrenia and in healthy individuals: A systematic review

A body of evidence has revealed positive effects of physical exercise on behavioral, cognitive and physical outcomes in patients with schizophrenia. Notably, the effect of exercise at the neural level may be particularly relevant as well as it is hypothesized that exercise may stimulate the brain in a way that might normalize neural alterations related to the disorder. The aim of the current systematic review was to provide an up to date overview of studies investigating the neural effects of exercise in individuals with a schizophrenia spectrum disorder and healthy individuals. The majority of included studies focused on hippocampal effects, reporting beneficial effects of exercise. In addition, in schizophrenia increased extrastriate body area (EBA) activation and increased white matter fiber integrity in tracts relevant to the disorder were found and in healthy individuals decreased connectivity of the dorsolateral prefrontal cortex (DLPFC) indicating greater cognitive efficiency was reported. Comparing individuals with a schizophrenia spectrum disorder and healthy individuals within a similar age range, most studies found similar effects on hippocampal volume and white matter tracts for both groups, although the effect in schizophrenia spectrum disorders may be attenuated which is in line with previous literature on brain plasticity. The current review indicates a lack of studies investigating neural correlates other than the hippocampus. Although those studies that did focus on other neural correlates revealed promising results, these have not been replicated in other studies and call for replication. Furthermore, future studies should expand their focus, by investigating neural mechanisms underlying positive effects of physical exercise on positive symptoms, negative symptoms and symptoms such as depression, social withdrawal and social cognition.

[Young adult with psychotic disorders have problems relating to sexuality, intimacy and relationships. An explanatory study based on focus group]

BACKGROUND

Research has shown that young adults with psychotic disorders frequently have problems relating to sexuality, intimacy and relationships. Such problems are often neglected in clinical practice.

AIM

To perform a study that explores, on the basis of focus groups, how issues such as sexuality, intimacy and relationships can be addressed as part of the treatment of adolescents suffering from a psychotic disorder.

METHOD

We created eight focus groups consisting of clients attending the department of psychotic disorders and caregivers who worked there. The meetings of each focus group were fully transcribed and analysed by means of Nvivo.

RESULTS

Clients indicated they wanted to address the topics of sexuality, intimacy and relationships in a group setting. They expressed the wish to have mixed gender groups and decided that in the group discussions the main focus should be on the exchange of personal experiences.

CONCLUSION

In our view, it is desirable that psychiatry should pay more attention to the subject of sexuality. By giving adolescents suffering from psychotic disorders the opportunity to discuss their experiences, problems and feelings of insecurity in a group setting and in a low-threshold environment, psychiatrists can greatly improve the quality of care that they provide for their patients.

[Metacognition in psychotic disorders: from concepts to intervention]

BACKGROUND

Persons with a psychotic disorder commonly experience difficulties with what is considered to be metacognitive capacity. In this article we discuss several definitions of this concept, the measurement instruments involved and the clinical interventions that target this concept.

AIM

To present a review of various frequently used definitions of metacognition and related concepts and to describe the measurement instruments involved and the treatment options available for improving the metacognitive capacity of persons with a psychotic disorder.

METHOD

We present an overview of several definitions of metacognition in psychotic disorders and we discuss frequently used measurement instruments and treatment options. The article focuses on recent developments in a model devised by Semerari et al. The measurement instrument involved (Metacognition Assessment Scale - A) is discussed in terms of it being an addition to existing methods.

RESULTS

On the basis of the literature it appears that metacognition and related concepts are measurable constructs, although definitions and instruments vary considerably. The new conceptualisation of social information processing also leads to the development of a new form of psychotherapy that aims to help patients suffering from psychotic disorders to improve metacognitive capacity.

CONCLUSION

There seems to be evidence that metacognitive abilities are a possible target for treatment, but further research is needed.

Metacognitive Reflection and Insight Therapy (MERIT) With a Patient With Severe Symptoms of Disorganization

One recent development within the realm of psychotherapeutic interventions for schizophrenia has been a shift in focus from symptom management to consideration of metacognition, or the processes by which people synthesize information about themselves and others in an integrated manner. One such approach, metacognitive reflection and insight therapy (MERIT); in particular, offers a description of 8 therapeutic activities that should occur in each session, resulting in the stimulation and growth of metacognitive capacity. In this report, we present a description of 12 sessions with a patient suffering from schizophrenia manifesting significantly disorganized symptoms. Each MERIT element is described along with observed clinical and metacognitive gains. As illustrated in this report, these procedures helped the patient move from a state of having no complex ideas about himself or others, to one in which he could begin to develop integrated and realistic ideas about himself and others and use that capacity to think about life challenges.

Differential effects of antipsychotic drugs on insight in first episode schizophrenia: Data from the European First-Episode Schizophrenia Trial (EUFEST)

Although antipsychotics are widely prescribed, their effect of on improving poor illness insight in schizophrenia has seldom been investigated and therefore remains uncertain. This paper examines the effects of low dose haloperidol, amisulpride, olanzapine, quetiapine, and ziprasidone on insight in first-episode schizophrenia, schizoaffective disorder, or schizophreniform disorder. The effects of five antipsychotic drugs in first episode psychosis on insight were compared in a large scale open randomized controlled trial conducted in 14 European countries: the European First-Episode Schizophrenia Trial (EUFEST). Patients with at least minimal impairments in insight were included in the present study (n=455). Insight was assessed with item G12 of the Positive and Negative Syndrome Scale (PANSS), administered at baseline and at 1, 3, 6, 9, and 12 months after randomization. The use of antipsychotics was associated with clear improvements in insight over and above improvements in other symptoms. This effect was most pronounced in the first three months of treatment, with quetiapine being significantly less effective than other drugs. Effects of spontaneous improvement cannot be ruled out due to the lack of a placebo control group, although such a large spontaneous improvement of insight would seem unlikely.

[Functional remission of people with serious mental illness (SMI): psychometric properties of a new ROM-instrument]

BACKGROUND

Instruments are used for routine outcome monitoring of patients with severe mental illness in order to measure psychiatric symptoms, care needs and quality of life. By adding an instrument for measuring functional remission a more complete picture can be given of the complaints, the symptoms and general functioning, which can give direction to providing care for patients with severe mental illness.

AIM

To describe the development and testing of a new instrument of functional remission (FR) among people with a psychotic disorder or another serious mental disorder (SMI) as an addition to the symptomatic remission (SR), according to international criteria.

METHOD

The FR-assessment involves assessment by a mental health professional who conducts a semi-structured interview with the patient and his or her family and/or uses patient files relating to the three areas of functioning: daily living and self-care; work, study and housekeeping; and social contacts. These areas are rated on a three-point scale of 0: independent; 1: partially independent; 2: dependent. The assessment covers a period of six months, in accordance with the measurement of symptomatic remission and should be part of regular routine outcome monitoring (ROM) procedures. The FR-instrument was used in 2012 with 840 patients from eight Dutch mental care institutions and included a one-year follow-up among 523 patients (response 62%).

RESULTS

The results showed that the instrument is relatively easily to complete. It was also relevant for clinical practice, although further research is needed because of the raters' low response. Intra- and inter-rater reliability, discriminating and convergent validity, and sensitivity to change were rated sufficient to good.

CONCLUSION

If the FR-instrument becomes part of regular ROM-procedures and is used as a measure of societal participation, it could be a useful addition to current measures of symptomatic remission.

The influence of adjunctive treatment and metacognitive deficits in schizophrenia on the experience of work

Enhancing work function is now widely considered a core element of comprehensive schizophrenia treatment. While research efforts have illuminated factors that influence how well patients perform at work, less is known about the factors influencing the subjective experience of work. It is not known how, and to what extent, symptoms, cognitive deficits or metacognitive capacities impact job satisfaction and whether treatment can have an effect on job satisfaction. To explore this issue, data from a trial in which participants in a six-month vocational program were assigned to either a standard support group or a cognitive behavioral group therapy, and asked to fill in weekly self-reports of job satisfaction was analyzed. Work satisfaction and the consistency of these ratings were compared between the two groups and the moderating influence of metacognitive capacity was analyzed. A significant interaction effect revealed that higher metacognitive capacity predicted higher average job satisfaction only in the CBT group. Additionally, higher metacognitive capacity led to a more varied appraisal of work satisfaction only in the support group.

Insight change in psychosis: relationship with neurocognition, social cognition, clinical symptoms and phase of illness

OBJECTIVE

Impaired insight is an important and prevalent symptom of psychosis. It remains unclear whether cognitive disturbances hamper improvements in insight. We investigated the neurocognitive, social cognitive, and clinical correlates of changes in insight.

METHOD

One hundred and fifty-four patients with a psychotic disorder were assessed at baseline (T0 ) and after three years (T3 ) with the Birchwood Insight Scale, the Positive And Negative Syndrome Scale, measures of neurocognition and social cognition. Linear regression analyses were conducted to examine to what extend neurocognition, social cognition, clinical symptoms and phase of illness could uniquely predict insight change. Subsequently, changes in these factors were related to insight change.

RESULTS

Better neurocognitive performance and fewer clinical symptoms at baseline explained insight improvements. The additional effect of clinical symptoms over and above the contribution of neurocognition was significant. Together, these factors explained 10% of the variance. Social cognition and phase of illness could not predict insight change. Changes in clinical symptoms, but not changes in neurocognitive performance were associated with insight change.

CONCLUSION

Neurocognitive abilities may predict, in part, the development of insight in psychosis.

Insight in schizophrenia: associations with empathy

Many people with schizophrenia (50-80%) demonstrate impaired insight, something which has been associated with a poorer outcome. Two types of empathy can be distinguished: affective empathy via shared emotions and cognitive empathy, also referred to as Theory of Mind (ToM). ToM can be subdivided into cognitive ToM (knowledge about beliefs of other people via perspective taking) and affective ToM (knowledge about other people's emotions via perspective taking). Recent studies show a relationship between Theory of Mind (ToM) and insight. However, the relationship between affective empathy and insight in schizophrenia was not examined previously. This was the aim of the present study. We expected that affective empathy would show a stronger relationship with insight than both cognitive and affective ToM. We assessed forty-six patients with a diagnosis of schizophrenia, and fifty-three healthy controls were assessed with a test battery consisting of tests of social cognition (a self-rating scale for affective empathy, a ToM task assessing both cognitive and affective ToM, and two tests of emotion perception), verbal memory, executive functioning, psychomotor speed, and intelligence. Insight was assessed with item G12 of the PANSS-interview. A regression equation showed that affective empathy made the strongest unique contribution to insight, followed closely by affective ToM. Together, they explained 45% of the variance in insight. None of the other independent variables made a unique contribution to the prediction of insight. Both affective ToM and affective empathy are associated with insight in schizophrenia. Being able to take empathize with other peoples feeling at both the affective and cognitive level may enhance insight in schizophrenia.

REFLEX, a social-cognitive group treatment to improve insight in schizophrenia: study protocol of a multi-center RCT

BACKGROUND

Insight is impaired in a majority of people with schizophrenia. Impaired insight is associated with poorer outcomes of the disorder. Based on existing literature, we developed a model that explains which processes may possibly play a role in impaired insight. This model was the starting point of the development of REFLEX: a brief psychosocial intervention to improve insight in schizophrenia. REFLEX is a 12-sessions group training, consisting of three modules of four sessions each. Modules in this intervention are: "coping with stigma", "you and your personal narrative", and "you in the present".

METHODS/DESIGN

REFLEX is currently evaluated in a multicenter randomized controlled trial. Eight mental health institutions in the Netherlands participate in this evaluation. Patients are randomly assigned to either REFLEX or an active control condition, existing of cognitive remediation exercises in a group. In a subgroup of patients, fMRI scans are made before and after training in order to assess potential haemodynamic changes associated with the effects of the training.

DISCUSSION

REFLEX is one of the few interventions aiming specifically to improving insight in schizophrenia and has potential value for improving insight. Targeting insight in schizophrenia is a complex task, that comes with several methodological issues. These issues are addressed in the discussion of this paper.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN50247539.

The efficacy of SMS text messages to compensate for the effects of cognitive impairments in schizophrenia

BACKGROUND AND AIMS

Many people with schizophrenia have severe cognitive impairments that hamper their activities. The effect of pharmacological and behavioural interventions on cognitive functioning has been demonstrated, but even after successful intervention considerable impairments can remain. Therefore, we sought for alternative ways to help patients cope with the effects of their cognitive impairments. In the present study, we have evaluated the efficacy of short message service (SMS) text messages to compensate for the effects of cognitive impairments in schizophrenia in daily life.

DESIGN

A waiting list controlled trial was conducted: patients were quasi-randomly assigned to an A-B-A (baseline-intervention-follow-up) condition or an A-A-B-A condition that included an additional 7-week waiting list. The waiting list was included to control for the effect of time on relevant outcome.

METHOD

Sixty-two people with schizophrenia or related psychotic disorders were included in the study. All patients showed impaired goal-directed behaviour in daily life-situations. Patients were prompted with SMS text messages to improve their everyday functioning. The primary outcome measure was the percentage of goals achieved.

RESULTS

The overall percentage of goals achieved increased with prompting, while performance dropped to baseline level after withdrawing the prompts. Keeping appointments with mental health workers and carrying out leisure activities increased with prompting, while medication adherence and attendance at training sessions remained unchanged. A majority of the patients enjoyed receiving the SMS text messages.

DISCUSSION

Prompting can significantly improve achievement of a number of relevant goals. For other goals, combining prompting with interventions that enhance motivation seems indicated.

Impaired perception of negative emotional prosody in schizophrenia

This paper aims to report on the perception of emotional prosody in schizophrenia and to discuss its relationship with performance on neurocognitive measures. It consists of a comparison of 20 clinically stable schizophrenia patients with 20 healthy controls. Schizophrenia patients were impaired in emotional prosody perception, in particular in the perception of negative emotions. This impairment could not be explained on the basis of task difficulty or a general impairment in the decoding of speech intonation. Emotional prosody perception correlated moderately strongly with neurocognitive measures. We did not find a negative bias in the perception of emotional prosody.

Disturbed cognitive functioning and clinical symptoms: two independent problem areas in schizophrenia

BACKGROUND

Research findings on the relationship between cognitive functioning and psychiatric symptoms in schizophrenia have yielded inconsistent results. Although several models were postulated linking cognition and symptoms, the most recent studies point in the direction of cognition and symptoms being relatively independent disease processes.

OBJECTIVE

The hypothesis that cognitive decline and psychiatric symptoms are independent disease processes was tested.

METHODS

The relationship between cognitive functioning and clinical symptoms was examined in a large sample of 100 schizophrenia patients.

RESULTS

The hypothesis was largely confirmed.

CONCLUSION

No convincing evidence was found that symptoms and cognition were related.