Impact of Delusions and Hallucinations on Clinical Insight Dimensions in Schizophrenia Spectrum Disorders

INTRODUCTION

Insight in psychosis has been conceptualized as a continuous, dynamic, and multidimensional phenomenon. This study aims to determine the impact of delusions and hallucinations in different dimensions of clinical insight in schizophrenia spectrum disorders.

METHODS

Cross-sectional multicenter study including 516 patients (336 men) diagnosed with schizophrenia spectrum disorders. Based on dichotomized scores of Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations), patients were assigned to four groups according to current clear presence of delusions (scores 4 or above 4 in PANSS item P1) and/or hallucinations (scores 4 or above 4 in PANNS item P3). Insight was assessed using the three main dimensions of the Scale of Unawareness of Mental Disorder (SUMD).

RESULTS

Around 40% of patients showed unawareness of illness; 30% unawareness of the need for treatment; and 45% unawareness of the social consequences of the disorder. Patients with current clear presence of delusions had higher overall lack of awareness, regardless of current clear presence of hallucinations. Similarly, the clear presence of delusions showed a greater predictive value on insight than the presence of hallucinations, although the implication of both in the prediction was modest.

CONCLUSIONS

Our results confirm that lack of insight is highly prevalent in schizophrenia spectrum disorders, particularly when patients experience delusions. This study adds insight-related data to the growing symptom-based research, where specific types of psychotic experiences such as hallucinations and delusions could form different psychopathological patterns, linking the phenomenology of delusions to a lack of clinical insight.

Revisiting delusion subtypes in schizophrenia based on their underlying structures

A clear understanding of the pathophysiology of schizophrenia and related spectrum disorders has been limited by clinical heterogeneity. We investigated whether relative severity and predominance of one or more delusion subtypes might yield clinically differentiable patient profiles. Patients (N = 286) with schizophrenia spectrum disorders (SSD) completed the 21-item Peters et al. Delusions Inventory (PDI-21). We performed factor analysis followed by k-means clustering to identify delusion factors and patient subtypes. Patients were further assessed via the Brief Psychiatric Rating Scale, Brief Negative Symptom Scale, Digit Symbol and Digit Substitution tasks, use of cannabis and tobacco, and stressful life events. The overall patient sample clustered into subtypes corresponding to Low-Delusion, Grandiose-Predominant, Paranoid-Predominant, and Pan-Delusion patients. Paranoid-Predominant and Pan-Delusion patients showed significantly higher burden of positive symptoms, while Low-Delusion patients showed the highest burden of negative symptoms. The Paranoia delusion factor score showed a positive association with Digit Symbol and Digit Substitution tasks in the overall sample, and the Paranoid-Predominant subtype exhibited the best performance on both tasks. Grandiose-Predominant patients showed significantly higher tobacco smoking severity than other subtypes, while Paranoid-Predominant patients were significantly more likely to have a lifetime diagnosis of Cannabis Use Disorder. We suggest that delusion self-report inventories such as the PDI-21 may be of utility in identifying sub-syndromes in SSD. From the current study, a Paranoid-Predominant form may be most distinctive, with features including less cognitive impairment and a stronger association with cannabis use.

Schizophrenia and Emergency Medicine

Schizophrenia is a chronic condition characterized by positive symptoms (auditory hallucinations, delusion), negative symptoms (avolition, social withdrawal), and disorganized thoughts/behaviors. Although the pathophysiology is incompletely understood, several neurobiological mechanisms have been proposed. Treatment usually involves antipsychotic medication as well as psychotherapy and supportive services. When evaluating patients in the emergency department, acute safety considerations are paramount. Patients should be assessed for suicide risk, violence risk, inability to care for self, and the risk of being the victim of a crime. Persons with schizophrenia are at an increased risk of substance use and a variety of medical problems.

Pimavanserin for psychosis in Parkinson's disease dementia: Subgroup analysis of the HARMONY Trial

INTRODUCTION

Pimavanserin is FDA-approved to treat Parkinson's disease (PD) psychosis. We analyzed the effect of pimavanserin on psychosis in the PD dementia (PDD) subgroup from the phase 3 HARMONY trial.

METHODS

This subgroup analysis included PDD patients enrolled in an international, multicenter, randomized discontinuation study of pimavanserin for dementia-related psychosis. PDD patients with moderate-to-severe psychosis, age 50-90 years, received pimavanserin 34 mg/day for 12 weeks (open-label period). Those with a sustained psychosis response to pimavanserin at weeks 8 and 12 were randomized during the double-blind period to continue pimavanserin or receive placebo. Primary efficacy endpoint was time to psychosis relapse as measured by the SAPS-H + D and CGI-I. Safety was assessed, as were effects on motor symptoms and cognitive abilities using the ESRS-A and MMSE.

RESULTS

392 patients were enrolled in HARMONY (mean age: 72.6 years; 38.8 % female): 59 had PDD; 49/59 remained on pimavanserin during the open-label period (safety analysis set), and 36/49 were randomized to pimavanserin (n = 16) or placebo (n = 20) in the double-blind phase (intent-to-treat analysis set). Risk of psychosis relapse was lower with pimavanserin 34 mg compared with placebo in the double-blind phase (HR = 0.052; 95 % CI 0.016-0.166; 1-sided nominal p < 0.001). During the open-label period, 46.9 % experienced a treatment-emergent adverse event; event incidence was similar across arms in the double-blind period. Pimavanserin did not adversely affect motor or cognitive function in either treatment phase.

CONCLUSIONS

Pimavanserin significantly reduced risk of psychosis relapse in patients with PDD, was well tolerated, and did not worsen motor or cognitive function.

The Apple Doesn't Fall Far from the Tree? Paranoia and Safety Behaviours in Adolescent-Parent-Dyads

Paranoia is a common experience in adolescence that may entail the use of safety behaviours (e.g. avoidance), which are assumed to maintain paranoia in the long run. As the development of paranoia and related safety behaviours in youth may be influenced by their caregivers, we aimed to investigate the associations of paranoia and safety behaviours in adolescents and their parents. Adolescents from the general population aged 14-17 and one of their parents (N = 142 dyads) were recruited via Qualtrics to complete online surveys including measures of paranoia, safety behaviour use, anxiety, and demographics. We fitted an Actor-Partner-Interdependence Model (APIM) for testing dyadic parent-child interaction by using structural equation modelling and controlled for adolescents' and parents' anxiety. Results indicated that paranoia positively predicted safety behaviour use in adolescents and in parents. There were significant positive intra-dyad (i.e. parent-adolescent) correlations for both paranoia and safety behaviour use. One partner effect was significant: parental paranoia positively predicted the safety behaviour use of their adolescent child. Conversely, adolescents' paranoia did not predict their parents' safety behaviour use. Our findings corroborate prior research demonstrating an association between paranoia and safety behaviours among adults, and extend this association to adolescents. Children of parents experiencing paranoia are at increased risk of developing paranoia and safety behaviours, which indicates the need for interventions that target paranoia and safety behaviours in family systems.

Clinical and sociodemographic predictors of inpatient admission after presentation in a psychiatric emergency room: an observational study

BACKGROUND

The admission decision after presentation in the psychiatric emergency room (PER) has potentially far-reaching consequences for the patient and the community. In a short amount of time, information must be collected and evaluated for a well-founded admission decision. The present study aimed to identify risk factors associated with inpatient psychiatric admission (IPA) after previous emergency presentation to the PER.

METHODS

Electronic patient records for all patients presenting in the PER of Hannover Medical School (MHH) in the year 2022 were retrospectively examined (n = 2580). Out of these, 2387 were included in this study. Two multivariate binary logistic regression analyses were performed to identify risk factors for IPA within sociodemographic, circumstantial and clinical variables.

RESULTS

1300 (54.5%) consultations resulted in IPA. The most significant sociodemographic and circumstantial risk factors for IPA were found to be suicide attempt (depending on method: OR 9.1-17.4), aggressive behavior towards people prior to presentation (OR 2.9, 95% CI 1.7-4.8), previous psychiatric treatment (OR 1.8, 95% CI 1.4-2.3) and transfer from another hospital or medical discipline of MHH as means of presentation (OR 6.3, 95% CI 3.0-13.0). Among psychopathological aspects, suicidal ideation (OR 3.8, 95% CI 2.9-4.9), suicidal intent (OR 116.0, 95% CI 15.9-844.8), disturbance of orientation (OR 3.7, 95% CI 2.5-5.3), delusions (OR 2.3, 95% CI 1.6-3.1), visual hallucinations (OR 2.9, 95% CI 1.6-5.1), hopelessness/despair (OR 2.4, 95% CI 1.7-3.2) and inhibition of drive (OR 1.6, 95% CI 1.3-2.1) were significantly associated with IPA.

CONCLUSIONS

The admission decision is a complex process influenced by a multitude of sociodemographic, circumstantial and clinical factors. A deeper understanding of the decision-making process can be used to improve patient care and facilitate the evaluation process in the PER.

The distorted memories of patients treated in the intensive care unit during the COVID-19 pandemic: A qualitative study

BACKGROUND

During the COVID-19 pandemic, patients cared for in the intensive care unit were exposed to many risk factors for developing delirium and subsequent distorted memories. Further, seeing healthcare professionals who have been dressed in personal protective equipment and face masks could have affected the patients' memories. Therefore, the aim of this study was to explore memories and how they are experienced and managed by former patients who have been treated for COVID-19 in an intensive care unit.

METHODS

Sixteen former patients treated for COVID-19 at a large emergency hospital in Sweden were interviewed 3-8 months after discharge from the intensive care unit. The data were interpreted using thematic analysis. The Consolidated Criteria for Reporting Qualitative Research checklist was followed in the reporting of the study.

FINDINGS

Participants' descriptions of their memories of treatment in the intensive care unit for COVID-19 generated three themes: 'Distorted truth' the content in the memories which implied facing death in an unreal distorted environment. 'Captive,' was the experience and feelings linked to memories with a feeling of being exposed and alone, and 'Coping with memories' explained how participants managed the implications of the memories using a mixture of strategies.

CONCLUSIONS

For former patients who were admitted to an intensive care unit after a diagnosis of COVID-19, memories caused considerable distress, which were similar to other intensive care patientś experiences, before the pandemic. Emotion-focused and problem-focused strategies could be used to cope with these memories. Healthcare professionals wearing protective equipment gave the patient a distant feeling, but more important was to be treated with attention/care and respect.

IMPLICATIONS FOR CLINICAL PRACTICE

Awareness of the impact of distorted memories on patients who are severely ill and their needs and strategies to cope with these memories can form the basis for early interventions that promotes well-being during care and recovery. Healthcare professionals have an important task to inform patients and their family members about the existence of distorted memories, and talk about the patients' experience of them, to facilitate their recovery.

Metacognition and psychosis-spectrum experiences: A study of objective and subjective measures

BACKGROUND

Metacognition refers to appraising one's thoughts and behaviours. Deficits in metacognition are associated with psychosis-spectrum experiences, such as hallucinations and delusions, in both clinical and non-clinical populations. Assessments of metacognitive function and abilities in clinical populations often vary in administration duration, and subjectivity of scores. This study investigates associations between different measures of metacognition and their prediction of psychosis spectrum experiences using objective and self-report measures in a cross-sectional study of psychosis-spectrum disorder (PSD) participants and controls.

METHOD

Twenty-three individuals with PSD and forty-four controls were recruited online and completed in-the-moment objective ratings of metacognitive accuracy (meta-Dots Task), and retrospective self-report of metacognitive self-reflection (Beck Cognitive Insight Scale) and abilities (Metacognition Self-Assessment Scale).

RESULTS

There were group differences in self-reported metacognition, with PSD participants having lower scores of metacognitive ability, but no differences in self-reflectiveness or objective metacognitive accuracy. In the PSD group, only self-reported metacognitive ability was associated with and predicted distress about, and conviction in, delusional thoughts.

CONCLUSIONS

The findings demonstrate group differences in some self-reported, but not objective, measures of metacognition, and highlight that prediction of PSD experiences depends on the metacognitive construct being measured, and the type of measurement used.

Longitudinal associations between stroke and psychosis: a population-based study

BACKGROUND

The co-occurrence of stroke and psychosis is a serious neuropsychiatric condition but little is known about the course of this comorbidity. We aimed to estimate longitudinal associations between stroke and psychosis over 10 years.

METHODS

A 10-year population-based study using data from the English Longitudinal Study of Ageing. A structured health assessment recorded (i) first-occurrence stroke and (ii) psychosis, at each wave. Each were considered exposures and outcomes in separate analyses. Logistic and Cox proportional hazards regression and Kaplan-Meier methods were used. Models were adjusted for demographic and health behaviour covariates, with missing covariates imputed using random forest multiple imputation.

RESULTS

Of 19 808 participants, 24 reported both stroke and psychosis (median Wave 1 age 63, 71% female, 50% lowest quintile of net financial wealth) at any point during follow-up. By 10 years, the probability of an incident first stroke in participants with psychosis was 21.4% [95% confidence interval (CI) 12.1-29.6] compared to 8.3% (95% CI 7.8-8.8) in those without psychosis (absolute difference: 13.1%; 95% CI 20.8-4.3, log rank p < 0.001; fully-adjusted hazard ratio (HR): 3.57; 95% CI 2.18-5.84). The probability of reporting incident psychosis in participants with stroke was 2.3% (95% CI 1.4-3.2) compared to 0.9% (95% CI 0.7-1.1) in those without (absolute difference: 1.4%; 95% CI 0.7-2.1, log rank p < 0.001; fully-adjusted HR: 4.98; 95% CI 2.55-9.72).

CONCLUSIONS

Stroke is an independent predictor of psychosis (and vice versa), after adjustment for potential confounders.

Hasty decision making and belief inflexibility in the more delusion prone? A modified disambiguating-scenarios paradigm assessing cognitive biases implicated in delusions

INTRODUCTION

Contemporary models of psychosis imply that cognitive biases such as the jumping to conclusions (JTC), the bias against disconfirmatory evidence (BADE), and the liberal acceptance (LA) bias play a role in the pathogenesis of delusions. Most of the studies investigating the role of cognitive biases, however, have been conducted with socially neutral or abstract stimuli and have assessed patients with established psychoses. For the present study, we aimed to concurrently investigate multiple biases (i.e., the JTC, BADE, and LA biases) in a community sample with a new paradigm using more socially engaging stimuli.

METHODS

A large sample of participants (N = 874) recruited via Amazon Mechanical Turk was subdivided into two groups based on the frequency of their psychotic-like experiences (PLEs) according to the positive subscale score of the Community Assessment of Psychic Experiences (CAPE) and matched based on major demographics variables, resulting in two equally sized groups called High-PLE (at least 2 SD above the mean) and Low-PLE (maximum 0.5 above the mean; n = 46 for each group). Using a modified version of the written-scenarios BADE task, which emphasized social interactions between agents embedded in the scenario, participants rated the plausibility of response options in the face of new information.

RESULTS

In line with previous findings, the High-PLE group demonstrated the JTC, BADE, and LA biases. That is, the members of this group made more decisions after the initial piece of information, were less likely to revise their beliefs in light of new information, and provided higher plausibility ratings for implausible response options compared to the Low-PLE group.

CONCLUSIONS

Results corroborate prior findings suggesting that the JTC, BADE, and LA biases may be contributing factors in delusional ideation and that metacognitive biases extend to social situations.

Delusional beliefs in adolescents with anorexia nervosa, obsessive-compulsive disorder, or first-episode psychosis: A comparative study

Delusional thinking is a key symptom of first-episode psychosis (FEP), but it has also been studied in obsessive-compulsive disorder (OCD) and anorexia nervosa (AN). This study aimed to analyze the psychometric properties of the Brown Assessment of Beliefs Scale (BABS) in a sample of adolescents diagnosed with a FEP, AN, or OCD, and to compare delusional thinking among the three samples. The sample comprised 60 patients in three groups of 20 diagnosed with OCD, AN, or FEP. Participants underwent assessment by diagnostic interview, the BABS scale, and a measure of depressive symptomatology. Specific instruments were also used to assess the main symptomatology of each disorder. The BABS had good internal consistency, and high validity and reliability. The OCD group scored significantly lower than the other two groups in all scale items except for items 4 (fixation of ideas), 6 (insight), and 7 (delusions of reference). A significant difference only existed between the AN and FEP groups for item 7 (delusions of reference). The BABS scale is a valid and reliable tool for assessing delusionality in adolescents diagnosed with OCD, AN, or FEP, with evidence of marked differences between the disorders. Assessing these symptoms could influence management, helping to improve treatment adherence and prognosis.

Socio-demographic and clinical characteristics of migrants to Ireland presenting with a first episode of psychosis

OBJECTIVES

When presenting with a first episode of psychosis (FEP), migrants can have different demographic and clinical characteristics to the native-born population and this was examined in an Irish Early Intervention for Psychosis service.

METHODS

All cases of treated FEP from three local mental health services within a defined catchment area were included. Psychotic disorder diagnoses were determined using the SCID and symptom and functioning domains were measured using validated and reliable measures.

RESULTS

From a cohort of 612 people, 21.1% were first-generation migrants and there was no difference in the demographic characteristics, diagnoses, symptoms or functioning between migrants and those born in the Republic of Ireland, except that migrants from Africa presented with less insight. Of those admitted, 48.6% of admissions for migrants were involuntary compared to 37.7% for the native-born population (p = 0.09).

CONCLUSIONS

First-generation migrants now make up a significant proportion of people presenting with a FEP to an Irish EI for psychosis service. Broadly the demographic and clinical characteristics of migrants and those born in the Republic of Ireland are similar, except for less insight in migrants from Africa and a trend for a higher proportion of involuntary admissions in the total migrant group.

Detecting at-risk mental states for psychosis (ARMS) using machine learning ensembles and facial features

AIMS

Our study aimed to develop a machine learning ensemble to distinguish "at-risk mental states for psychosis" (ARMS) subjects from control individuals from the general population based on facial data extracted from video-recordings.

METHODS

58 non-help-seeking medication-naïve ARMS and 70 healthy subjects were screened from a general population sample. At-risk status was assessed with the Structured Interview for Prodromal Syndromes (SIPS), and "Subject's Overview" section was filmed (5-10 min). Several features were extracted, e.g., eye and mouth aspect ratio, Euler angles, coordinates from 51 facial landmarks. This elicited 649 facial features, which were further selected using Gradient Boosting Machines (AdaBoost combined with Random Forests). Data was split in 70/30 for training, and Monte Carlo cross validation was used.

RESULTS

Final model reached 83 % of mean F1-score, and balanced accuracy of 85 %. Mean area under the curve for the receiver operator curve classifier was 93 %. Convergent validity testing showed that two features included in the model were significantly correlated with Avolition (SIPS N2 item) and expression of emotion (SIPS N3 item).

CONCLUSION

Our model capitalized on short video-recordings from individuals recruited from the general population, effectively distinguishing between ARMS and controls. Results are encouraging for large-screening purposes in low-resource settings.

Delusions and the dilemmas of life: A systematic review and meta-analyses of the global literature on the prevalence of delusional themes in clinical groups

We investigated the prevalence of persecutory, grandiose, reference, control, and religious delusions in adult clinical populations worldwide and whether they differed according to country characteristics or age, gender, or year of publication. 123 studies met inclusion criteria, across 30 countries; 102 (115 samples, n = 20,979) were included in the main random-effects meta-analysis of studies measuring multiple delusional themes (21 in a separate analysis of studies in recording a single theme). Persecutory delusions were most common (pooled point estimate: 64.5%, CI = 60.6-68.3, k = 106, followed by reference (39.7%, CI 34.5-45.3, k = 65), grandiose (28.2, CI 24.8-31.9, k = 100), control 21.6%, CI 17.8-26.0, k = 53), and religious delusions 18.3%, CI 15.4-21.6, k = 50). Data from studies recording one theme were broadly consistent with these findings. There were no effects for study quality or publication date. Prevalences were higher in samples exclusively with psychotic patients but did not differ between developed and developing countries, or by country individualism, power distance, or prevalence of atheism. Religious and control delusions were more prevalent in countries with higher income inequality. We hypothesize that these delusional themes reflect universal human dilemmas and existential challenges.

Are symptoms assessed differently for schizophrenia and other psychoses in legal insanity evaluations of violent crimes?

BACKGROUND

Forensic evaluations of legal insanity include the experts' assessment of symptoms present at the mental state examination (MSE) and the mental state at the time of offense (MSO). Delusions and hallucinations are most important. We explored how often symptoms were recorded in written forensic reports.

DESIGN

This exploratory, cross-sectional study included 500 reports of legal insanity written in 2009-2018 from cases of violent crimes in Norway. The first author read all reports and coded symptoms recorded from the experts' assessments of the offenders. Two co-authors repeated this procedure for 50 randomly selected reports. Interrater reliability was calculated with Gwet's AC1. Generalized Linear Mixed Models with Wald tests for fixed effects and Risk Ratios as effect sizes were used for the statistical analyses.

RESULTS

Legal insanity was the main conclusion in 23.6% of the reports; 71.2% of these were diagnosed with schizophrenia while 22.9% had other psychotic disorders. Experts recorded few symptoms from MSO, but more from MSE, although MSO is important for insanity. We found a significant association between delusions and hallucinations recorded present in the MSO and legal insanity for defendants with other psychotic disorders, but no association for defendants with schizophrenia. The differences in symptom recordings between diagnoses were significant.

CONCLUSION

Few symptoms were recorded from the MSO. We found no association between presence of delusions or hallucinations and legal insanity for defendants with schizophrenia. This may indicate that a schizophrenia diagnosis is more important to the forensic conclusion than the symptoms recorded in the MSO.

Network Localization of Spontaneous Confabulation

OBJECTIVE

Spontaneous confabulation is a symptom in which false memories are conveyed by the patient as true. The purpose of the study was to identify the neuroanatomical substrate of this complex symptom and evaluate the relationship to related symptoms, such as delusions and amnesia.

METHODS

Twenty-five lesion locations associated with spontaneous confabulation were identified in a systematic literature search. The network of brain regions functionally connected to each lesion location was identified with a large connectome database (N=1,000) and compared with networks derived from lesions associated with nonspecific (i.e., variable) symptoms (N=135), delusions (N=32), or amnesia (N=53).

RESULTS

Lesions associated with spontaneous confabulation occurred in multiple brain locations, but they were all part of a single functionally connected brain network. Specifically, 100% of lesions were connected to the mammillary bodies (familywise error rate [FWE]-corrected p<0.05). This connectivity was specific for lesions associated with confabulation compared with lesions associated with nonspecific symptoms or delusions (FWE-corrected p<0.05). Lesions associated with confabulation were more connected to the orbitofrontal cortex than those associated with amnesia (FWE-corrected p<0.05).

CONCLUSIONS

Spontaneous confabulation maps to a common functionally connected brain network that partially overlaps, but is distinct from, networks associated with delusions or amnesia. These findings lend new insight into the neuroanatomical bases of spontaneous confabulation.

Neural correlates of referential/persecutory delusions in schizophrenia: examination using fMRI and a virtual reality underground travel paradigm

BACKGROUND

The brain functional correlates of delusions have been relatively little studied. However, a virtual reality paradigm simulating travel on the London Underground has been found to evoke referential ideation in both healthy subjects and patients with schizophrenia, making brain activations in response to such experiences potentially identifiable.

METHOD

Ninety patients with schizophrenia/schizoaffective disorder and 28 healthy controls underwent functional magnetic resonance imaging while they viewed virtual reality versions of full and empty Barcelona Metro carriages.

RESULTS

Compared to the empty condition, viewing the full carriage was associated with activations in the visual cortex, the cuneus and precuneus/posterior cingulate cortex, the inferior parietal cortex, the angular gyrus and parts of the middle and superior temporal cortex including the temporoparietal junction bilaterally. There were no significant differences in activation between groups. Nor were there activations associated with referentiality or presence of delusions generally in the patient group. However, patients with persecutory delusions showed a cluster of reduced activation compared to those without delusions in a region in the right temporal/occipital cortex.

CONCLUSIONS

Performance of the metro task is associated with a widespread pattern of activations, which does not distinguish schizophrenic patients and controls, or show an association with referentiality or delusions in general. However, the finding of a cluster of reduced activation close to the right temporoparietal junction in patients with persecutory delusions specifically is of potential interest, as this region is believed to play a role in social cognition.

Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion

OBJECTIVE

COVID-19 conspiracy theories have become widespread since the onset of the pandemic and compound the existing challenges of decisional capacity assessment. This paper aims to review the literature pertaining to decisional capacity assessment in the context of COVID-19 conspiracy beliefs and synthesize a practical approach with an emphasis on differential diagnosis and clinical pearls for the practicing physician.

METHODS

We reviewed papers on decisional capacity assessment and differential diagnosis in the context of COVID-19 conspiracy beliefs. A literature search was conducted using the US National Library of Medicine's PubMed.gov resource and Google Scholar.

RESULTS

The resulting article content was utilized to synthesize a practical approach to decisional capacity assessment in the context of COVID-19 conspiracy beliefs. Specifically, aspects related to the history, taxonomy, evaluation, and management are reviewed.

CONCLUSIONS

Appreciating the nuanced differences between delusions, overvalued ideas, and obsessions while with integrating the non-cognitive domains of capacity into the assessment are crucial to navigating the wide differential diagnosis of COVID-19 conspiracy beliefs. It is important to attempt to clarify and optimize patient decision-making abilities by addressing circumstances, attitudes, and cognitive styles specific to patients with seemingly irrational beliefs about COVID-19.

The frequency of psychotic symptoms in types of dementia: a systematic review

The frequency of psychotic symptoms in older adults is high, mainly in neurocognitive cognitions of the most varied etiologies.

Objectives

This study aimed to review the studies that analyze the frequency of the types of delusions, hallucinations, and misidentifications in dementia conditions of different etiologies.

Methods

A systematic review was conducted on August 9, 2021, in the PubMed, PsycInfo, Embase, Web of Science, and Scopus databases with the following descriptors: (dementia OR alzheimer disease OR dementia with Lewy bodies OR frontotemporal dementia OR mixed dementia OR vascular dementia OR major neurocognitive disorder OR parkinson disease dementia) AND (psychotic symptoms OR psychosis OR hallucinations OR delusions OR psychopathology OR misidentification) AND (prevalence OR epidemiology).

Results

A total of 5,077 articles were found, with a final inclusion of 35. The overall frequency of psychotic symptoms ranged from 34 to 63% in dementia conditions of the most varied etiologies. Alzheimer's disease (AD) presents more delusions and hallucinations and has a higher frequency regarding the presence of misidentifications. On the contrary, Dementia with Lewy bodies (DLB) seems to present more hallucinations, even auditory, when compared to the other dementias, concomitantly with delusions. Vascular and frontotemporal dementia present fewer psychotic symptoms than DLB and AD.

Conclusions

We identified a gap in the literature on the description of the psychotic symptoms of dementia, mainly in those of non-AD etiologies. Studies that assess the neuropsychiatric symptoms of dementias deeply might contribute in a more definite manner to the causal diagnosis of dementia.

Decreased insight, but not self-stigma or belief about medicine, is associated with greater severity of delusions in a sample of long-stay patients with schizophrenia: a cross-sectional study

BACKGROUND

There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia.

METHODS

A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used.

RESULTS

The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta = 0.004) was significantly associated with more delusions, whereas higher insight (Beta = - 0.89) was significantly associated with less delusions. No significant associations were found between insight, self-stigma and hallucinations.

CONCLUSION

Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.

Prevalence of multisensory hallucinations in people at risk of transition to psychosis

Hallucinations can occur in single or multiple sensory modalities. Greater attention has been paid to single sensory experiences with a comparative neglect of hallucinations that occur across two or more sensory modalities (multisensory hallucinations). This study explored how common these experiences were in people at risk of transition to psychosis (n=105) and considered whether a greater number of hallucinatory experiences increased delusional ideation and reduced functioning, both of which are associated with a greater risk of transition to psychosis. Participants reported a range of unusual sensory experiences, with two or three being common. However, when a strict definition of hallucinations was applied, in which the experience has the quality of a real perception and in which the person believes them to be real experiences, then multisensory experiences were rare and when reported, single sensory hallucinations in the auditory domain were most common. The number of unusual sensory experiences or hallucinations was not significantly associated with greater delusional ideation or poorer functioning. Theoretical and clinical implications are discussed.

Restructuring insight: An integrative review of insight in problem-solving, meditation, psychotherapy, delusions and psychedelics

Occasionally, a solution or idea arrives as a sudden understanding - an insight. Insight has been considered an "extra" ingredient of creative thinking and problem-solving. Here we propose that insight is central in seemingly distinct areas of research. Drawing on literature from a variety of fields, we show that besides being commonly studied in problem-solving literature, insight is also a core component in psychotherapy and meditation, a key process underlying the emergence of delusions in schizophrenia, and a factor in the therapeutic effects of psychedelics. In each case, we discuss the event of insight and its prerequisites and consequences. We review evidence for the commonalities and differences between the fields and discuss their relevance for capturing the essence of the insight phenomenon. The goal of this integrative review is to bridge the gap between the different views and inspire interdisciplinary research efforts for understanding this central process of human cognition.

Update to the study protocol Face Your Fears: Virtual reality-based cognitive behavioral therapy (VR-CBT) versus standard CBT for paranoid ideations in patients with schizophrenia spectrum disorders: a randomized clinical trial

We unfortunately need to make an update to our published study protocol that describes a significant change in the design of the study. The Committee on Health Research Ethics of the Capital Region Denmark recently rejected the approval of changing the primary outcome in the trial, on the invariable grounds that the trial has already commenced. It is therefore necessary to retain the Green Paranoid Thought Scale (GPTS) part B, ideas of persecution, as our primary outcome, and GPTS part A, ideas of social reference, as a secondary outcome, which is described opposite in our published study protocol. The exchange of outcomes has not affected participation in our trial or the informed consent. Intervention in both groups and assessments are unchanged. The two outcomes together constitute GPTS and the unifying concept we attempt to treat, namely paranoid ideations. As this is a blinded, methodologically rigorous trial, we did not have-and still do not have-access to preliminary data, and therefore, we have no knowledge of the distribution of our two intervention groups nor the potential effect of the intervention. The power calculation remains unchanged irrespective of the selection of the primary outcome. We have been fully transparent with the changes in primary and secondary outcomes on ClinicalTrials.gov throughout the trial. Due to the considerations mentioned above, we assumed that there would not be any ethical implications of the change of primary outcome. We sincerely apologize for the irregularity caused because of this assumption.Trial registrationClinicalTrials.gov NCT04902066 . Initial release April 19th, 2021.

"The more things change…"? Stability of delusional themes across 12 years of presentations to an early intervention service for psychosis

PURPOSE

While the prevalence of delusional themes appears to be consistent across geographic contexts, little is known about the relative prevalence of such themes within a given setting over periods of time. We therefore investigated delusional themes across 12 years of presentation to a catchment-based early intervention service for first episode psychosis (FEP).

METHODS

Systematically collected data from 500 patients at an early intervention service for FEP were analyzed. Four cohorts of 3 years each, from 2006 to 2017, were used to compare the frequency of delusion themes across cohorts. We also integrated into the analysis baseline sociodemographic factors such as gender, age, and highest level of education and clinical factors such as anxiety, depression, suicidality, hallucinations, and primary diagnosis (affective or non-affective psychosis).

RESULTS

Sex and education level were stable across cohorts, while patient age varied (p = 0.047). Clinical anxiety, depression, and suicidality at entry were also stable. Across cohorts, the proportion of patients with affective versus non-affective diagnosis differed (p = 0.050), with no differences in global rating of delusion severity or theme prevalence except for delusions of guilt or sin (p = 0.001). This single theme difference was not correlated with age or diagnosis.

CONCLUSION

Our study suggests relatively stable prevalence of delusion themes across cohorts of individuals experiencing FEP. This demonstrates the potential utility of studying thematic content both for understanding delusions in clinical populations and in research. Future explorations of the relationships between delusion themes and across individual patient episodes should be conducted.

Accelerated atrophy in dopaminergic targets and medial temporo-parietal regions precedes the onset of delusions in patients with Alzheimer's disease

People with Alzheimer's disease (AD) and delusions have worse quality of life and prognosis. However, early markers of delusions have not been identified yet. The present study investigated whether there are any detectable differences in grey matter (GM) volume and cognitive changes in the year before symptom onset between patients with AD who did and did not develop delusions. Two matched samples of AD patients, 63 who did (PT-D) and 63 who did not develop delusions (PT-ND) over 1 year, were identified from the Alzheimer's Disease Neuroimaging Initiative database. The Neuropsychiatric Inventory (NPI) was used to assess the presence of delusions. Sixty-three additional matched healthy controls (HC) were selected. Repeated-measures ANCOVA models were used to investigate group-by-time effects on the volume of selected GM regions of interest and on cognitive performance. No neurocognitive differences were observed between patient groups prior to symptom onset. Greater episodic memory decline and GM loss in bilateral caudate nuclei, medio-temporal and midline cingulo-parietal regions were found in the PT-D compared with the PT-ND group. A pattern of faster GM loss in brain areas typically affected by AD and in cortical and subcortical targets of dopaminergic pathways, paralleled by worsening of episodic memory and behavioural symptoms, may explain the emergence of delusions in patients with AD.

Effectiveness of a Metacognitive Intervention for Schizophrenia (MCI-S) Program for Symptom Relief and Improvement in Social Cognitive Functioning in Patients with Schizophrenia

This study investigated the effectiveness of a metacognitive intervention program for symptom relief and improvement in social cognitive functioning among adults with schizophrenia. The program focused on enhancing metacognition to encourage self-awareness and step-by-step perspective expansion. There were 24 participants in the experimental group and 19 participants in the control group. Delusions decreased, and social cognition and social functioning improved in the experimental group compared to the control group. The program demonstrated utility as a treatment modality, which can be part of an overall program of a mental health promotion institution to improve functioning in patients with schizophrenia.

Translating affective and cognitive mechanisms of psychotic symptoms into better therapies

For a long time, psychotic symptoms were seen as too different from normal experiences to be explicable by psychological theories, let alone modifiable by psychological therapy. In the 1990s, the epidemiological research pointing to a continuum of psychotic symptoms and the clinical success in using cognitive approaches for psychosis strongly challenged this view. This inspired the field - along with my own work - to focus on a better understanding of the psychological mechanisms of psychotic symptoms in order to develop increasingly effective interventions. Together with other researchers, I have found that negative affect and aberrant arousal play a crucial role in the formation of delusions where they appear to interact with more fundamental problems in belief updating. While our understanding of the basic mechanisms that drive psychotic symptoms is gaining precision, the challenge remains to find the most suitable ways of targeting these mechanisms.

Belief Updating and Paranoia in Individuals With Schizophrenia

BACKGROUND

Persecutory delusions are among the most common delusions in schizophrenia and represent the extreme end of the paranoia continuum. Paranoia is accompanied by significant worry and distress. Identifying cognitive mechanisms underlying paranoia is critical for advancing treatment. We hypothesized that aberrant belief updating, which is related to paranoia in human and animal models, would also contribute to persecutory beliefs in individuals with schizophrenia.

METHODS

Belief updating was assessed in 42 participants with schizophrenia and 44 healthy control participants using a 3-option probabilistic reversal learning task. Hierarchical Gaussian Filter was used to estimate computational parameters of belief updating. Paranoia was measured using the Positive and Negative Syndrome Scale and the revised Green et al. Paranoid Thoughts Scale. Unusual thought content was measured with the Psychosis Symptom Rating Scale and the Peters et al. Delusions Inventory. Worry was measured using the Dunn Worry Questionnaire.

RESULTS

Paranoia was significantly associated with elevated win-switch rate and prior beliefs about volatility both in schizophrenia and across the whole sample. These relationships were specific to paranoia and did not extend to unusual thought content or measures of anxiety. We observed a significant indirect effect of paranoia on the relationship between prior beliefs about volatility and worry.

CONCLUSIONS

This work provides evidence that relationships between belief updating parameters and paranoia extend to schizophrenia, may be specific to persecutory beliefs, and contribute to theoretical models implicating worry in the maintenance of persecutory delusions.

State-like changes in the salience network correlate with delusion severity in first-episode psychosis patients

BACKGROUND AND HYPOTHESIS

Delusions are characteristic of psychotic disorders; however, the brain correlates of delusions remain poorly known. Imaging studies on delusions typically compare images across individuals. Related confounding of inter-individual differences beyond delusions may be avoided by comparing delusional and non-delusional states within individuals.

STUDY DESIGN

We studied correlations of delusions using intra-subject correlation (intra-SC) and inter-subject correlation of functional magnetic resonance imaging (fMRI) signal time series, obtained during a movie stimulus at baseline and follow-up. We included 27 control subjects and 24 first-episode psychosis patients, who were free of delusions at follow-up, to calculate intra-SC between fMRI signals obtained during the two time points. In addition, we studied changes in functional connectivity at baseline and during the one-year follow-up using regions where delusion severity correlated with intra-SC as seeds.

RESULTS

The intra-SC correlated negatively with the baseline delusion severity in the bilateral anterior insula. In addition, we observed a subthreshold cluster in the anterior cingulate. These three regions constitute the cortical salience network (SN). Functional connectivity between the bilateral insula and the precuneus was weaker in the patients at baseline than in patients at follow-up or in control subjects at any time point.

CONCLUSIONS

The results suggest that intra-SC is a powerful tool to study brain correlates of symptoms and highlight the role of the SN and internetwork dysconnectivity between the SN and the default mode network in delusions.

Efficacy of Metacognitive Training in a Chilean Sample of People with Schizophrenia

INTRODUCTION

Moritz et al.'s metacognitive training (MCT), a new development of cognitive therapy, is a manualised group training programme, designed to correct cognitive biases involved in the formation and maintenance of psychotic symptoms, especially delusions. We report on the efficacy of MCT in a Chilean sample of people with schizophrenia.

METHODS

50 outpatients from the Hospital Del Salvador in Valparaíso, Chile, were randomly assigned to the intervention group that received MCT or the control group that only received treatment as usual (TAU). Subjects were assessed at the beginning and end of the study with the Positive and Negative Syndrome Scale (PANSS), Cognitive Biases Questionnaire for Psychosis (CBQ-P) and Beck Cognitive Insight Scale (BCIS).

RESULTS

Greater statistically significant improvements were recorded in the MCT group, both in symptoms and cognitive biases and in cognitive insight, than in the control group. When comparing both groups, significant results in favor of MCT were only observed in positive symptoms.

CONCLUSIONS

The results of this study suggest MCT is superior to TAU in treating positive symptoms. It was not possible to demonstrate its superiority in improving cognitive biases and cognitive insight.

Clinical insight in first-episode psychosis: Clinical, neurocognitive and metacognitive predictors

OBJECTIVE

Poor insight is a major problem in psychosis, being detrimental for treatment compliance and recovery. Previous studies have identified various correlates of insight impairment, mostly in chronic samples. The current study aimed to determine clinical, neurocognitive, metacognitive, and socio-cognitive predictors of insight in first-episode psychosis.

METHODS

Regression analyses of different insight dimensions were conducted in 190 patients with first-episode psychosis. Measures of clinical symptoms, neurocognition, metacognition, social cognition, and 'jumping to conclusions' bias were entered as predictors.

RESULTS

Delusions, disorganisation, and certain negative symptoms were associated with unawareness in various domains, while depression was associated with greater awareness of illness. Deficit in theory of mind and self-reflective processes, as well as a 'jumping to conclusions' bias, contributed to poor insight. Several neuropsychological scores also contributed to this but their contribution was no longer observed in regression analyses that included all the previously identified clinical and cognitive predictors. A measure of perseverative errors was still associated with unawareness and misattribution of symptoms.

CONCLUSION

In models that account for 28 % to 50 % of the variance, poor insight in first-episode psychosis is mainly associated with delusions and certain negative symptoms. At the cognitive level it does not appear to result from neuropsychological impairment but rather from altered reasoning bias and dysfunction in metacognitive processes. Therapeutic strategies specifically directed at these mechanisms could help improve the evolution of insight in first episode psychosis.

Emerging role of psychosis in Parkinson's disease: From clinical relevance to molecular mechanisms

Parkinson’s disease (PD) is the second most common neurodegenerative disease. Psychosis is one of the common psychiatric presentations in the natural course of PD. PD psychosis is an important non-motor symptom, which is strongly correlated with a poor prognosis. Increasing attention is being given to PD psychosis. In this opinion review, we summarized and analyzed the identification, screening, epidemiology, mechanisms, risk factors, and therapeutic approaches of PD psychosis based on the current clinical evidence. PD psychosis tends to have a negative effect on patients' quality of life and increases the burden of family caregiving. Screening and identification in the early stage of disease is crucial for establishing tailored therapeutic strategies and predicting the long-term outcome. Development of PD psychosis is believed to involve a combination of exogenous and endogenous mechanisms including imbalance of neurotransmitters, structural and network changes, genetic profiles, cognitive impairment, and antiparkinsonian medications. The therapeutic strategy for PD psychosis includes reducing or ceasing the use of dopaminergic drug, antipsychotics, cholinesterase inhibitors, and non-pharmacological interventions. Ongoing clinical trials are expected to provide new insights for tailoring therapy for PD psychosis. Future research based on novel biomarkers and genetic factors may help inform individualized therapeutic strategies.

The Relationships Between Childhood Abuse and Neglect, Sub-clinical Symptoms of Psychosis and Self-harm in a Non-clinical Community Sample

There is now substantial evidence that childhood adverse events are a significant risk factor for symptoms of psychosis in both clinical and community samples. Both childhood trauma and positive symptoms of psychosis are associated with an increased risk of self-harming behaviours. Therefore the current study aimed to consider the relationship between retrospective reports of childhood adversity, sub-clinical positive symptoms of psychosis and self-harm in a non-clinical community sample. The study employed a cross-sectional survey design, distributed online. Participants were asked to complete psychometric assessments relating to: demographic characteristics including past-year substance misuse; childhood adversity; sub-clinical symptoms of psychosis (delusions and hallucinations) and self-harming behaviours. The results found that, after controlling for substance misuse, childhood adversity predicted significant variance in sub-clinical delusions and hallucinations in the general population. Both symptoms of psychosis and childhood adversity increased the risk of self-harming behaviours. Positive symptoms partially mediated the relationship between early adversity and self-harming behaviours. For some people, the sequelae of early adversity including sub-clinical delusions and hallucinations may increase the risk of self-harming behaviours. Future research would benefit from considering the role of dissociation in these relationships and the affective impact of pseudo-psychotic experiences. Practitioners should consider the impact of childhood adversity, unusual perceptual experiences and distorted beliefs when working with people who self-harm. The current research was limited by the cross-sectional survey design and non-random sampling methodology.

Face Your Fears: Virtual reality-based cognitive behavioral therapy (VR-CBT) versus standard CBT for paranoid ideations in patients with schizophrenia spectrum disorders: a randomized clinical trial

BACKGROUND

Schizophrenia spectrum disorders cause suffering for patients, relatives, and the surrounding society. Paranoid ideations, encompassing ideas of social reference and manifest persecutory delusions, are among the most frequent symptoms in this population and a cause of significant distress. Recent meta-analyses of cognitive behavioral therapy (CBT) for psychosis show small to moderate effect sizes in reducing paranoid ideations. Virtual reality-based CBT (VR-CBT) could improve therapy efficacy as exposure and behavioral experiments in VR can be optimized, individualized, and carried out in a safe environment. Few VR-CBT studies exist for paranoid ideations and there is a need for large-scale, methodologically rigorous trials.

METHODS

This study is a randomized, assessor-blinded parallel-groups multi-center superiority clinical trial, fulfilling the CONSORT criteria for non-pharmacological treatment. A total of 256 patients diagnosed with schizophrenia spectrum disorder, including schizotypal disorder (ICD-10 F20-29), will be allocated to either 10 sessions of symptom-specific CBT-VR plus treatment as usual-versus 10 sessions of standard symptom-specific CBT for paranoid ideations (CBT) plus treatment as usual. All participants will be assessed at baseline, treatment end (3 months post baseline), and then 9 months post baseline. A stratified block-randomization with concealed randomization sequence will be conducted. Independent assessors blinded to the treatment will evaluate the outcome. Analysis of outcome will be carried out with the intention to treat principles. The primary outcome is ideas of social reference measured with Green Paranoid Thought Scale Part A (GPTS-A) at the cessation of treatment at 3 months post baseline. Secondary outcomes are ideas of persecution (GPTS-B), Social Interaction Anxiety Scale (SIAS), Personal and Social Performance scale (PSP), Safety Behavior Questionnaire (SBQ), and CANTAB Emotion Recognition Task.

DISCUSSION

The trial will elucidate whether VR-CBT can enhance therapy efficacy for paranoid ideations. Additionally, Trial findings will provide evidence on the effectiveness and cost-effectiveness of VR-CBT for paranoid ideations that can guide the possible dissemination and implementation into clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902066 . Initial release April 9th, 2021.

The psychometric properties of the Nepean Belief Scale as a tool for assessing delusions in schizophrenia and related psychotic disorders

OBJECTIVES

To examine the psychometric characteristics of the Nepean Belief Scale (NBS) in psychiatric inpatients with delusions. The NBS is a five-item, clinician-administered scale that assesses the characteristics of beliefs, i.e. conviction, fixity, fluctuation, resistance and awareness that the belief is unreasonable.

METHODS

Fifty-five patients were interviewed by two clinicians, within three days of admission to an acute psychiatric unit and were assessed using the NBS, the Brown Assessment of Belief Scale (BABS), the MINI International Neuropsychiatric Interview (MINI) and the Depression Anxiety Stress Scale 21-Item Version (DASS-21). The NBS was administered after two weeks to available participants, to assess test-retest reliability.

RESULTS

Results demonstrated excellent inter-rater reliability of 0.93, Cronbach's alpha coefficient for internal consistency was 0.77. The NBS was found to have good convergent validity with the BABS and good discriminant validity with the DASS. Two-week test-retest reliability suggests that the NBS is sensitive to therapeutic change.

CONCLUSIONS

Advantages of the NBS include its brevity, its ability to assess belief-related insight, its clear instructions and its definitions of belief characteristics. Thus, the NBS has the potential to greatly improve our ability to more objectively assess delusional beliefs.

Sex-based differences in the longitudinal association between autistic traits and positive psychotic experiences in adolescents: A population-based cohort study

Previous reports have suggested a cross-sectional association between autistic traits and psychotic experiences (PEs) in adolescents. However, while both autistic traits and PEs show sex-related differences, no studies have directly assessed whether such differences exist in the longitudinal association between autistic traits and PEs. Using a population-based adolescent cohort sample (n = 3007), we tested whether the longitudinal association between autistic traits and positive PEs was affected by sex-based differences using regression analyses. Autistic traits were assessed at 12 years old (timepoint 1 [T1]), and PEs were assessed at 12 and 14 years old (T1 and T2). Subsequently, we tested whether subdomains of autistic traits (difficulties in social interaction, communication, imagination, attention to detail, and attention switching) were associated with subtypes of PEs (auditory hallucinations, visual hallucinations, and delusions) using structural equation modeling, after controlling for PEs at T1, socio-economic status, school performance and parents' psychiatric disorders. After controlling for PEs at T1, we did not find any associations between autistic traits at T1 and PEs at T2 in both sexes. There was no significant positive or negative association between all subdomains of autistic traits and subtypes of PEs in both sexes. Autistic traits do not seem to predict future PEs in general adolescents regardless of sex.

Relationships among subclinical psychotic symptoms in young adults over time

BACKGROUND

Subclinical psychotic symptoms are common in the general population and are often benign. However, those that become distressing or persistent may increase risk for the development of a psychotic disorder. Cognitive models have proposed that certain appraisals of hallucinatory experiences can lead to delusional beliefs, particularly if an individual is experiencing negative mood. However, the dynamic relationships among these symptoms are poorly understood. This study examined the longitudinal relationships among subclincal hallucinations, delusional ideation, and depression in a sample of young adults.

METHODS

677 college students completed baseline questionnaires to assess: delusional ideation (Peters Delusions Inventory), hallucinations (Launay-Slade Hallucinations Scale-Extended), and depression (Beck Depression Inventory). These measures were repeated 7, 13, 19, and 25 months later.

RESULTS

Higher baseline severity of hallucinations was strongly predictive of severity of delusions across all future follow-up timepoints, specifically when baseline depression was high. However, the severity of hallucinations did not change over time, nor were they predicted by baseline delusional ideation.

CONCLUSIONS

These findings support the proposal that hallucinations frequently precede more severe delusional ideation, rather than the reverse sequence, particularly when depressive symptoms are present. Such longitudinal relationships provide clues to the underlying mechanisms of psychosis, highlighting one pathway for intervention.

Screening, Diagnosis, and Management of Parkinson's Disease Psychosis: Recommendations From an Expert Panel

INTRODUCTION

Hallucinations and delusions present with psychosis are debilitating non-motor symptoms of Parkinson's disease, with a prevalence of up to 50-70% at some point during the course of the disease. Often patients and caregivers do not report the presence of hallucinations or delusions unless specifically questioned. A panel of experts in neurology and geriatric psychiatry convened to develop a simple screening tool and guidance on diagnosis and treatment of Parkinson's disease psychosis (PDP).

METHODS

The working group reviewed literature for existing PDP guidelines on diagnosis and management and identified gaps in recommendations. The group discussed and developed a screening tool and treatment guidance that addressed the gaps in existing methodology based on their clinical experience.

RESULTS

The proposed screening tool consists of two parts: (1) a brief pre-visit screening portion to be completed by the patient and caregiver, and (2) a clinician portion to be completed via clinical interview of the patient and caregiver. If psychotic symptoms are present, an appropriate treatment plan is developed for PDP based on evaluation.

CONCLUSIONS

This simple screening tool and treatment guidance offers a practical clinical approach for clinicians in the diagnosis and management of PDP.

Aberrant salience correlates with psychotic dimensions in outpatients with schizophrenia spectrum disorders

BACKGROUND

Aberrant salience is a well-known construct associated with the development and maintenance of psychotic symptoms in schizophrenia. However, only a few studies have investigated aberrance salience as a trait, with no study investigating the association between the five aberrant salience domains and psychotic symptoms. We aimed to explore the role of aberrant salience and its domains on psychotic dimensions in both clinically remitted and non-remitted patients.

METHODS

A sample of 102 patients diagnosed with schizophrenia spectrum disorders was divided according to the Positive and Negative Syndrome Scale (PANSS) remission criteria into two groups: remitted and non-remitted. Differences regarding psychotic symptomatology assessed by the PANSS and aberrant salience measured by the Aberrant Salience Inventory (ASI) were explored. Finally, a correlation analysis between the PANSS and the ASI was run.

RESULTS

Significantly higher ASI scores were evident among non-remitted patients. Positive symptoms (i.e. delusions, conceptual disorganization, and hallucinatory behaviour) and general psychopathology (i.e. postural mannerisms, unusual thought content) were correlated to the aberrant salience subscales 'sharpening of senses', 'heightened emotionality' and 'heightened cognition' and with the ASI total score. Significant correlations emerged between negative symptoms (blunted affect and social withdrawal) and 'heightened cognition'. Finally, lack of spontaneity of conversation was related to the subscales 'heightened emotionality' and 'heightened cognition', as well as to the ASI total score.

CONCLUSIONS

These preliminary results support the hypothesis of an association between aberrant salience and psychotic symptoms in schizophrenia. Further research is needed, especially into the mechanisms underlying salience processing, in addition to social and environmental factors and cognitive variables.

Everything is connected: Inference and attractors in delusions

Delusions are, by popular definition, false beliefs that are held with certainty and resistant to contradictory evidence. They seem at odds with the notion that the brain at least approximates Bayesian inference. This is especially the case in schizophrenia, a disorder thought to relate to decreased - rather than increased - certainty in the brain's model of the world. We use an active inference Markov decision process model (a Bayes-optimal decision-making agent) to perform a simple task involving social and non-social inferences. We show that even moderate changes in some model parameters - decreasing confidence in sensory input and increasing confidence in states implied by its own (especially habitual) actions - can lead to delusions as defined above. Incorporating affect in the model increases delusions, specifically in the social domain. The model also reproduces some classic psychological effects, including choice-induced preference change, and an optimism bias in inferences about oneself. A key observation is that no change in a single parameter is both necessary and sufficient for delusions; rather, delusions arise due to conditional dependencies that create 'basins of attraction' which trap Bayesian beliefs. Simulating the effects of antidopaminergic antipsychotics - by reducing the model's confidence in its actions - demonstrates that the model can escape from these attractors, through this synthetic pharmacotherapy.

Functional brain networks underlying probabilistic reasoning and delusions in schizophrenia

Delusions in schizophrenia are false beliefs that are assigned certainty and not afforded the scrutiny that normally gives rise to doubt, even under conditions of weak evidence. The goal of the current functional magnetic resonance imaging (fMRI) study is to identify the brain network(s) involved in gathering information under conditions of weak evidence, in people with schizophrenia experiencing delusions. fMRI activity during probabilistic reasoning in people with schizophrenia experiencing delusions (n = 29) compared to people with schizophrenia not experiencing delusions (n = 41) and healthy controls (n = 41) was observed when participants made judgments based on evidence that weakly or strongly matched (or mismatched) with the focal hypothesis. A brain network involved in visual attention was strongly elicited for conditions of weak evidence for healthy controls and patients not experiencing delusions, but this increase was absent for patients experiencing delusions. This suggests that the state associated with delusions manifests in fMRI as reduced activity in an early visual attentional process whereby weak evidence is incorrectly stamped as conclusive, manifestating as a feeling of fluency and misplaced certainty, short-circuiting the search for evidence, and providing a candidate neural process for 'seeding' delusions.

Rethinking delusions: A selective review of delusion research through a computational lens

Delusions are rigid beliefs held with high certainty despite contradictory evidence. Notwithstanding decades of research, we still have a limited understanding of the computational and neurobiological alterations giving rise to delusions. In this review, we highlight a selection of recent work in computational psychiatry aimed at developing quantitative models of inference and its alterations, with the goal of providing an explanatory account for the form of delusional beliefs in psychosis. First, we assess and evaluate the experimental paradigms most often used to study inferential alterations in delusions. Based on our review of the literature and theoretical considerations, we contend that classic draws-to-decision paradigms are not well-suited to isolate inferential processes, further arguing that the commonly cited 'jumping-to-conclusion' bias may reflect neither delusion-specific nor inferential alterations. Second, we discuss several enhancements to standard paradigms that show promise in more effectively isolating inferential processes and delusion-related alterations therein. We further draw on our recent work to build an argument for a specific failure mode for delusions consisting of prior overweighting in high-level causal inferences about partially observable hidden states. Finally, we assess plausible neurobiological implementations for this candidate failure mode of delusional beliefs and outline promising future directions in this area.

Investigating predictors contributing to the expression of schizotypy during the COVID-19 pandemic

The coronavirus (COVID-19) pandemic has caused major disruptions to social and other forms of functioning, which may influence schizotypy expression. The current study aimed to explore possible distal and proximal predictors contributing to schizotypy in a sample of the Australian general population during the COVID-19 pandemic. The COvid-19 and you: mentaL heaLth in AusTralia now survEy (COLLATE) project is an online mental health study aimed at tracking key mental health indicators over the progression of the pandemic. Adults residing in Australia were invited to take part using non-discriminative snowball sampling. Demographic-clinical information was collected for 850 participants in either October 2020 or January 2021. To assess schizotypy facets, the Launay-Slade Hallucinations Scale-Extended (LSHS-E) and Peters Delusions Inventory (PDI-21) were used to measure hallucination and delusion proneness respectively. Generalised linear models (with gamma and negative binomial distributions) were employed. Age, negative emotions and loneliness significantly contributed to both hallucination and delusion proneness; gender, education and religiosity also significantly contributed to delusion proneness, in the final regression models. Our study corroborated the specific contribution of loneliness, amongst other factors, in the prediction of schizotypy facets. Tackling loneliness represents a public health challenge that needs to be urgently addressed, especially in the face of the ongoing COVID-19 pandemic.

Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial

Background

People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists.

Methods

Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5–10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement.

Discussion

The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use.

Trial registration

ISRCTN93382525 (03/08/20)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06215-x.

Unmet needs in the diagnosis and treatment of Parkinson's disease psychosis and dementia-related psychosis

Dementia due to Parkinson's disease and Alzheimer's disease are associated with behavioural and psychological symptoms, including psychosis. Long-term management presents a challenge for health care providers and caregivers. Symptoms of psychosis include hallucinations and delusions; if untreated, these can lead to institutionalisation, decreased quality of life, and significant patient and caregiver distress. A critical step in the effective management of dementia-related psychosis (DRP) is the identification and diagnosis of affected patients. The lack of a standardised diagnostic approach presents a barrier to treatment and there are no consensus guidelines for DRP. Furthermore, there are no approved therapies for the treatment of DRP. Antipsychotic medications are often prescribed off-label, even though some are associated with an increased risk of adverse events or mortality. We present currently available screening tools and guidelines for the diagnosis and treatment of Parkinson's disease psychosis and DRP in the context of what is needed for effective management of psychosis.KEY POINTSWe present currently available screening tools and guidelines for Parkinson's disease psychosis and dementia-related psychosis, and discuss the unmet need for simple clinical diagnostic tools and treatment guidelines.The identification of psychosis is variable across different settings and specialties, without a unified approach to screening, definition, or diagnosis.Currently used tools for defining and assessing psychosis in a research setting are usually too cumbersome for everyday clinical practice.The development of a standardised set of diagnostic criteria would provide clinicians the opportunity to improve the detection, treatment, and quality of life of patients and their caregivers.

Comparative Outcomes of Commonly Used Off-Label Atypical Antipsychotics in the Treatment of Dementia-Related Psychosis: A Network Meta-analysis

INTRODUCTION

Dementia-related psychosis (DRP) is characterized by hallucinations and delusions, which may increase the debilitating effects of underlying dementia. This network meta-analysis (NMA) evaluated the comparative efficacy, safety, and acceptability of atypical antipsychotics (AAPs) commonly used off label to treat DRP.

METHODS

We included 22 eligible studies from a systematic literature review of AAPs (quetiapine, risperidone, olanzapine, aripiprazole, and brexpiprazole) used off label to treat DRP. Study outcomes were: (1) efficacy-neuropsychiatric inventory-nursing home (NPI-NH psychosis subscale), (2) safety-mortality, cerebrovascular events (CVAEs), and others (somnolence, falls, fractures, injuries, etc.), and (3) acceptability-discontinuations due to all causes, lack of efficacy, and adverse events (AEs). We used random-effects modeling to estimate pooled standardized mean differences (SMDs) for NPI-NH psychosis subscale scores and odds ratios (OR) for other dichotomous outcomes, with their respective 95% confidence intervals (CIs).

RESULTS

Compared with placebo, aripiprazole (SMD - 0.12; 95% CI - 0.31, 0.06), and olanzapine (SMD - 0.17; 95% CI - 0.04; 0.02) demonstrated small, non-significant numerical improvements in NPI-NH psychosis scores (5 studies; n = 1891), while quetiapine (SMD 0.04; 95% CI - 0.23, 0.32) did not improve symptoms. The odds of mortality (15 studies, n = 4989) were higher for aripiprazole (OR 1.58; 95% CI 0.62, 4.04), brexpiprazole (OR 2.22; 95% CI 0.30, 16.56), olanzapine (OR 2.21; 95% CI 0.84, 5.85), quetiapine (OR 1.68; 95% CI 0.70, 4.03), and risperidone (OR 1.63; 95% CI 0.93, 2.85) than for placebo. Risperidone (OR 3.68; 95% CI 1.68, 8.95) and olanzapine (OR 4.47; 95% CI 1.36, 14.69) demonstrated significantly greater odds of CVAEs compared to placebo. Compared with placebo, odds of all-cause discontinuation were significantly lower for aripiprazole (OR 0.71; 95% CI 0.51, 0.98; 20 studies; 5744 patients) and higher for other AAPs. Aripiprazole (OR 0.5; 95% CI 0.31, 0.82) and olanzapine (OR 0.48; 95% CI 0.31, 0.74) had significantly lower odds of discontinuation due to lack of efficacy (OR 12 studies; n = 4382) compared to placebo, while results for quetiapine and risperidone were not significant. Compared with placebo, the odds of discontinuation due to AEs (19 studies, n = 5445) were higher for olanzapine (OR 2.62; 95% CI 1.75, 3.92), brexpiprazole (OR 1.80; 95% CI 0.80, 4.07), quetiapine (OR 1.25; 95% CI 0.82, 1.91), aripiprazole (OR 1.38; 95% CI 0.90, 2.13), and risperidone (OR 1.41; 95% CI 1.02, 1.94).

CONCLUSIONS

Overall results demonstrate that, compared with placebo, quetiapine is not associated with improvement in psychosis in patients with dementia, while olanzapine and aripiprazole have non-significant small numerical improvements. These off-label AAPs (quetiapine, risperidone, olanzapine, aripiprazole, and brexpiprazole) are associated with greater odds of mortality, CVAEs, and discontinuations due to AEs than placebo. These results underscore the ongoing unmet need for newer pharmacological options with a more favorable benefit-risk profile for the treatment of DRP.

Long-term outcomes with pimavanserin for psychosis in clinical practice

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Psychosis in PD is a common problem, with limited treatment options.

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Pimavanserin is FDA approved for PDP, but long-term outcomes in clinical practice are lacking.

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While it has been proven to be effective in short-duration clinical trials, our clinical experiences, however, demonstrate less promising results in the long term.

Introduction

Pimavanserin is the only medication FDA-approved for the treatment of Parkinson disease (PD) psychosis (PDP), but reports of long-term, real-world clinical experience are lacking.

Methods

A retrospective chart review of all patients treated with pimavanserin was conducted at our large Movement Disorders practice in Providence, Rhode Island, USA. Demographic and clinical data for each patient were collected and descriptive analyses were performed.

Results

We identified 54 patients (23 female) who initiated pimavanserin, whose median age was 70 years (range 44–87 years) and the median duration of pimavanserin therapy was 26 weeks. Initial improvement was seen in 47% of the entire group, and 50% of the DLB patients. Additional antipsychotic medication was needed concomitantly with pimavanserin to maintain a positive response for 40% of patients. Only 15% of the entire group had effective treatment of their condition with pimavanserin monotherapy over a median of 52 weeks. Among the initial responders, 32% continued on pimavanserin monotherapy. Among the non-responders, the mean trial period for patients who did not improve was 27 weeks, for patients who worsened was 16 weeks, and for those who experienced adverse effects was 1–2 weeks. Reported sex was similar across responders (60%), non-responders (56%), and the overall cohort (57%).

Conclusion

Our real-world experience shows that pimavanserin is safe and tolerable, with a lower response rate than reported in other publications. While it has been proven to be effective in short-duration clinical trials, our clinical experiences, however, demonstrate less promising results in the long term.