Effects of Metacognitive Training on Cognitive Insight in a Sample of Patients with Schizophrenia

Metacognitive training (MCT) is a group intervention that addresses cognitive biases and distortions that could help maintain delusions and hallucinations in people with schizophrenia. This program has proven its effectiveness in reducing the symptoms, but its impact on cognitive insight has scarcely been investigated. Therefore, the aim of the study was to assess the program’s impact on cognitive insight in patients with long-term schizophrenia. A sample of 22 patients with schizophrenia was divided into two groups: one received 16 sessions of MCT (n = 11), while the other received the usual treatment (n = 11). They were assessed using the Beck Cognitive Insight Scale which measures two components, self-reflection and self-certainty, and the Positive and Negative Syndrome Scale (PANSS). The experimental group showed high levels of adherence, an increase in self-reflection, and a decrease in self-assurance levels as hypothesized. We found statistically significant differences between the control and experimental groups in excitation, hostility, positive symptomatology total score, hallucinatory behavior, and suspicion. In the usual treatment group, a non-significant decrease in positive symptoms was also observed. The findings showed that the implementation of the MCT program in real clinical settings can contribute to an improvement in the metacognitive ability and symptomatology of people with schizophrenia.

[The sense of the senseless, psychoanalytic aspects of delusion in psychosis]

The psychoanalytic approach to delusion in psychosis leads us to examine the function of a "furrow". It is necessary to remain in the furrow in order not to become delusional. References to Sigmund Freud, Jacques Lacan, Mélanie Klein and Jean-Claude Maleval enlighten us as to the origin and the function of delusion as an attempt to give meaning.

[Distress and delusion]

Delusional and pervasive speech, beyond the usual patient dialogue, is one of the fundamental aspects which the nursing team must deal with on a daily basis. The supportive care provided to Edouard, a delusional patient, is an example.

[Delusion in the critical patient]

Delirium, the acute confusional syndrome, is a common although infradiagnosed problem in the critically ill patient, especially the hypoactive subtype. Risk factors for delirium are previous cognitive disturbances, some comorbidities, ambiental factors and the acute organic alterations of critical illness. Delirium is associated to an increase in short and long term mortality, prolongation of mechanical ventilation, increased Intensive Care Unit (ICU) and hospital length of stay, and cognitive impairment after hospital discharge. In the last years several tools have been developed to detect delirium in critically ill patients. The Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for ICU patients (CAM-ICU) have been validated and are useful even in patients receiving mechanical ventilation. Some interventions on specific risk factors can decrease the incidence of delirium in hospitalized patients. Treatment of delirium is based on the identification and correction of contributing factors, the introduction of support measures, and pharmacological therapy for symptomatic control. Halloperidol is the first line therapy of delirium in the critically ill patient, while experience with atypical neuroleptics and other drugs is limited, precluding to do recommendations about its use. Neuroleptic drugs can produce severe side effects and need careful dosage and monitoring. When agitation is important, can be necessary the simultaneous use of benzodiazepines or propofol, and some times, the temporal and protocolized application of physical restraints.

Gender, threat/control-override delusions and violence

This study brings together the threat/control-override perspective and the literature on gender and stress coping to argue that gender moderates the association between threat delusions and violence. We suggest that men are more likely than women to respond to stressors such as threat delusions with violence. We test these ideas using data from the MacArthur Violence Risk Assessment Study, a multi-wave study of post-discharge psychiatric patients. Within-person results from two-level hierarchical models support the idea that men and women cope with threat delusions differently. Specifically, we find that men are significantly more likely to engage in violence during periods when they experience threat delusions, compared with periods when they do not experience threat delusions. In contrast, women are significantly less likely to engage in violence during times when they experience threat delusions, compared with periods when they do not. We discuss these findings in light of the literature on gender and stress coping.

The schizophrenia prodrome revisited: a neurodevelopmental perspective

Despite the widespread acceptance of the neurodevelopmental model of schizophrenia, its application to research concerned with the prodromal phase of illness is limited. Little recognition has been given to the concept of an enduring biological vulnerability to illness that may be responsive to early intervention. Rather, the focus of most prodromal studies is on emerging positive symptoms. The Recognition and Prevention (RAP) program follows the strategy of being equally concerned with the nonspecific symptoms reflecting the core of schizophrenia and those directly related to psychosis. Data were collected from 62 adolescents (mean age = 16.4 years) during the initial 3-year pilot phase of the RAP program (1998-2001). Subjects were divided into three clinical high-risk groups, characterized by (1) negative and nonspecific symptoms (e.g., social isolation, school failures), the earliest prodrome stage; (2) emerging attenuated positive symptoms of moderate intensity; and (3) severe attenuated (but subpsychotic) positive symptoms, considered most proximal to psychosis. Four risk factors, derived from the neurodevelopmental literature, were selected to reflect the vulnerability core: cognitive deficits, affective disturbances, social isolation, and school failure. All four domains were equally impaired across the three risk groups, supporting the presence of the underlying vulnerability core regardless of the magnitude of emerging positive symptoms. An observational pilot study was also conducted to identify the medications typically used to treat emerging positive symptoms. Antidepressants were used as frequently as antipsychotics to treat adolescents presenting with moderate attenuated positive symptoms. Regardless of type of medication, moderately symptomatic youngsters did quite well over the approximately 1-year followup period. By contrast, adolescents presenting with more severe (but nonpsychotic) attenuated symptoms were treated with antipsychotics, often in combination with other agents. Outcome for the more symptomatic youngsters was, however, more guarded, with nearly half (i.e., 47%) of the group converting to a schizophrenia spectrum psychotic disorder. Nonadherence to medication appeared to be a major risk factor in this group. We conclude that a neurodevelopmental model of schizophrenia is supported by our data and that a range of novel treatment strategies may be neuroprotective by directly affecting the disorder's vulnerability core.

Lithium combinations in acute and maintenance treatment of unipolar and bipolar depression

Bipolar illness and unipolar depression are both affective disorders associated with high lifetime morbidity and premature mortality due to suicide. Numerous double-blind, placebo-controlled trials have shown that lithium augmentation therapy is effective in treating acute episodes of bipolar depression, refractory major depression, and delusional depression as well as in reducing recurrences of these illnesses. Lithium is the only agent approved by the U.S. Food and Drug Administration for maintenance treatment of bipolar disorder. Further research is needed to specifically address whether the antidepressant effect of adding lithium is greater in bipolar disorder or in unipolar depressions. This article will summarize available evidence and clinical considerations regarding the use of lithium augmentation in acute and maintenance treatment of unipolar and bipolar depressions.

Cognitive therapy of schizophrenia: a new therapy for the new millennium

Over the past decade, major advances have been made in extending the principles and therapeutic strategies of cognitive therapy to the treatment of schizophrenia. In a number of large-scale outcome studies with cognitive therapy for schizophrenia, cognitive therapy has been shown to offer significant gains for those patients who have not been wholly helped with medications. It may even serve to prevent the consolidation of the illness if delivered with those in the early stage of the illness. We first outline the "state-of-the-art" conceptualization and strategies employed by cognitive therapists to treat positive and negative symptoms and then review the clinical trials.

The effects of olanzapine in reducing the emergence of psychosis among nursing home patients with Alzheimer's disease

BACKGROUND

Elderly patients with Alzheimer's disease (AD) commonly exhibit psychotic symptoms, prompting clinicians to administer antipsychotics. This article compares the effects of olanzapine and placebo in the emergence of hallucinations or delusions in AD patients with symptoms of agitation/aggression but little or no psychotic symptomatology at baseline.

METHOD

A multicenter, double-blind, placebo-controlled study was conducted in nursing home patients with AD according to DSM-IV criteria and symptoms of agitation/aggression and/or psychosis. Patients (N = 206) were randomly assigned to receive either placebo or fixed-dose olanzapine (5, 10, or 15 mg/day) for up to 6 weeks. This article analyzes data from a subgroup of patients (N = 165) with no or minimal delusions and/or hallucinations at baseline as measured by the Neuropsychiatric Inventory-Nursing Home Version (NPI/NH). Three subsets of patients were identified on the basis of their symptoms at baseline: those with no clinically significant hallucinations, those with no clinically significant delusions, and those with no clinically significant delusions or hallucinations.

RESULTS

Of the patients without hallucinations or delusions at baseline (N = 75), the placebo-treated patients showed significantly greater development of these symptoms compared with olanzapine-treated patients overall (NPI/NH hallucinations + delusions mean change score, +2.73 vs. +0.27, p = .006). Similarly, of the patients without baseline hallucinations (N = 153), the placebo-treated patients showed greater hallucinations score increases than did olanzapine-treated patients overall (+1.25 vs. +0.33, p = .026), whereas patients without baseline delusions (N = 87) showed no significant treatment effects. Olanzapine had a favorable safety profile in each patient subset.

CONCLUSION

These results suggest that, overall, olanzapine effectively attenuated emergence of psychosis in a short-term trial of patients with Alzheimer's disease.

Hallucinations and delusions. 2: A dual diagnosis case study

This article, the second of two parts, describes how evidence-based psychological interventions were used to help a client suffering from treatment-resistant delusions and substance misuse, allied to a chaotic lifestyle, that had previously presented a substantial challenge to services. The first part (Vol 8(15): 998-1002) Investigated how the neurobiological, social and environmental factors involved in the course and treatment of schizophrenia have helped to establish a pathway to recovery or remission that does not involve pharmacological therapy alone.

Outcome at discharge and six months in major depression. The significance of psychotic features

Inpatients with nonbipolar psychotic major depression (N = 46) had significantly lower Hamilton Rating Scale scores at discharge and a significantly greater number of weeks back to their "normal selves" during a 6-month follow-up than did patients with nonpsychotic major depression (N = 159). While both baseline severity and the receipt of electroconvulsive therapy distinguished these groups, neither accounted for the outcome differences noted. Severity ratings at discharge were clearly more predictive of follow-up course in psychotic patients than they were in nonpsychotic patients. Moreover, patients with psychotic depression had clearer outcomes in that their average follow-up weeks were more likely to involve either full syndromes or a complete absence of depressive symptoms. This finding, if replicated, may account in part for the lack of consensus on the prognostic significance of psychotic depression.