Hallucinating hallucinogens

Fighting the designer drug epidemic with generative AI.

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.

Effects of cognitive behavioural therapy for insomnia on the mental health of university students: study protocol for a randomized controlled trial

BACKGROUND

Insomnia, defined as repeated difficulties getting or staying asleep, is common in the general population. Such sleep difficulties are a problem in their own right, but increasingly it is being recognised that they may also be a contributory factor in the development of a wide range of mental health problems. Our focus is upon the relationship between insomnia and psychotic experiences, such as paranoia and hallucinations. Psychotic experiences commonly occur in mild forms in the general population and have been linked to disrupted sleep. These psychotic-like experiences raise the risk of development of a clinical disorder. Our aim is to reduce insomnia in a large general population group, and examine the effect on paranoia and hallucinations at the age when mental health problems typically emerge. The primary hypotheses are that cognitive behaviour therapy (CBT) for insomnia will reduce insomnia and also levels of paranoia and hallucinations. The theoretical links will be substantiated by a planned mediation analysis. Improvements in a number of other mental health outcomes are also predicted.

METHODS/DESIGN

We will carry out a parallel group, randomised controlled trial of 2,614 students with insomnia in universities across the UK. In the Oxford Access for Students Improving Sleep (OASIS) trial, participants will be randomised to digital CBT for insomnia (in addition to treatment as usual) or treatment as usual. Online assessments will take place at zero, three, 10 (post-treatment), and 22 (follow-up) weeks. Primary outcomes are insomnia and psychotic-like experiences (paranoia or hallucinatory experiences) at 10 weeks. Secondary outcomes are levels of mania, depression, anxiety, nightmares, psychological wellbeing, and the development of mental health disorders. All main analyses will be carried out at the end of the last follow-up assessment and will be based on the intention-to-treat principle. The trial is funded by the Wellcome Trust.

DISCUSSION

This study will be the first large-scale causal test of the relationship between sleep disturbance and psychotic experiences. It will provide evidence concerning the clinical effects of treating insomnia in young adults.

TRIAL REGISTRATION

This trial was registered with Current Controlled Trials (identifier: ISRCTN61272251 ) on 29 January 2015.

[Preventing dangerous psychotic acting out]

Delusions of having been wronged, of persecution, of having a mission or order to execute, are frequently the causes of dangerous psychotic acting out. The regular clinical assessment of these patients and their treatment is essential for preventing this acting out, which can have dramatic consequences on the potential victims. If there is a treatment indication but refusal on the part of the patient to cooperate, it is necessary to resort to treatment without the patient's consent.

Schizophrenia: a brief review of what nurses can do and say to help

Communicating with individuals who express delusions they believe are real is not easy. And nor is reaching out to engage individuals who present with severely blunted affect. But, those who live with schizophrenia need nurses' to understand their illness and help by monitoring medication compliance and asking questions about hallucinations, suicide and substance abuse.

Effects of a symptom management program on auditory hallucinations in Thai outpatients with a diagnosis of schizophrenia: A pilot study

The purpose of this pilot study was to evaluate the effects of a symptom management program on auditory hallucinations in outpatients diagnosed with schizophrenia. A quasi-experimental research design with convenience sample was used. Eighteen Thai outpatients diagnosed with schizophrenia were divided into a control group and an experimental group. Those who were in the experimental group received a 10-session symptom management program, while the control group received the usual care. The participants were assessed at baseline and post-treatment. The results revealed that the participants who attended the symptom management program experienced significantly decreased overall scores of the characteristics and severity of auditory hallucinations. The findings demonstrated that the symptom management program could attenuate auditory hallucinations in outpatients diagnosed with schizophrenia through their understanding of symptoms, and learning and practicing skills for managing their symptoms in both group and home settings.

Cognitive behavioural therapy group work with voice hearers. Part 2

This is the second of two papers that present a small, randomized control trial of cognitive behavioural therapy (CBT) within a group setting for the treatment of auditory hallucinations. In the previous paper, a method was described for an eight-session CBT group. Assessments were undertaken measuring control, power, frequency, and symptoms of distress and anxiety on commencement and on completion of the group. This second paper details the experience of the group and reports on the outcomes of the assessment measures. The study concludes that group CBT was helpful in the treatment of auditory hallucinations.

Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings

The use of special observations in psychiatric practice may be employed as an alternative to more restrictive methods such as the use of seclusion and restraint. From the literature, special observations are used for a complex array of signs and symptoms (and risk behaviours) which include suicidal intent, self-injurious behaviour, hallucinatory experiences, and absconding. This paper reports on research into the use of special observations in both forensic and non-forensic psychiatric settings. A comparative approach was adopted to establish if the perceived risk factors leading to the adoption of special observations were similar in both settings. Three groups of nursing staff were requested to assess 30 patients who were placed on special observations. Before this, nurses were requested to rate the risk factors in terms of their severity on a 7-point Likert scale. The rank-ordering analysis revealed a similarity of identified risk factors and anova (one-way, unrelated) and the Jonckheere Trend Test revealed that there were significant differences between the scores in the forensic and the non-forensic settings. The statistical differences existed for risk factors relating to harm to self and others but not for psychiatric symptomatology.

Self-care symptom management strategies for auditory hallucinations among patients with schizophrenia in Taiwan

This descriptive study explored self-care management strategies for controlling auditory hallucinations (AH) among Taiwanese patients with schizophrenia. Patients with schizophrenia (N = 200) were recruited by convenience from 2 general hospitals. Self-report and semistructured questionnaires were used to identify 41 self-management strategies. Strategies were categorized into 3 groups: physiological, cognitive, and behavioral. Ignoring AH, a cognitive strategy, was the single most frequently used strategy. As a group, strategies in the behavioral category were used the most. The most common resource for strategies was self-learning. These results can help health care providers better understand self-care management strategies for coping with AH among outpatients with schizophrenia. We suggest the development of a manual of selected self-care strategies identified by these patients to empower other patients to use self-care for AH.

Cognitive intervention for voice hearers

Cognitive behavioral therapy is an emerging treatment being used to attenuate negative thoughts and emotions tied to the formation, expression, and maintenance of verbal auditory hallucinations. This paper describes the theoretical underpinnings for the intervention and a clinical application of a prototype cognitive nursing intervention for treating faulty thinking and beliefs linked with problematic voice hearing experiences. The paper ends with a review of current evidence and implications concerning the efficacy of cognitive intervention approaches with voice hearers.

"Hitting" voices of schizophrenia patients may lastingly reduce persistent auditory hallucinations and their burden: 18-month outcome of a randomized controlled trial

OBJECTIVE

This study aimed to investigate the outcome of an 18-month randomized controlled trial (RCT) on subjective burden and psychopathology of patients suffering from schizophrenia.

METHOD

An RCT was used to compare hallucination-focused integrative treatment (HIT) and routine treatment (RT) in schizophrenia patients who persistently hear voices. We performed an intent-to-treat analysis on each of the 63 patients who were assessed at baseline, 9, and 18 months. On each of the 3 occasions, the differential effects of the treatment conditions were tested repeatedly. Sex, age, education, and illness (hallucination) duration were used as covariates.

RESULTS

Patients in the experimental group retained improvements over time. Improvements in hallucinations, distress, and negative content of voices remained significant at the 5% level.

CONCLUSION

HIT seems to be an effective treatment strategy with long-lasting effects for treatment-refractory voice-hearing patients.

Transcranial Magnetic Stimulation in the investigation and treatment of schizophrenia: a review

Transcranial Magnetic Stimulation (TMS) is a non-invasive method of stimulating the brain that is increasingly being used in neuropsychiatric research and clinical psychiatry. This review examines the role of TMS in schizophrenia research as a diagnostic and a therapeutic resource. After a brief overview of TMS, we describe the application of TMS to schizophrenia in studies of cortical excitability and inhibition, and we discuss the potential confounding role of neuroleptic medications. Based on these studies, it appears that some impairment of cortical inhibition may be present in schizophrenic subjects. We then review attempts to employ TMS for treating different symptoms of schizophrenia. Some encouraging results have been obtained, such as the reduction of auditory hallucinations after slow TMS over auditory cortex and an improvement of psychotic symptoms after high frequency TMS over left prefrontal cortex. However, these results need to be confirmed using better placebo conditions. Future studies are likely to employ TMS in combination with functional brain imaging to examine the effects produced by the stimulated area on activity in other brain regions. Such studies may reveal impaired effective connectivity between specific brain areas, which could identify these regions as targets for selective stimulation with therapeutic doses of TMS.

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.

Cannabis and psychosis

BACKGROUND

Cannabis use is commonly identified in people who present with psychosis.

OBJECTIVE

This case study aims to provide a practical approach for general practitioners seeing patients with comorbid cannabis and mental health concerns.

DISCUSSION

Cannabis related comorbidity is commonly seen in general practice. General practitioners can manage most presentations and help to reduce the likely occurrence of cannabis induced psychosis through the use of psychosocial support, brief interventions and harm minimisation.

Long-Term Effects of Teaching Behavioral Strategies for Managing Persistent Auditory Hallucinations in Schizophrenia

1. Attendance at a 10-week class designed to teach behavioral management strategies to people with schizophrenia was effective in reducing some of the negative characteristics of auditory hallucinations for 12 months and in reducing anxiety for 9 months after completion of the class. 2. The sustained improvement experienced by class participants was characterized by their voices being less frequent and more mumbled and the participants feeling more in control, less distractible, and less anxious. 3. Participants recommended that other mental health consumers take similar classes to learn how to better manage their voices. 4. Monthly support groups may help participants maintain gains lost during the follow-up period.

Simple coping strategies for people who hear voices

High levels of stress are common among people who hear voices, but few receive help to cope with the problem. The reason for this appears to be that many mental health nurses are not aware that there are simple coping strategies that could be used to help these people. Some of these are explained in this article. They represent an example of providing person-centred care, which is at the centre of good mental health nursing.

Human reliability and confinement

Problems inherent in the modifiability of circadian periodicity and in impoverished sensory environments were explored for the purpose of appraising attenuative effects upon human reliability. Accordingly, highly selected subjects were confined within a one-man altitude chamber for prolonged periods of time and under a variety of designed conditions. The findings relative to the modifiability of biological rhythm indicate that adjustment to a drastic revision of the 24-hour biological day was accomplished to a significant and practical extent by certain subjects, the extent of adjustment was directly related to the maintenance of high initial levels of proficiency, and just as subjects differ greatly in their adjustment to revised biological time, they differ to an equal extent in the degree of synchronization manifested by the apparent periodicities of the different physiological systems. In the investigation of impoverished sensory environments, it was found that the joint effects of impoverished sensory conditions and continuous work at an operator system drastically degraded the reliability of certain subjects. Further, neither prior experience nor knowledge acted to mitigate the degree of aberrancy experienced which in the case of one subject was so extreme as to necessitate his removal from the chamber prior to the termination of confinement period. Finally, management of certain aberrant behavior, specifically hallucinatory experiences, could be successfully achieved by those subjects who continuously attempted to maintain a diversity of sensory input.

Determinants of occurrence and recovery from hallucinations in daily life

BACKGROUND

Data related to the dynamics of hallucinatory experiences of patients suffering from schizophrenia are scarce. Detecting antecedent conditions and coping strategies may aid development of targeted psychological interventions.

METHOD

We studied hallucinating and non-hallucinating patients suffering from schizophrenia spectrum disorder (n = 57), and non-schizophrenic severe mentally ill patients with depression (n = 37). Data were collected using the Experience Sampling Method (ESM) over a period of 1 week. Contingent on a randomly signalling beep, subjects filled in reports of ongoing hallucinations as well as thought, mood, current activity, social circumstances and places frequented.

RESULTS

More subjects suffering from schizophrenia reported hallucinations, but for all hallucinating subjects the qualities of hallucination episodes were quite similar. More subjects reported visual hallucinations at least once. In contrast, the intensity of auditory hallucinations was higher. Anxiety was the most prominent emotion during hallucinations and reports of anxiety intensity exceeded baseline levels before the first report of auditory hallucinations. Context modified hallucination intensity over the course of an episode. Social withdrawal resulted in a decrease of hallucinatory intensity (AH > VH), while social engagement slightly raised intensity levels (VH > AH). Doing nothing (VH > AH) and work activities (AH > VH) led to decreases in intensity levels over time, while passive leisure activities (watching TV) resulted in increases in intensity levels of hallucinations (AH > VH).

CONCLUSION

The results suggest that hallucinating experiences are subject to a host of contextual influences. Understanding variation offers useful insights for therapy.

Making sense of the voices

Hearing voices is a common occurrence, and an experience of many people in psychiatric/mental health care. Nurses are challenged to provide care, which is empowering and helps people who hear voices. Nursing practice undertaken in partnership with the voice hearer and informed by a working explanatory model of hallucinations offers greater helping potential. This paper uses Slade's (1976. The British Journal of Social and Clinical Psychology 15, 415-423.) explanatory model as a framework for exploring interventions which may assist people in exerting some control over the experience and which might be used alongside pharmacological interventions. Principles and practical ideas for how nurses might assist people to cope with and make sense of the experience are explored.

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.

Symptom Management of Auditory Hallucinations in Schizophrenia Results of 1-Year Follow up

1. The majority of participants reported that they were still using behavioral strategies to manage their auditory hallucinations throughout the 12-month follow-up period and that they had experienced a decrease in symptom severity. 2. The answers to managing the symptom of auditory hallucinations are as individual as the symptom itself. All of the behavioral management strategies worked for at least one participant, but no strategy worked for everyone. 3. Practicing strategies in a group and at home seemed to promote long-term use of the behavioral strategies.

Ca2+ channel blockade prevents lysergic acid diethylamide-induced changes in dopamine and serotonin metabolism

To investigate the effect of a single and multiple administration of lysergic acid diethylamide (LSD) on cerebral metabolism of dopamine and serotonin, male Wistar rats were treated with low and high doses (0.1 and 2.0 mg/kg i.p.) of LSD and the levels of dopamine, 3,4-dihydroxyphenylacetic acid, homovanillic acid, 3-methoxytyramine, serotonin and 5-hydroxyindoleacetic acid were assayed by HPLC in the nucleus accumbens, striatum and frontal cortex. Some rats received nifedipine, 5 mg/kg i.p., before each injection of LSD to assess the effect of a Ca2+ channel blockade. High-dose LSD treatment (8 x 2 mg/kg per day) caused a strong stimulation of dopamine metabolism in the nucleus accumbens and striatum, and serotonin metabolism in the nucleus accumbens: the changes were observed 24 (but not 1 h) after the last dose. The changes induced by the low-dose treatment (8 x 0.1 mg/kg per day) had a different pattern, suggesting the release of dopamine from vesicles to cytoplasm. Co-administration of nifedipine completely prevented the LSD-induced biochemical changes. The results suggest that Ca2+ channel blocking agents may prevent development of some behavioral consequences of chronically used LSD.

Self-help techniques for auditory hallucinations in schizophrenia

Even with the best treatment available in the United States, people with schizophrenia often remain troubled by auditory hallucinations. Given the less than optimal results of traditional mental health care, the following exploratory study was conducted. A convenience sample of 33 adult outpatients with schizophrenia were interviewed to elicit what (if any) self-help strategies they used for coping with auditory hallucinations. The patients were all being treated at a community mental health clinic. The self-help strategies reported by the patients included (a) physiological changes, (b) cognitive processes, and (c) behavioral changes. The strategies were then rank-ordered by frequency of use and self-reported effectiveness. Various self-help strategies used by subgroups were examined. Men used techniques that were more isolative, and women used more interpersonal techniques to cope with their auditory hallucinations. Participants hearing hostile "voices" (both men and women) tended to use substances such as alcohol and prescribed medications. The results of this study may be used to increase understanding of socially appropriate self-help coping strategies in patients with schizophrenia who experience auditory hallucinations.

Subcutaneous sumatriptan during the migraine aura. Sumatriptan Aura Study Group

This double-blind, placebo-controlled, multicenter, parallel-group study assessed whether subcutaneous sumatriptan administered during the migraine aura would prolong or modify the aura and prevent or delay development of the headache. One hundred seventy-one patients (88 receiving 6 mg sumatriptan, 83 receiving placebo) treated a single attack of migraine with typical aura at home, by self-injection. The median duration of aura following the first injection was 25 minutes for the sumatriptan group and 30 minutes for the placebo group (NS). The aura symptom profile was similar for the two treatment groups. The proportion of patients who developed a moderate or severe headache within 6 hours after dose administration was similar in the two groups--68% among those receiving sumatriptan and 75% among those receiving placebo (NS). Sumatriptan given during the aura did not prolong or alter the nature of the migraine aura and did not prevent or significantly delay headache development.

Propofol-ketamine technique

Case reports are presented demonstrating a new, safe, and simple intravenous technique for outpatient anesthesia. Vinnik's technique requires hypnotic doses of diazepam (Valium) to prevent ketamine-induced hallucinations. The initial hypothesis tested in this clinical series was whether hypnotic doses of propofol would prevent hallucinations from ketamine as satisfactorily as diazepam. Once the initial hypothesis was confirmed, consideration was given to moderating the cost of propofol by determining the effect of two levels of midazolam premedication on propofol requirements. Hypnotic doses of propofol do prevent ketamine-induced hallucinations. It is possible to achieve significant propofol savings by premedication with midazolam without compromising patient readiness for discharge by the end of the first postoperative hour.

Failure of a binaural comprehension deficit to select responders to earplug use in schizophrenia

Previous studies have suggested that on the Auditory Comprehension Test, a significant proportion of schizophrenics demonstrate a binaural comprehension deficit. To test whether wearing an earplug in their more poorly performing ear would be beneficial, we studied 34 in-patient schizophrenics and noted a binaural deficit in 12 (35%). Of these, eight patients subsequently wore an earplug in each ear for at least one week. We found no effect of the earplug on psychopathology.

Musical hallucinations in a deaf elderly woman

Musical hallucinations had caused an 86-year-old deaf woman to become anxious and depressed. She was admitted, and tranquilizing and hypnotic drugs afforded some slight improvement. The use of her hearing aid to increase ambient noise levels reduced the intensity of the hallucinations, and the patient improved.

Reducing persistent auditory hallucinations by wearing an ear-plug

A case study is presented of the effects of wearing an ear-plug in a single patient with persistent auditory hallucinations. Beneficial effects were detected when the plug was in the dominant ear only.

The role of the idealizing transference in the treatment of psychotic patients

A segment of the psychotherapy with a schizophrenic woman and her psychological testing are presented in this paper. The authors focus on the role of the idealizing transference, and illustrate how its operation, along with the mechanisms of fusion, basic trust, and narcissistic alliance, facilitates the process of therapeutically transforming this patient's object representations. Changes in her hallucinations and delusions reflected this process. The idealizing transference may be more generally applicable in the treatment of individuals with schizophrenic psychosis than was previously thought. Its importance lies in catalyzing changes in patient object representations, object relations, and psychotic symptoms.