Evaluation of the 'Jumping to conclusions' bias in different subgroups of the at-risk mental state: from cognitive basic symptoms to UHR criteria.

BACKGROUND: Patients with psychosis display the so-called 'Jumping to Conclusions' bias (JTC) - a tendency for hasty decision-making in probabilistic reasoning tasks. So far, only a few studies have evaluated the JTC bias in 'at-risk mental state' (ARMS) patients, specifically in ARMS samples fulfilling 'ultra-high risk' (UHR) criteria, thus not allowing for comparisons between different ARMS subgroups. METHOD: In the framework of the PREVENT (secondary prevention of schizophrenia) study, a JTC task was applied to 188 patients either fulfilling UHR criteria or presenting with cognitive basic symptoms (BS). Similar data were available for 30 healthy control participants matched for age, gender, education and premorbid verbal intelligence. ARMS patients were identified by the Structured Interview for Prodromal Symptoms (SIPS) and the Schizophrenia Proneness Instrument - Adult Version (SPI-A). RESULTS: The mean number of draws to decision (DTD) significantly differed between ARM -subgroups: UHR patients made significantly less draws to make a decision than ARMS patients with only cognitive BS. Furthermore, UHR patients tended to fulfil behavioural criteria for JTC more often than BS patients. In a secondary analysis, ARMS patients were much hastier in their decision-making than controls. In patients, DTD was moderately associated with positive and negative symptoms as well as disorganization and excitement. CONCLUSIONS: Our data indicate an enhanced JTC bias in the UHR group compared to ARMS patients with only cognitive BS. This underscores the importance of reasoning deficits within cognitive theories of the developing psychosis. Interactions with the liability to psychotic transitions and therapeutic interventions should be unravelled in longitudinal studies.

[Comparison of Two Symptom-Triggered Treatments for Alcohol Withdrawal: HAES vs. SAB-P]. / Zwei Alkoholentzugsscores im Vergleich: Hamburger Alkoholentzugs-Skala (HAES) vs. Scoregesteuerte Alkoholentzugsbehandlung nach Rating durch das Pflegepersonal (SAB-P).

INTRODUCTION: For alcohol withdrawal during hospitalization, often a medication as means for withdrawal needs to be chosen. Modern, score-controlled processes that can be used by the nursing staff after instruction by physicians are frequently not used and even unknown in hospitals. One reason for this is that some of the scores require checking several criteria and are therefore more time-consuming and complicated than use of a fixed-dosage strategy. The SAB-P and HAES are short with only 6 items that can be checked by the nursing staff. METHODS: Safety of the Hamburg Alcohol Withdrawal Scale (Hamburger Alkoholentzugs-Skala (HAES)) was analyzed retrospectively and prospectively with regard to score-controlled alcohol-withdrawal treatment after rating by the nurse staff (Scoregesteuerte Alkoholentzugsbehandlung nach Rating durch das Pflegepersonal (SAB-P)). RESULTS: Incidence of complications in patients treated with SAB-P and HAES was nearly similar with 1% start of delirium and 3% seizures (SAB-P) and 0.5 to 1.5% start of delirium and 0 to 0.5% seizures in the HAES group. With both scales it was possible to start medical treatment while still under falling alcohol levels (0.93 and 0.91%, respectively). Medication dosage was initially higher using the HAES, so that the time needed to monitor withdrawal symptoms could be reduced (3.8 vs. 3.1 days). DISCUSSION: Using a score-controlled strategy for alcohol withdrawal leads to a lower complication rate than found in literature. The structured procedure was helpful for the nursing staff as well as for the physicians. SAB-P as well as HAES made withdrawal for the patients more comfortable and led to fewer complaints. Because of rapid reaction and faster symptom reduction of HAES, there was less time necessary for monitoring. Simple handling, clomethiazol, oxazepam or diazepam as applicable medication and clear documentation are the advantages of HAES.

What are depressive symptoms in acutely ill patients with schizophrenia spectrum disorder?

BACKGROUND: Aim was to examine depressive symptoms in acutely ill schizophrenia patients on a single symptom basis and to evaluate their relationship with positive, negative and general psychopathological symptoms. METHODS: Two hundred and seventy-eight patients suffering from a schizophrenia spectrum disorder were analysed within a naturalistic study by the German Research Network on Schizophrenia. Using the Calgary Depression Scale for Schizophrenia (CDSS) depressive symptoms were examined and the Positive and Negative Syndrome Scale (PANSS) was applied to assess positive, negative and general symptoms. Correlation and factor analyses were calculated to detect the underlying structure and relationship of the patient's symptoms. RESULTS: The most prevalent depressive symptoms identified were depressed mood (80%), observed depression (62%) and hopelessness (54%). Thirty-nine percent of the patients suffered from depressive symptoms when applying the recommended cut-off of a CDSS total score of >6 points at admission. Negligible correlations were found between depressive and positive symptoms as well as most PANSS negative and global symptoms despite items on depression, guilt and social withdrawal. The factor analysis revealed that the factor loading with the PANSS negative items accounted for most of the data variance followed by a factor with positive symptoms and three depression-associated factors. LIMITATIONS: The naturalistic study design does not allow a sufficient control of study results for the effect of different pharmacological treatments possibly influencing the appearance of depressive symptoms. CONCLUSION: Results suggest that depressive symptoms measured with the CDSS are a discrete symptom domain with only partial overlap with positive or negative symptoms.

[Remission and recovery: new hopes--realistic aims in the therapy for schizophrenia]. / Remission und Recovery: Neue Hoffnung--realistische Ziele in der Schizophrenietherapie.

The present review critically appraises the various different definitions of and the ongoing discussions about the terms remission and recovery, which represent important aspects for describing the disease course, therapy planning and the setting of therapeutic targets for the patient, relatives and the professional care-giver. A symptomatic remission is well defined and is reached by about 30-60% of the first-time patients. However, this is not to be equated with functional, social and subjective remission. The term recovery has various definitions and has as yet only been studied in a relatively unempirical manner but represents an important supplement to the often strictly formulated therapeutic targets that need to be complemented by subjective and objective as well as personal and clinical perspectives. To inspire and maintain hope is thus an essential factor that extends beyond the therapeutic target of an often rather resigning symptomatic therapy. Even so, the provision of hope remains a balancing act. Too little hope can induce pessimism which in turn may have considerable negative therapeutic and personal consequences. On the other hand an uncritical attitude to hope may lead to unrealistic expectations--inevitably to be followed by frustration and resignation again.

[Long-term treatment of schizophrenia spectrum disorders: focus on pharmacotherapy]. / Pharmakologische Langzeitbehandlung schizophrener Erkrankungen.

Schizophrenia spectrum disorders (SSD) constitute a group of psychiatric illnesses which frequently lead to persisting mental impairment. Although some patients show a clinical course with few episodes and good long-term outcome, the course of the disease is often chronic and unfavorable. Long-term treatment (LTT) of SSD pertains to the postacute stabilization period and the remission period following pharmacological and psychosocial therapy of an acute illness episode. This article provides an overview of treatment recommendations concerning long-term pharmacotherapy, dealing with side effects, treatment of non-response and therapy resistance and the treatment of psychiatric comorbidities. Furthermore, an overview of non-pharmacological treatment options is presented. An integrated therapeutic setting combining evidence-based pharmacotherapy, psychosocial interventions, and supportive therapies is recommended for optimal LTT of SSD. Considering the limited financial resources available in the healthcare system, one of the major challenges is to provide patients with access to the evidence-based treatment options available.

Obsessive-compulsive symptoms in at-risk mental states for psychosis: associations with clinical impairment and cognitive function.

OBJECTIVE: Obsessive-compulsive symptoms (OCS) constitute a major comorbidity in schizophrenia. Prevalence estimations of OCS for patients with at-risk mental states (ARMS) for psychosis vary largely. It is unclear how ARMS patients with or without comorbid OCS differ regarding general psychosocial functioning, psychotic and affective symptoms and neurocognitive abilities. METHOD: At-risk mental states patients (n = 233) from the interventional trial PREVENT (Secondary Prevention of Schizophrenia) were stratified according to the presence or absence of comorbid OCS and compared on several clinical variables. RESULTS: Patients, who fulfilled the criteria for obsessive-compulsive disorder (OCD) or presented with subclinical OCS (ARMSposOCS sample), did not significantly differ from patients without OCS (ARMSnegOCS) with regard to gender, age, premorbid verbal intelligence and levels of education. Furthermore, similar severity of depressive syndromes, basic cognitive, attenuated psychotic and brief limited intermittent psychotic symptoms were found. However, ARMSposOCS patients showed more impairment of psychosocial functioning and higher general psychopathology. In contrast, they scored higher in cognitive tasks measuring working memory and immediate verbal memory. CONCLUSION: Findings extend upon previous results due to the multidimensional assessment. Subsequent longitudinal studies might elucidate how comorbid OCS influence differential treatment response, especially to cognitive behavioural interventions and the transition rates to psychosis.

[Expression, identification and experience of emotions in mental diseases. An overview]. / Ausdruck, Erkennen und Erleben von Emotion bei psychischen Störungen. Eine Übersicht.

Several studies in clinical neuroscience have focused on the analysis of expression of emotions, identification of emotions and experience of emotions. These empirical studies produced certain insights into emotional competency in different mental diseases, most of them in schizophrenia. The current article gives a description of the scientific data about alterations in emotional competency in several mental diseases (e.g. schizophrenia, depression, bipolar and borderline diseases) and links the data, if possible, with clinical relevance with a special focus on emotional competency in prodromal schizophrenia.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 1: Häufigkeit, Störungspersistenz, Belastungsfaktoren, Service-Inanspruchnahme und Behandlungsverzögerung mit Konsequenzen.

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

Predicting a 'combined treatment outcome' in chronic schizophrenia: the role of demographics, symptomatology, functioning and subjective well-being.

OBJECTIVES: The aim of this study was to determine what variables predict a 'combined treatment outcome' (COMBOUT) in patients with chronic schizophrenia. METHODS: This analysis (n=522) was based on a randomized, double-blind, flexible-dose, 12-week study that enrolled chronically-ill patients diagnosed with schizophrenia or a related disorder. COMBOUT was assessed using the PANSS for symptoms, CGI-S for overall clinical status, MADRS for depressive symptoms, QLS for functioning/QOL, and SWN-K for subjective well-being. Possible predictors included demographics as well as baseline scores (Model I), and early change (week 2) scores (Model II). RESULTS: Model I: significantly better outcome (higher COMBOUT score) was observed in patients with lower MADRS (T= - 6.36; p<0.001) or higher QLS (T=5.05; p<0.001) scores at baseline. Model II: significantly better COMBOUT was observed in patients with early improvement of QLS (T=4.93; p<0.001), SWN-K (T=3.88; p<0.001), PANSS (T= - 2.32; p=0.021) and CGI-S scores (T= - 2.22; p=0.027). Changes in EPS were not predictors of COMBOUT in the models tested. CONCLUSION: COMBOUT at endpoint was predicted by lower depressive symptom score and higher QOL at baseline and by early improvement in psychopathology, quality of life and subjective well-being.

Insight in schizophrenia-course and predictors during the acute treatment phase of patients suffering from a schizophrenia spectrum disorder.

BACKGROUND: To analyse insight of illness during the course of inpatient treatment, and to identify influencing factors and predictors of insight. METHODS: Insight into illness was examined in 399 patients using the item G12 of the Positive and Negative Syndrome Scale ("lack of insight and judgement"). Ratings of the PANSS, HAMD, UKU, GAF, SOFAS, SWN-K and Kemp's compliance scale were performed and examined regarding their potential association with insight. The item G12 was kept as an ordinal variable to compare insight between subgroups of patients. RESULTS: Almost 70% of patients had deficits in their insight into illness at admission. A significant improvement of impairments of insight during the treatment (p<0.0001) was observed. At admission more severe positive and negative symptoms, worse functioning and worse adherence were significantly associated with poorer insight. Less depressive symptoms (p=0.0004), less suicidality (p=0.0218), suffering from multiple illness-episodes (p<0.0001) and worse adherence (p=0.0012) at admission were identified to be significant predictors of poor insight at discharge. CONCLUSION: The revealed predictors might function as treatment targets in order to improve insight and with it outcome of schizophrenia.

Long-term efficacy and safety of asenapine or olanzapine in patients with schizophrenia or schizoaffective disorder: an extension study.

INTRODUCTION: Safety and efficacy results, collected in schizophrenia and schizoaffective disorder patients treated for up to nearly 3 years, are presented for asenapine and olanzapine. RESULTS: Patients completing a 52-week randomized double-blind core study on flexible-dose asenapine (5 or 10 mg BID) or olanzapine (10 or 20 mg QD) could continue treatment until study blind was broken.290 patients on asenapine and 150 on olanzapine continued treatment for variable lengths of time [mean ± SD (range) 311.0 ± 146.1 (10 - 653) d and 327.4 ± 139.6 (15 - 631) d, respectively]. Adverse event (AE) incidence was lower during the extension (asenapine, 62%; olanzapine, 55%) than during the core study (78%, 80%). In both groups, body weight increase and incidence of extrapyramidal AEs were negligible during the extension. Mean PANSS total score changes during first year of treatment were - 37.0 for asenapine and - 35.3 for olanzapine, with further changes of 1.6 for asenapine and - 0.8 for olanzapine at the extension study endpoint. CONCLUSIONS: Clinical stability on asenapine as well as olanzapine was maintained, with few recurrent or newly emerging AEs beyond 1 year of treatment.

Are ratings on the positive and negative syndrome scale for schizophrenia biased by personality traits?

OBJECTIVE: The aim of this study was to estimate the potential bias by personality traits for ratings on the Positive and Negative Syndrome Scale (PANSS). METHODS: Personality dimensions (five factor model), personality traits (SCID-II) and PANSS scores were assessed prospectively in 45 patients with schizophrenia spectrum disorders (SSD). RESULTS: Borderline (r=0.34; p=0.021), avoidant (r=0.66; p<0.001) and depressive (r=0.51; p<0.001) personality traits were significantly correlated with the PANSS total score. There were significant correlations for all PANSS subscores with the exemption of PANSS positive. In multivariate analyses, the final models for PANSS total score and PANSS depressive explained a total of 45.3% and 54.3% of the variance. Avoidant traits could lead to a difference of 13.1 (95% CI: 5.6-20.7) points regarding PANSS total score, depressive traits could cause differences of 4.8 points (95% CI: 2.2-7.3) for PANSS depressive subscore. CONCLUSION: Although PANSS positive subscore and PANSS excited component are relatively robust against bias by personality traits, PANSS total score and the remaining subscores are affected to a clinically relevant degree. Outcome studies in SSD patients should control for personality traits.

Subjective well-being of patients with schizophrenia as a target of drug treatment.

An important development within the last decades is the consideration of the patient's perspective and the acknowledgement that the majority of patients are able to judge their state of well-being. Several self-report scales such as the "The Subjective Well-being under Neuroleptics Scale" (SWN) have been established. Additionally to their beneficial impact, current antipsychotics have considerable limitations. Antipsychotic-related side effects, such as extrapyramidalmotor symptoms, weight gain and obesity, apathy and anhedonia have an important influence on the patient's wellbeing. Evidence suggests that the so-called neuroleptic-induced deficit syndrome under antipsychotics might be caused by the inhibition of the dopaminergic reward system. A reduced activation of the ventral striatum, including the nucleus accumbens is associated with negative symptom severity. Second-generation antipsychotics (henceforth SGA) block striatal D2 receptors less and show a weaker binding to D2 receptors, have interactions with several other neurotransmitters and inhibit to a lesser degree the reward functions compared to first-generation antipsychotics (henceforth FGA). This may support the reduction of negative symptoms, contributes to a higher subjective well-being, a better medication adherence and thereby an improved therapeutic outcome. The involvement of the patient and the consideration of his/her subjective wellbeing will be a major aspect in the development of new treatment strategies in schizophrenia and has a significant impact on the adherence and the long-term prognosis.

Unmet needs in patients with first-episode schizophrenia: a longitudinal perspective.

BACKGROUND: This study aimed to identify the course of unmet needs by patients with a first episode of schizophrenia and to determine associated variables. METHOD: We investigated baseline assessments in the European First Episode Schizophrenia Trial (EUFEST) and also follow-up interviews at 6 and 12 months. Latent class growth analysis was used to identify patient groups based on individual differences in the development of unmet needs. Multinomial logistic regression determined the predictors of group membership. RESULTS: Four classes were identified. Three differed in their baseline levels of unmet needs whereas the fourth had a marked decrease in such needs. Main predictors of class membership were prognosis and depression at baseline, and the quality of life and psychosocial intervention at follow-up. Depression at follow-up did not vary among classes. CONCLUSIONS: We identified subtypes of patients with different courses of unmet needs. Prognosis of clinical improvement was a better predictor for the decline in unmet needs than was psychopathology. Needs concerning social relationships were particularly persistent in patients who remained high in their unmet needs and who lacked additional psychosocial treatment.

Remitted but still impaired? Symptomatic versus functional remission in patients with schizophrenia.

INTRODUCTION: Studies reported close associations between functional outcome and symptomatic remission as defined by the Remission in Schizophrenia Working Group. This observational study was aimed at the investigation of deficits in daily functioning, symptoms and subjective well-being in remitted and non-remitted patients with schizophrenia. METHODS: Symptoms (PANSS), functional outcome (FROGS, GAF), subjective well-being (SWN-K) and other characteristics were assessed in 131 patients with schizophrenia (DSM-IV) within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project. RESULTS: A significant better level of functioning was measured for remitted versus non-remitted patients, though remitted patients still showed areas with an inadequate level of functioning. Functional deficits were most often seen in social relations (40%), work (29%) and daily life activities (17%). Best functioning was assessed for self-care, self-control, health management and medical treatment. A moderate to severe level of disorganization and emotional distress was observed in 38% and impaired subjective well-being in 29% of patients defined as being in symptomatic remission. DISCUSSION: The results confirm a close association between symptomatic remission and functional outcome. However, deficits in different areas of functioning, symptoms and well-being underline the need for combined outcome criteria for patients with schizophrenia.

Remission as perceived by people with schizophrenia, family members and psychiatrists.

INTRODUCTION: Studies indicate that patient-rated outcomes and symptomatic remission as defined by the remission in schizophrenia working group rely on different assumptions. The aim of this observational study was to assess symptomatic remission by patients with schizophrenia, family members and psychiatrists and to compare their assessments with standardized criteria and clinical measures. METHODS: One hundred and thirty-one patients with schizophrenia (DSM-IV), family members and psychiatrists assessed remission within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project. Symptoms (Positive and Negative Syndrome Scale [PANSS]), functional outcome (Functional Recovery Scale in Schizophrenia [FROGS]), subjective well-being (SWN-K) and demographic characteristics were investigated. RESULTS: Remission assessed by psychiatrists showed the best accordance with standardized remission (80%), followed by remission assessed by family members (52%) and patients (43%). Only in 18%, patients, relatives and psychiatrists agreed in their assessments. Good subjective well-being was most important for remission estimated by patients, good subjective well-being and symptom reduction by family members, and finally better symptom scores, well-being and functioning by psychiatrists. DISCUSSION: Self- and expert-rated clinical outcomes differ markedly, with a preference on the patients' side for subjective outcome. Symptomatic remission as assessed by the standardized criteria plays a secondary role for patients and relatives in daily clinical practice. A more thorough consideration of patients' and caregivers' perspectives should supplement the experts' assessment.

Subjective experience and meaning of psychoses: the German Subjective Sense in Psychosis Questionnaire (SUSE).

BACKGROUND: Clinical research on subjective determinants of recovery and health has increased, but no instrument has been developed to assess the subjective experience and meaning of psychoses. We have therefore constructed and validated the Subjective Sense in Psychosis Questionnaire (SUSE) to measure sense making in psychotic disorders. METHOD: SUSE was based on an item pool generated by professionals and patients. For pre-testing, 90 psychosis patients completed the instrument. Psychometric properties were assessed using methods of classical test theory. In the main study, SUSE was administered to a representative sample of 400 patients. Factor structure, reliability and validity were assessed and confirmatory factor analyses (CFAs) were used for testing subscale coherence and adequacy of the hypothesized factor structure. Response effects due to clinical settings were tested using multilevel analyses. RESULTS: The final version of SUSE comprises 34 items measuring distinct aspects of the experience and meaning of psychoses in a consistent overall model with six coherent subscales representing positive and negative meanings throughout the course of psychotic disorders. Multilevel analyses indicate independence from clinical context effects. Patients relating psychotic experiences to life events assessed their symptoms and prospects more positively. 76% of patients assumed a relationship between their biography and the emergence of psychosis, 42% reported positive experience of symptoms and 74% ascribed positive consequences to their psychosis. CONCLUSIONS: SUSE features good psychometric qualities and offers an empirical acquisition to subjective assessment of psychosis. The results highlight the significance of subjective meaning making in psychoses and support a more biographical and in-depth psychological orientation for treatment.