Psychological Treatments for Psychosis: History and Overview.

This article is part of the ISPS (International Society for the Psychological Treatment of the Schizophrenias and other Psychoses) task force report on the PORT (Patients Outcome Research Team) recommendations for treatment of schizophrenia. It reviews psychological treatment approaches in psychosis to date and assesses recent trends. The most influential therapies have been psychoanalytic/psychodynamic, cognitive behavioral (CBT), and supportive therapy.

Axis I and II comorbidity and psychosocial functioning in female adolescents with borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is known to be associated with high rates of comorbidity and severe impairment of psychosocial functioning in adults. The aim of this study was to investigate Axis I and Axis II disorders, as well as psychosocial functioning, in a clinical sample of adolescents with BPD and to compare these with participants with mixed psychiatric diagnoses. METHODS: Female adolescent patients were consecutively recruited from the child and adolescent psychiatry department of a university hospital. Axis I and Axis II diagnoses were assessed by experienced clinicians using well-established semistructured interviews, along with psychosocial functioning. RESULTS: The final sample (87 participants) comprised 31 participants with a diagnosis of BPD and 56 participants with mixed psychiatric diagnoses. The most common comorbid disorders in the adolescent BPD sample were mood, eating, dissociative, and substance use disorders in Axis I, and cluster C personality disorders in Axis II. The BPD group showed a significantly higher average number of comorbid Axis I and Axis II diagnoses and significantly lower psychosocial functioning compared with the clinical control group. Regression analyses revealed that psychosocial functioning was predicted by socioeconomic status and comorbid disorders, as well as the unique influence of BPD itself. CONCLUSION: Adolescent BPD in females is accompanied by high rates of psychiatric comorbidity and poor psychosocial functioning. This underscores the need for diagnosis of BPD at its early stages, in order to facilitate appropriate interventions.

Indeterminacy of translation and impaired intersubjectivity in schizophrenia.

Impaired intersubjectivity in schizophrenia has been subject to debate in clinical psychiatry and psychotherapy. In this paper, we will discuss recent perspectives on disordered intersubjectivity among the core symptoms of schizophrenic psychoses. Based on symptoms crucial for communication deficits in schizophrenia, we address indeterminacy of translation as a potential default in the therapeutic setting. The concept of indeterminacy of translation reviewed here assumes that no reference for translation of languages is given, but principles to substitute this non-referring space of unknown terms are to be demonstrated: firstly, a maxim of indulgence which requires that as many true considerations as possible have to be achieved by the final interpretation of a proposition, and secondly, a coherence which is given when the considerations are deductable and not contradictory. Indulgence and coherence are hypothesized as reflecting an approximation process of reconstructing intersubjectivity in conditions where it is severely disturbed such as schizophrenia.

Validación y utilidad de la encuesta PHQ-9 (Patient Health Questionnaire) en el diagnóstico de depresión en pacientes usuarios de atención primaria en Chile / Validity and utility of PHQ9 (Patient Helth Questionnaire) in the diagnosis of depression in user patients of primary care in Chile

Background: Depressive disorders (TD) is a set of prevalent diseases that require proper diagnosis and treatment. In Chile, the instruments of evaluation and diagnosis are scarce. As a way to address this difficulty, the objective of this study was to validate the Spanish version of the self-reported Patient Health Questionarie (PHQ-9), the consulting population in primary care in Chile. The PHQ-9 to detect depressive symptoms as mild, moderate or severe, and has proven to be an efficient diagnostic tool. Methods: 1327 patients evaluated in June 2005 from five urban general practices of the Commune of Valdivia answered individually the PHQ-9. A subsample was compared with the Hamilton scale for depression, ICD-10 criteria for depression and XX version of the PHQ-9. Results: The PHQ-9 demonstrated a sensitivity of 92 percent and 89 percent specificity in detecting depressive patients, when compared to the Hamilton-D scale. It presents a construct validity and predictive validity concurrent with the ICD-10 criteria for depression. Conclusions: The PHQ-9 showed a psychometric allowing clinical use in primary care patients in Chile.

Introducción: Los trastornos depresivos (TD) son un conjunto de enfermedades prevalentes que requieren de un adecuado diagnóstico y tratamiento. En Chile, los instrumentos de evaluación y diagnóstico son escasos. Como forma de enfrentar esta dificultad, el objetivo del presente estudio fue validar la versión en español del auto-reporte Patient Health Questionarie (PHQ-9), en la población consultante de la atención primaria en Chile. El PHQ-9 permite detectar sintomatología depresiva leve, moderada o severa, y ha demostrado ser un eficiente instrumento de diagnóstico. Material y Método: 1.327 pacientes evaluados en junio 2005, provenientes de 5 consultorios generales urbanos de la Comuna de Valdivia respondieron individualmente el PHQ-9. Una sub-muestra fue comparada con la escala de Hamilton para depresión, los criterios CIE-10 para depresión y la versión XX del PHQ-9. Resultados: El PHQ-9 demuestra una sensibilidad de un 92 por ciento y especificidad de 89 por ciento en la detección de pacientes depresivos, al compararla con la escala de Hamilton-D. Además, presenta una validez de constructo y una validez predictiva concurrente con los criterios de CIE-10 para depresión. Conclusiones: El PHQ-9 mostró un comportamiento psicométrico que permite su utilización clínica en pacientes de atención primaria en Chile.

Attentional bias in depressive patients and the moderating effect of concurrent anxiety.

BACKGROUND: Most previous studies finding positive results in the emotional Stroop test did not control for concurrent anxiety symptoms. This study investigated depressive patients without comorbid anxiety disorders in order to clarify existing inconsistent findings. Furthermore, we examined the relationship between anxiety level and the emotional Stroop effect in patients and healthy subjects. SUBJECTS AND METHODS: Twenty-three depressive patients without comorbid anxiety disorder and 27 healthy subjects performed a mixed computerized version of the emotional Stroop test (attentional bias test). We assessed the state and trait anxiety and examined its correlation with the emotional Stroop effect. RESULTS: We failed to find evidence for attentional bias in the patients as measured by longer reaction times to the emotional stimuli. However, there was a positive correlation between state anxiety and attentional bias in depressed patients. On the other hand, in healthy subjects the trait anxiety correlated negatively with attentional bias. CONCLUSIONS: Attentional bias is not found in depressed patients if only patients without comorbid anxiety disorders are included. Furthermore, healthy subjects with high trait anxiety levels may be vulnerable to affective disorders because they use avoidance strategies when encountering negative information.

Psychometric evaluation of the Psychotic Symptom Rating Scales.

BACKGROUND: The aims of this study were to examine the psychometric properties of a German version of the Psychotic Symptom Rating Scales (PSYRATS) in a sample of patients with schizophrenic spectrum disorders and affective disorders with delusions and to validate subscales of the PSYRATS with other ratings of psychotic symptoms. SAMPLING AND METHODS: Two hundred patients with schizophrenic spectrum disorder and affective disorders with delusions were examined. Psychometric properties of the PSYRATS items and scales were determined, and the scores of the PSYRATS scales and subscales were compared to the Positive and Negative Syndrome Scale (PANSS) and other ratings of psychotic symptoms. RESULTS: The PSYRATS items and scales were found to have excellent interrater reliability. Two factors for the delusions scale (DS) and 4 factors of the auditory hallucinations scale were found. Subscales of the DS and auditory hallucinations scale were replicated by factor analysis, and the validity of the subscales was supported. CONCLUSIONS: The German version of the PSYRATS is a reliable and valid assessment tool for delusions and hallucinations. The findings support the validity of the PSYRATS subscales. The DS is also applicable for patients with affective disorders.

Quality of marital relationship and depression: results of a 10-year prospective follow-up study.

BACKGROUND: Although the long-term course of depression has been intensively examined, there are only few studies on the long-term development of depressed patients' spousal relationships. The aim of the study was to assess the quality and stability of depressed patients' spousal relationships in the long-term course of depression and to identify predictors of relationship outcome. METHODS: In the study, 50 inpatients with Major Depression were followed-up one, two and ten years after discharge from hospital and compared to a healthy control group matched by age and sex. Marital satisfaction was measured by the Terman item. Expressed Emotion (EE) was assessed with the Five-Minute Speech Sample (FMSS) and the Perceived Criticism Index (PC). RESULTS: In the follow-up period of ten years, 26 patients (56.5%) had a recurrence. Ten years after discharge from hospital 8 couples were separated, 11 were unhappy and 26 couples were happy with their spousal relationship. The quality of marital relationship decreased over the follow-up period. In comparison to a healthy control group, patients showed a significantly worse quality of marital relationship at follow-up. Besides age and course of depression, the spousal EE status was a prognostic factor for the quality of the relationship after 10 years. CONCLUSIONS: The results confirm the decrease of marital satisfaction over time in the long-term course of depression. Identified interpersonal predictors of the quality of spousal relationship in major depression could be used as indication criteria for couple therapy.

Interactive coordination of currently depressed inpatient mothers and their infants during the postpartum period.

In healthy mother-infant dyads, interactions are characterized by a pattern of matching and mismatching interactive states with quick reparation of mismatches into matches. In contrast, dyads in which mothers have postpartum depression show impaired mother-infant interaction patterns over the first few months of the infant's life. The majority of studies that have examined such interaction patterns have drawn on community samples rather than on depressed inpatient samples of mothers who were in a state of current depression at the time of assessment. To date, no study has investigated specific microanalytic patterns of interactive coordination between depressed German mothers and their infants using the Face-to-Face Still-Face paradigm (FFSF). The primary goal of this study was to evaluate specific patterns of dyadic coordination and the capacity for repairing states of miscoordination in an inpatient sample of postpartum currently depressed mothers and their infants as compared with a healthy control group. A sample of 28 depressed inpatient German mothers and their infants (age range = 1-8 months, M age = 4.06 months) and 34 healthy dyads (range = 1-8 months, M age = 3.89 months) were videotaped while engaging in the FFSF. A focus was placed on the play and reunion episodes. Compared with healthy dyads, dyads with depressed mothers showed less coordination of positive matched states and longer latencies when repairing interactive mismatching states into positive matched states. Clinical implications are discussed.

Psychometric evaluation of the characteristics of delusions rating scale as an expert rating scale.

BACKGROUND: Research suggests delusions may be better viewed as multidimensional rather than dichotomous phenomena. The aim of this study was to assess the reliability and validity of a German version of the Characteristics of Delusions Rating Scale (CDRS) as an expert rating scale. METHOD: 200 inpatients with schizophrenic spectrum and affective disorders with delusions were assessed with the CDRS and other delusion rating scales. Factorial validity was analysed, and differences between diagnostic groups on the CDRS subscales as well as on the total score were examined. RESULTS: The CDRS was found to have good inter-rater reliability and internal consistency as an expert rating. Factor analysis yielded an interpretable structure with 3 factors - cognition, emotion and bizarreness - accounting for 70% of the variance. The convergent and differential validity of the scales was supported. Compared to other scales, the CDRS measures all dimensions of delusional experience that have been suggested to date with the exception of behavioural aspects. CONCLUSIONS: The results support the view of delusions as multidimensional phenomena. The CDRS as an expert rating is a reliable and valid assessment tool for dimensions of delusional experience and an economical instrument for research and clinical practice. Further research is needed to examine the dimensional structure underlying delusional phenomena and the relationship of the dimensions to neurobiological and psychotherapeutic processes.

Dimensions of delusional experience scale: a psychometric evaluation of a german version.

BACKGROUND: Delusional experience is a fundamental symptom of psychotic illness. Over recent years, a multidimensional perspective has become increasingly important regarding this phenomenon. Several instruments to measure different dimensions of delusions have been constructed. The aims of this study were to examine the reliability and validity of a German version of the Dimensions of Delusional Experience Scale (DDE). METHODS: Two hundred inpatients with a schizophrenic spectrum disorder or an affective disorder with delusions were examined with the DDE, the Positive and Negative Syndrome Scale (PANSS) and other rating scales for delusional experiences. RESULTS: The scale was found to have good reliability and excellent inter-rater reliability. The 2 factors, delusional involvement and delusional construct, found by Kendler et al. [Am J Psychiatry 1983;140:466-469] could be replicated. The convergent and differential validity of the scale was supported. Besides the content-related aspect 'bizarreness', the DDE mainly assesses cognitive aspects, emotional and behavioral aspects are not incorporated. CONCLUSIONS: The results support the value of a multidimensional perspective of delusional experiences. The German version of the DDE is a reliable and valid assessment tool for different dimensions of delusions, and an economical instrument for research and clinical practice. Further research is needed to reveal the dimensional structure underlying delusional experience.

Initial orienting to emotional faces in female adolescents with borderline personality disorder.

BACKGROUND: Previous research has implicated a general hypervigilance for negative emotional words in adults with borderline personality disorder (BPD) as compared to healthy controls. The purpose of this study was to assess initial orienting to negative and positive emotional faces in female adolescents with BPD. METHOD: Adolescent patients with BPD (n = 30), adolescent patients with other psychiatric diagnoses (n = 29) and adolescent healthy comparison subjects (n = 29) were tested with the visual dot probe task to examine attentional orienting to emotional and neutral faces. RESULTS: In contrast to the adolescent healthy comparison subjects, both the adolescent patients with BPD and the adolescent patients with other psychiatric diagnoses showed a stronger orienting to negative emotional stimuli. However, no differences were found between the clinical groups. Data regarding positive stimuli showed that BPD is not associated with a specific orienting to positive faces. CONCLUSIONS: These findings suggest that attentional orienting to negative faces is not specific to adolescent patients with BPD but also affects adolescent patients with other psychiatric diagnoses. Furthermore, no distortion in information processing concerning positive cues was observed in adolescent patients with BPD. If these findings were confirmed, further BPD research could no longer assume that BPD is specifically associated with distortions in initial orienting processes.

[Evidence-based treatment of depression: what does the new S3- and national healthcare guideline Unipolar Depression really recommend?]. / Evidenzbasierte Behandlung bei depressiven Erkrankungen--was empfiehlt die neue S3-/Nationale Versorgungsleitlinie "Unipolare Depression" wirklich?

The paper reflects central recommendations and methodological issues of the new German guidelines for the treatment of depression, as discussed in the article New German Guidelines for the Treatment of Depression - The Central Role of Psychotherapy (Schauenburg et al. 2009). Members of the steering group for these guidelines disagree with the authors' description in several points, especially with reference to the efficacy of pharmacotherapy with antidepressants and psychotherapy, as well as the relationship between both strategies of therapy and their combination in diverse phases of treatment (acute/maintenance). Furthermore, we try to clarify some misunderstandings in matters of the guideline's methodology which arose in the paper cited.

Attentional bias in later stages of emotional information processing in female adolescents with borderline personality disorder.

BACKGROUND: Bias in emotional information processing has been described in patients with borderline personality disorder (BPD). This study investigates whether adolescent patients with a diagnosis of BPD demonstrate abnormalities in attentional maintenance in viewing emotional faces. SAMPLING AND METHODS: Thirty female adolescents with a diagnosis of BPD, 29 female adolescents with mixed psychiatric diagnoses, and 30 healthy participants were tested with the visual dot probe task. The task involved showing photographs of actors with faces depicting neutral, negative, and positive expressions for 1,500 ms each. RESULTS: Attentional bias to negative faces was not generally associated with BPD, but patients with BPD did show a strong correlation between current mood and attentional bias to negative faces. Only in adolescents with BPD did attention to negative faces narrow when they were currently in a state of negative mood. Conversely, both control groups avoided negative faces in conjunction with a decline in positive mood. CONCLUSIONS: This study indicates that borderline pathology is linked to an inability to disengage attention from negative facial expressions during attentional maintenance when in a negative mood. Based on these findings, mood-dependent therapeutic interventions focusing on attentional processes may represent a useful add-on to established therapies in patients with BPD.

P50 gating deficit in Alzheimer dementia correlates to frontal neuropsychological function.

BACKGROUND: Cognitive inhibition processes were found to be deficient early in the clinical course of Alzheimer's disease (AD). The inhibition of redundant information is a precondition for efficient cognitive processing and presumably modulated by prefrontal attentional networks. Deficits in the suppression of the evoked potential P50 response to paired clicks are well known in schizophrenic patients and undergo cholinergic modulation. In this study, we aimed to investigate inhibitory gating deficits of P50 in AD and their relation to neuropsychological measures. METHOD: P50 suppression was assessed in 19 AD-patients in comparison to a young and elderly control group (n=17 each) and related to MMSE and specific neuropsychological assessments. RESULTS: Patients showed reduced sensory gating compared to healthy elderly (p<0.021) and exhibited significantly higher N40-P50-amplitudes. There were no age or gender effects in controls. Frontal neuropsychological tests (TMT-B, verbal fluency) and working memory requiring inhibition, but not declarative memory functions, were significantly correlated with inhibitory gating and test amplitude in both, AD-patients and controls. CONCLUSIONS: The results support an early inhibitory deficit interfering with executive functions and working memory in AD independent from physiological aging. P50 gating might be applicable as a marker for inhibition deficits and thereby be important for prognosis estimation.

Hippocampal volume in first episode and recurrent depression.

Abnormalities in limbic-thalamic-cortical networks are hypothesized to modulate human mood states. In the present study differences in hippocampal volumes of patients with a first episode of depression, recurrent major depression and healthy control subjects were examined with high-resolution magnetic resonance imaging (MRI). Male patients with a first episode of major depression had a significantly smaller left hippocampal volume than male control subjects. Also, these patients had a significant left-right asymmetry in hippocampal volume. Female patients showed no significant alterations in hippocampal volumes. The results support the hypothesis that the hippocampus plays an important role in the pathophysiology of the early phase of major depression, especially for male patients. Implications for the neurodevelopmental and the neurodegenerative model of hippocampal change are discussed.

Validation of a German version of the Confusion Assessment Method for delirium detection in a sample of acute geriatric patients with a high prevalence of dementia.

OBJECTIVES: To assess validity and interrater reliability of an operationalized German version of the Confusion Assessment Method (CAM) in geriatric patients with comorbid dementia and high delirium risk. DESIGN: Prospective cross-sectional cohort study with double CAM assessment by a medical and nonmedical rater. SETTING: Random sample of frail, cognitively impaired elderly with acute disease requiring hospital care. PARTICIPANTS: A total of 39 frail elderly, mean age 83 +/- 7 years, 72% (n = 28) female, with cognitive impairments, a high prevalence of dementia (86%, n = 33) and a significant risk of delirium. Of these, 13 revealed delirium, which was superimposed on dementia in 11. MEASUREMENTS: A translated and operationalized version of the CAM was validated against a neuropsychiatric and geriatric consensus reference standard based on DSM-IV. Additional measures included the Short Portable Mental Status Questionnaire, the Mini-Mental State Examination and the Delirium Index for cognitive impairment severity, the Informant Questionnaire on Cognitive Decline for dementia diagnosis and the Barthel Index, illness severity (Cumulative Illness Rating Scale) and medication. RESULTS: Delirium was correctly detected by CAM algorithm in 10 out of 13 delirious patients resulting in a high sensitivity of 0.77 and a specificity of 0.96-1.00 for both raters. Likelihood ratio revealed an almost 20-fold risk of delirium with positive CAM testing. Interrater reliability was excellent with a Cohen's k of 0.95 (CI 0.74-1.0) for the algorithm, single items' k values varied between 0.5 and 1. CONCLUSIONS: The German CAM is a reliable and valid measure of delirium, even in frail, acutely diseased elderly with concomitant dementia.

The controversial link between antidepressants and suicidality risks in adults: data from a naturalistic study on a large sample of in-patients with a major depressive episode.

Some meta-analyses of randomized placebo-controlled trials on antidepressants conclude that there might be an increased risk for suicidal behaviour, especially in children and adolescents but also in adults. Placebo-controlled trials exclude patients with serious suicidality and might therefore underestimate the risk of respective adverse events. The change of suicidal ideation and the prevalence of suicides and non-fatal suicide attempts were therefore analysed in a large naturalistic prospective multicentre study of depressed in-patients. Additionally, specific risk factors for new emergence of suicidal ideation were investigated. The naturalistic prospective study was performed in 12 psychiatric hospitals of the German research network on depression and suicidality (seven psychiatric university hospitals and five district hospitals) in Germany. All patients (n=1014) were hospitalized and had to meet DSM-IV criteria for major depressive disorder. Six events were defined for the purposes of statistical analysis: 'emergence', 'extended emergence', 'improvement' and 'worsening of suicidal ideation', 'suicide attempts' and 'suicides'. Logistic regression analysis and classification and regression trees (CART) analyses were conducted to determine specific risk factors for new emergence of suicidal ideation. The mean HAMD total score decreased from 24.8 at baseline to 10 after 10 wk. An effect on suicidality was evident by week 2 in the sense of a decrease of the mean HAMD item-3 score. Emergence, worsening and improvement of suicidal ideation occurred in 3.2%, 14.74% and 90.79% of patients, respectively. A total of 10 suicide attempts and two suicides were reported. The rate of suicides (13.44/1000 patient-years) was rather low and comparable to the rate observed in randomized controlled antidepressant trials. Five risk factors for emergence of suicidal ideation were determined with two independent statistical methods: age (with higher risk at age <45 yr), treatment resistance, number of hospitalizations, presence of akathisia and comorbid personality disorder. Age <45 yr as one of five risk factors for the emergence of suicidal ideation is in line with the meta-analysis performed for the recent US Food & Drug Administration (FDA) memorandum; although the naturalistic study design does not permit definite conclusions to be made about certain compounds. The rate of suicides was comparable to that seen in randomized controlled trials, as were the rates of emergence and worsening of suicidal ideation, but more improvement was found. Thus, in-patient treatment in a psychiatric care setting, including daily assessments of suicidality by trained psychiatrists adhering to the rules of good clinical practice (e.g. use of specific co-medications, supportive psychotherapy and continuous medical attendance by nursing staff) might be beneficial.

Stroop interference effect in schizophrenic patients: an electrophysiological approach.

Schizophrenic patients present deficits in executive control functions. The Stroop test requires executive control functions, in particular response inhibition. So far only one study has employed the high temporal resolution of electrophysiological methods to investigate the neural correlates of the Stroop effect in schizophrenia. This study investigated medicated patients with schizophrenia or schizoaffective disorder (n=15) and healthy controls (n=15) using event-related potentials. The analyses of the P1 and N1 components revealed no differences between the groups indicating intact sensory processing in schizophrenia during the Stroop test. We found greater negativity in the incongruent as compared to the congruent and neutral conditions between 350 and 450 ms over prefrontal scalp areas in healthy subjects but not in schizophrenic patients. Later on, a sustained positivity was observed over parietal scalp regions in healthy subjects. This later sustained potential was attenuated in patients but only in the first block. This suggests that following practice patients show similar parietal effects as healthy subjects. The total errors in the incongruent condition in patients correlated negatively with the difference in mean activity between incongruent and congruent conditions over the left parietal area (time window 600-1000 ms). In other words the more errors were made by patients, the more attenuated was the Stroop related electrophysiological effect. This suggests that the parietal activity is related to successful resolution of the Stroop conflict in schizophrenic patients. Furthermore, the absence of the frontal deflection in patients reflects dysfunctional neural processes associated with executive control.

Does early improvement triggered by antidepressants predict response/remission? Analysis of data from a naturalistic study on a large sample of inpatients with major depression.

BACKGROUND: Delayed onset of efficacy of antidepressants and a high proportion of depressed patients being poor or non-responders to antidepressants are well known clinical challenges. Therefore, it seems to be necessary to identify predictors for response and - even more important - for remission. It has been suggested that reduction of depressive symptoms at an early stage of antidepressant treatment may predict treatment outcome. Our objective was to test, if this hypothesis derived from randomized controlled studies (RCTs) in outpatients, would be confirmed in a large naturalistic study in a cohort of inpatients with major depression. Patients were treated with various antidepressants and co-medication according to the protocol based on evidence-based clinical guidelines. METHODS: This was a large naturalistic prospective study. All patients (N=795) were hospitalized and met DSM-IV criteria for major depression according to a structured clinical interview (SCID). Assessments were conducted biweekly. Several definitions of early improvement (20%, 25% and 30% reduction in HAMD-21 baseline total scores) at two different visits were tested. Sensitivity, specificity and predictive values were calculated for the different definitions of early improvement. ROC-analyses as well as logistic regression models have been performed. Response was defined as 50% improvement of the total baseline HAMD-21 score and remission as a score of