Reducing Distress from Auditory Verbal Hallucinations: A Multicenter, Parallel, Single-Blind, Randomized Controlled Feasibility Trial of Relating Therapy.

INTRODUCTION: There is a significant demand for interventions that reduce distress related to auditory verbal hallucinations (AVHs). AVH distress is associated with the way voice hearers relate with AVHs. We aimed to establish the feasibility of a randomized controlled trial to demonstrate that adding "Relating Therapy" (RT) to treatment as usual (TAU) is superior to TAU in reducing AVH distress. METHODS: We conducted a multicenter, parallel, single-blind, randomized controlled feasibility trial in five mental health centers in Germany. Participants were ≥19 years of age, had persistent and distressing AVHs, and had a diagnosis of a schizophrenia-spectrum disorder. RT was delivered over a maximum of 16 sessions within 5 months. Blind assessments were conducted at baseline and at 5 and 9 months. Feasibility outcomes were the number of patients recruited and retained, and safety and therapist adherence. The primary endpoint was the distress factor score of the AVH subscale of the Psychotic Symptoms Rating Scales at 9 months. RESULTS: Eighty-five of 177 enrolled participants were randomized into RT + TAU (n = 43) or TAU (n = 42). Feasibility was excellent with 87% retention at 9 months, 86% reaching treatment uptake criteria, 98% therapist adherence, and no unexpected serious adverse reactions. Compared to TAU, RT + TAU showed nonsignificant trends toward less AVH distress (b = -2.40, SE = 1.52, p = 0.121, 90% CI (-4.94 to 0.15) and stronger improvement on all but one of the secondary outcomes. CONCLUSION: A randomized controlled trial of RT is feasible, safe, and well accepted. Our results provide an encouraging basis to further test the efficacy of RT in a definitive multicenter trial.

Neural substrates of anorexia nervosa patient's deficits to decode emotional information.

PURPOSE: The aim of the study was to define specific substrates of pathological behaviour patterns by analysing cortical activity using functional magnetic resonance imaging (fMRI) during an emotional processing task. METHODS: In a sample of N = 11 adolescent patients with AN (16.36 years, SD ± 1.36) and N = 11 age-matched controls, we performed a functional MRI study to detect BOLD signal changes in a 3 T MRI scanner while presenting emotional facial stimuli. RESULTS: Young people with AN presented with a generally reduced cortical activation pattern in key areas of emotion recognition for happy and fearful faces. Areas essential for control of social behaviour were associated with symptoms of depression. CONCLUSION: Obviously, there are already indications of cortical patterns in young affected persons, which indicate a changed emotional reaction to potentially aversive stimuli in the sense of a changed top-down process of emotion avoidance. Thus, the current study provides further evidence that the disorder of anorexia nervosa is closely related to deficits in emotion processing in the early course of ontogenesis. Depressive symptoms might additionally trigger pathological behavior. Due to the small sample size, the data should be considered preliminary and require further validation. LEVEL OF EVIDENCE: Level of evidence III: case-control study.

Keep calm! Gender differences in mental rotation performance are modulated by habitual expressive suppression.

Men have been frequently found to perform more accurately than women in mental rotation tasks. However, men and women also differ with regard to the habitual use of emotion regulation strategies, particularly with regard to expressive suppression, i.e., the suppression of emotional expression in behavior. As emotional suppression is more often used by men, emotion regulation strategies might be a variable modulating gender differences in mental rotation performance. The present study, therefore, examined the influences of gender and emotion regulation strategies on mental rotation performance accuracy and feedback processing. Twenty-eight men and 28 women matched for relevant demographic variables performed mental rotation tasks of varying difficulty over a prolonged time. Emotional feedback was given immediately after each trial. Results showed that women reported to use expressive suppression less frequently than men. Women made more errors in the mental rotation task than men confirming earlier demonstrations of gender differences. Furthermore, women were more impaired by the negative feedback as indicated by the increased likelihood of subsequent errors compared with men. Task performance of women not habitually using expressive suppression was most inferior and most strongly influenced by failure feedback compared with men. Women using expressive suppression more habitually did not significantly differ in mental rotation accuracy and feedback processing from men. Hence, expressive suppression reduces gender differences in mental rotation accuracy by improving cognitive performance following failure feedback.

Cognitive performance following spontaneous subarachnoid haemorrhage versus other forms of intracranial haemorrhage.

OBJECTIVE: The exact cause of cognitive deficits following intracranial haemorrhage is unclear. This prospective study examines the abilities after spontaneous subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and chronic subdural haematoma (SDH) to elucidate the cognitive outcome. PATIENTS AND METHODS: Ninety-nine patients with SAH (N = 60), ICH (N = 25), and SDH (N = 14) were followed up for an average of 6 and 12 months post-haemorrhage. Cognitive tests were used to examine attention, memory, concentration, and executive function. Following were used for analysis: 1. the percentage of patients falling below the 25th percentile per test, 2. the general development from the first to second test point and 3. the incidence of significant changes between the test points. Significance was established as p ≤ 0.05. RESULTS: All three types of haemorrhage resulted in deficits as concerns abstract language (53%-75%). The processing speed was below the normal levels in more than 70% of the patients tested. The cognitive performance of SAH patients was similar to that of patients with SDH and ICH patients after 6 months. The number of patients with outcomes falling below the 25th percentile (to some extent more than 75% in patients post-SAH) is high in all patient groups and mostly decreases over the course. Nevertheless, patients with SAH reveal improvements in many more areas than with ICH and SDH (p ≤ 0.006). CONCLUSIONS: The cognitive impairments following SAH, ICH and SDH deficits appear to develop in a similar way regardless of the type of haemorrhage. Cognitive improvement is most pronounced in patients with SAH.

Anorexia nervosa and its relation to depression, anxiety, alexithymia and emotional processing deficits.

PURPOSE: Psychopathological changes and dysfunction in emotion processing have been described for anorexia nervosa (AN). Yet, findings are applicable to adult patients only. Furthermore, potential for discriminative power in clinical practice in relation to clinical parameters has to be discussed. The aim of this study was to investigate psychopathology and emotional face processing in adolescent female patients with AN. METHODS: In a sample of 15 adolescent female patients with AN (16.2 years, SD ± 1.26) and 15 age and sex matched controls we assessed alexithymia, depression, anxiety and empathy in addition to emotion labelling and social information processing. RESULTS: AN patients had significantly higher alexithymia, higher levels of depression, and state and trait anxiety compared to controls. There was a trend for a lower ability to recognize disgust. Happiness as a positive emotion was recognized better. All facial expressions were recognized significantly faster by AN patients. Associations of pathological eating behaviour and trait anxiety were seen. CONCLUSION: In accordance with the stress reduction hypothesis, typical psychopathology of alexithymia, anxiety and depression is prevalent in female adolescent AN patients. It is present detached from physical stability. Pathogenesis of AN is multifactorial and already fully present in adolescence. An additional reinforcement process can be discussed. For clinical practice, those parameters might have a better potential for early prognostic factors related to AN than physical parameters and possible implication for intervention is given.

The relevance of goal-orientation for motivation in high versus low proneness to negative symptoms.

BACKGROUND: The psychological mechanisms of why individuals with negative symptoms fail to initiate and perform goal-directed behavior are not well understood. Drawing on the reward-sensitivity and expectancy-value theories, we investigate whether negative symptom-like experiences (NSLE) are associated with generating less approach goals (aimed at reaching a positive outcome) and more avoidance goals (aimed at avoiding a negative outcome) and whether this type of goal-orientation explains motivational deficits (i.e., perceiving goals as less feasible and important and being less committed to them). METHODS: Based on the continuum model of negative symptoms, we identified two parallelized extreme groups with high and low levels of NSLE (n = 37, respectively) in an ad-hoc online-sample of healthy individuals (N = 262) using the Community Assessment of Psychic Experiences. In an online study, these participants were instructed to generate approach and avoidance goals and to rate each goal in terms of feasibility, importance and goal-commitment. RESULTS: Participants with low levels of NSLE generated more approach than avoidance goals. Participants with high levels of NSLE showed no such difference due to increased numbers of avoidance goals. Furthermore, avoidance goal-orientation predicted reduced subjective feasibility and importance of goals and less goal-commitment. LIMITATIONS: Results are based on a healthy sample rather than people with psychosis. No longitudinal or behavioral data for goal-striving was collected. CONCLUSION: People with NSLE generate more avoidance goals than controls. This is dysfunctional because it correlates with feeling less committed to reach one's goals. Optimizing goal-setting could be a promising starting-point for psychological interventions aimed at reducing negative symptoms.

Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms.

Although numerous interventions are available for negative symptoms, outcomes have been unsatisfactory with pharmacological and psychological interventions producing changes of only limited clinical significance. Here, we argue that because negative symptoms occur as a complex syndrome caused and maintained by numerous factors that vary between individuals they are unlikely to be treated effectively by the present "one size fits all" approaches. Instead, a well-founded selection of those interventions relevant to each individual is needed to optimize both the efficiency and the efficacy of existing approaches. The concept of functional analysis (FA) can be used to structure existing knowledge so that it can guide individualized treatment planning. FA is based on stimulus-response learning mechanisms taking into account the characteristics of the organism that contribute to the responses, their consequences and the contingency with which consequences are tied to the response. FA can thus be flexibly applied to the level of individual patients to understand the factors causing and maintaining negative symptoms and derive suitable interventions. In this article we will briefly introduce the concept of FA and demonstrate-exemplarily-how known psychological and biological correlates of negative symptoms can be incorporated into its framework. We then outline the framework's implications for individual assessment and treatment. Following the logic of FA, we argue that a detailed assessment is needed to identify the key factors causing or maintaining negative symptoms for each individual patient. Interventions can then be selected according to their likelihood of changing these key factors and need to take interactions between different factors into account. Supplementary case vignettes exemplify the usefulness of functional analysis for individual treatment planning. Finally, we discuss and point to avenues for future research guided by this model.

A neural signature of anorexia nervosa in the ventral striatal reward system.

OBJECTIVE: Animal studies assessing mechanisms of self-starvation under conditions of stress and diet suggest a pivotal role for the mesolimbic reward system in the maintenance of core symptoms in anorexia nervosa, which is corroborated by initial empirical evidence in human studies. The authors examined activity in the ventral striatal system in response to disease-specific stimuli in women with acute anorexia nervosa. METHOD: Participants were 14 women with acute anorexia nervosa and 14 matched healthy comparison women who underwent functional magnetic resonance imaging (fMRI) during evaluation of visual stimuli depicting a female body with underweight, normal weight, and overweight canonical whole-body features according to standardized body mass indices. Participants were required to process each stimulus in a self-referring way. Ratings for each weight category were used as the control task. RESULTS: Behaviorally, women with anorexia nervosa provided significantly higher positive ratings in response to underweight stimuli than in response to normal-weight stimuli, while healthy comparison women showed greater preference for normal-weight stimuli relative to underweight stimuli. Functionally, ventral striatal activity demonstrated a highly significant group-by-stimulus interaction for underweight and normal-weight stimuli. In women with anorexia nervosa, activation was higher during processing of underweight stimuli compared with normal-weight stimuli. The reverse pattern was observed in healthy comparison women. CONCLUSIONS: These findings are consistent with predictions in animal studies of the pivotal role of the human reward system in anorexia nervosa and thus support theories of starvation dependence in maintenance of the disorder.