[Use of metaphors in treatments]. / Metaforen als taal in behandelingen.

BACKGROUND: Language is the most important tool for every psychiatrist and psychotherapist. Metaphors can enhance the effect of language. AIM: To stimulate reflection on the role of metaphors in psychiatric discourse. METHOD: Discuss illustrative examples and some relevant studies. RESULTS: Psychotherapeutic schools each have their own way of using metaphors. Many psychiatrists also like to use them. A successful metaphor refers to the main clinical problem in treatment, contains an element that the patient is still missing, and are adapted to the patient’s person. CONCLUSION: A personalized application of metaphors works best. Well-chosen metaphors lead to recognition, inspiration and satisfaction for both patient and therapist.

[The arrest-related excited delirium syndrome; prevention, treatment and controversies]. / Het opwindingsdelier bij gewelddadige arrestatie: preventie, behandeling en controverses.

BACKGROUND: Patients with an acute confusional state can develop a potentially life-threatening medical emergency when arres­ted by police. This phenomenon has been named the excited delirium syndrome. Controversy regarding this topic has arisen both in the medical literature and in the civil media. AIM: To provide an overview regarding the pathophysiological, epidemiological and clinical aspects of the excited delirium syndrome, the controversy and the opportunities for prevention of a fatal outcome. METHOD: A systematic review of the literature from 1985 to 2021. RESULTS: We included 103 studies in our review. The excited delirium syndrome occurs predominantly in young, physically healthy men who are under the influence of drugs or a psychiatric illness. Several pathophysiological theories exist: the dopaminergic and catecholaminergic hypotheses and restraint asphyxia. There is controversy both in the medical scientific discourse and in the civil media regarding the existence of this syndrome and the cause of death. There are suggestions that mortality can be decreased by timely recognition, de-escalation and medical treatment. CONCLUSION: The excited delirium syndrome is a medical emergency that can arise during physical arrest of patients with a drugs intoxication or psychiatric illness. Improved collaboration between mental health care professionals and police could prevent fatal outcomes.

[Euthanasia requests by patients with a borderline personality organisation]. / Euthanasieverzoek door een patiënt met een borderlinepersoonlijkheidsorganisatie.

Psychodynamic processes may play a role in the evaluation of a euthanasia request from a patient with a borderline personality organization. From the perspective of two-person psychology it is understandable that, unbearable and irremediable suffering (important conditions for euthanasia) are not only characteristics of the patients’ suffering, but also acquire meaning in the interaction with the psychiatrist. It is important that the psychiatrist recognizes immature defence mechanisms and forms of non-mentalizing. Understanding how symptoms of personality pathology may become manifest in the therapeutic relationship can be helpful in the dialogue with the patient about the potential impact of personality dynamics on the request for euthanasia and treatment options.

['When I talk with you about discrimination, I don't feel so small']. / 'Als ik met jou over discriminatie praat, voel ik me niet zo klein'.

Background   In recent years, diversity among therapists in terms of migratory background and openly expressed LGBTQ+ identity has increased. As a result, there are more often dyads in which the patient and therapist belong to the same minority. Aim   To illustrate how having a similar background can influence the therapeutic relationship. These illustrations can help practitioners reflect on how best make use of this similarity. Method   We describe two therapies where therapist and patient shared migratory background and a LGBTQ+ identity. Possible advantages and disadvantages of these similarities are discussed. Finally, we discuss the barriers that therapists can experience to introduce these themes in supervision and intervision. Results   In the case reports, both patients seemed to benefit from having a therapist from the same minority group, partly because he made the similarities in identity open to discussion. They felt that they were understood and were less afraid of negative reactions, which made them feel safe and supported to work on their own conflicts in this dyad. Conclusion   Discussing similarities in identity between therapist and patient can be of added value. With a shared migration background and LGBTQ+ identity, it seems that the same mechanisms often play a role.

The D*Phase-study: study protocol for a pragmatic two-phased, randomised controlled (non-inferiority) trial that addresses treatment non-response and compares cognitive behavioural therapy and short-term psychodynamic supportive psychotherapy for major depression.

BACKGROUND: Several evidence-based psychotherapeutic treatment options are available for depression, but the treatment results could be improved. The D*Phase study directly compares short-term psychodynamic supportive psychotherapy (SPSP) and cognitive behavioural therapy (CBT) for Major Depressive Disorder (MDD). The objectives are 1. to investigate if, from a group level perspective, SPSP is not inferior to CBT in the treatment of major depressive disorder, 2. to build a model that may help predict the optimal type of treatment for a specific individual; and 3. to determine whether a change of therapist or a change of therapist and treatment method are effective strategies to deal with non-response. Furthermore (4.), the effect of the therapeutic alliance, treatment integrity and therapist allegiance on treatment outcome will be investigated. METHOD: In this pragmatic randomised controlled trial, 308 patients with a primary diagnosis of MDD are being recruited from a specialised mental health care institution in the Netherlands. In the first phase, patients are randomised 1:1 to either SPSP or CBT. In case of treatment non-response, a second phase follows in which non-responders from treatment phase one are randomised 1:1:1 to one of three groups: continuing the initial treatment with the same therapist, continuing the initial treatment with another therapist or continuing the other type of treatment with another therapist. In both treatment phases, patients are offered sixteen twice-weekly psychotherapy sessions. The primary outcome is an improvement in depressive symptoms. Process variables, working alliance and depressive symptoms, are frequently measured. Comprehensive assessments take place before the start of the first phase (at baseline), in week one, two and four during the treatment, and directly after the treatment (week eight). DISCUSSION: While the naturalistic setting of the study involves several challenges, we expect, by focusing on a large and diverse number of research variables, to generate important knowledge that may help enhance the effect of psychotherapeutic treatment for MDD. TRIAL REGISTRATION: The study was registered on 26 August 2016 with the Netherlands Trial Register, part of the Dutch Cochrane Centre (NL5753), https://www.trialregister.nl/trial/5753.

[The importance of inter-rater reliability in psychopharmacological trials]. / Het belang van interbeoordelaars­betrouwbaarheid in psychofarmacologisch onderzoek.

BACKGROUND: There are concerns about the declining efficacy of antidepressants and antipsychotics in clinical trials. A potential cause may be found in poor training practices to achieve sufficient inter-rater reliability (IRR). However, it is unknown whether IRR and training procedures are currently reported. AIM: To determine the proportion of publications concerning double-blind randomized controlled trials (RCTs) investigating antipsychotics or antidepressants that report IRR and training procedures. METHOD: We extracted all double-blind RCTs from five large meta-analyses concerning antidepressants and antipsychotics. Further, we conducted a Medline-search for double-blind RCTs investigating antidepressants from January 2016 - January 2020, and antipsychotics from January 2000 - January 2019. RESULTS: In 179 double-blind RCTs with antidepressants, only 4.5% reported an IRR coefficient whereas 27.9% reported on training procedures. Further, in 207 double-blind RCTs with antipsychotics, 11.2% reported an IRR coefficient and 34.8% reported training procedures. CONCLUSION: There is a substantial lack of reporting IRR and training procedures in RCTs with antidepressants and antipsychotics. Considering the implications of insufficient IRR, it is necessary to conduct and report training procedures and IRR. Reporting IRR and training procedures should be made mandatory by editorial boards of scientific journals.

[The use and appreciation of the mental status examination in the Netherlands]. / Gebruik en waardering van het status-mentalisonderzoek in Nederland.

BACKGROUND: The mental status examination (MSE) is part of everyday psychiatric practice. However, it is unknown which items of the MSE are considered important and how the MSE is appreciated in the Netherlands.
AIM: To gain insight in the importance of the MSE, and to investigate which items are used in everyday practice.
METHOD: Dutch psychiatrists and residents filled in a questionnaire, using a 5-point Likert scale, where they rated frequency of use and importance of 24 different items of the Dutch MSE. They also reported which items, in their opinion, should be rated 'always', 'on indication only' or 'never'. Finally, the respondents were asked about their need of education and training in the MSE. The data were collected through an online questionnaire, which was distributed through email and the website of the Dutch psychiatric association.
RESULTS: A total of 402 respondents filled in the questionnaire, of which 60.4% were psychiatrists and 39.6% were residents. The MSE was seen as an essential part of the everyday psychiatric practice. The current format was appreciated strongly. In current practice, 10 items of the MSE were 'always' rated by more than 50% of the respondents. Ten items were rated very rarely, if ever. Respondents thought these items should only be rated on specific indication. There was a need for extra training in the MSE amongst residents and psychiatrists.
CONCLUSION: The Dutch MSE, consisting of 24 items, is strongly appreciated by psychiatrists and residents as an essential part of the psychiatric diagnostic process. In the everyday practice only a part of the items are used frequently.

[The psychodynamic psychiatry has the future]. / De toekomst is aan de psychodynamische psychiatrie.

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[Time for cluster C personality disorders: state of the art]. / Tijd voor cluster C-persoonlijkheids-stoornissen: state of the art.

BACKGROUND: Compared to cluster B personality disorders, the assessment and treatment of people with obsessive-compulsive, dependent, and avoidant personality disorders (cluster C) is given little attention in the field of research and clinical practice. AIM: Presenting the current state of affairs in regard to cluster C personality disorders. METHOD: A systematic literature search was conducted using the main data bases. RESULTS: Cluster C personality disorders are present in approximately 3-9% of the general population. In about half of the cases of mood, anxiety, and eating disorders, there is co-morbid cluster C pathology. This has a major influence on the progression of symptoms, treatment effectiveness and potential relapse. There are barely any well conducted randomized studies on the treatment of cluster-C in existence. Open cohort studies, however, show strong, lasting treatment effects. CONCLUSION: Given the frequent occurrence of cluster C personality disorders, the burden of disease, associated societal costs and the prognostic implications in case of a co-morbid cluster C personality disorder, early detection and treatment of these disorders is warranted.

[Is a personalised approach of the borderline personality disorder useful?] / Is een gepersonaliseerde benadering bij de borderlinepersoonlijkheidsstoornis zinvol?

BACKGROUND: Borderline personality disorder (bpd) seems to have a progressive course, starting during adolescence. It's prevalence peaks during early adulthood, after which it declines. The symptom profile changes during its course. Consequently, a personalised approach based on staging and profiling appears suitable for bpd. AIM: To describe a useful model for clinical staging and profiling of bpd. METHOD: A literature analysis, reviewing the evidence of clinical stages and risk factors. RESULTS: bpd can be described in different stages, ranging from a preliminary stage associated with a higher risk of developing bpd to a chronic, therapy resistant stage. Although there are no specific predictors, there are several factors that increase the risk of developing bpd. CONCLUSION: Clinical staging and profiling can contribute to a more personalised approach and treatment selection. More research is needed to develop this model further.

[Discrepancies in reported medication use in elderly psychiatric outpatients]. / Discrepanties in gerapporteerd medicatiegebruik bij ouderen in ambulante psychiatrische behandeling.

BACKGROUND: Different fields of study have revealed discrepancies between the reported medication use presented by patients and medical records held by their doctor or apothecary. These also appear to have clinically relevant consequences. At present only two studies have explored medication discrepancies in psychiatry.
AIM: To investigate the occurrence of discrepancies in the reported medication use of a psychiatric elderly out-patient population.
METHOD: Comparing 40 medication records of patients to their respective general practitioner and pharmacy records. Information on their social situation, Mini-Mental State Examination score and diagnosis was collected.
RESULTS: One or more discrepancies were present in 80 percent of cases. Patients living alone had a higher percentage of discrepancies. Patients with cognitive problems or a low score on the Mini-Mental State Examination had less discrepancies.
CONCLUSION: Medication discrepancies are also common in a psychiatric elderly outpatient population.