Theory of mind, emotion recognition, delusions and the quality of the therapeutic relationship in patients with psychosis - a secondary analysis of a randomized-controlled therapy trial.

BACKGROUND: Cognitive models of psychosis postulate an important role of Theory of mind (ToM) in the formation and maintenance of delusions, but research on this plausible conjecture has gathered conflicting findings. In addition, it is still an open question whether problems in emotion recognition (ER) are associated with delusions. We examined the association of problems in ToM and ER with different aspects of delusions in a large sample of patients with psychosis enrolled in a therapy trial. This also enabled us to explore the possible impact of ToM and ER on one part of patients' social life: the quality of their therapeutic relationship. METHODS: Patients with psychotic disorders and delusions and/or hallucinations (n = 185) and healthy controls (n = 48) completed a ToM picture sequencing task and an ER task. Subsequently, patients were enrolled in a randomized-controlled Cognitive Behavior Therapy (CBT) trial (ISRCTN29242879). Patients and therapists rated the quality of the therapeutic relationship during the first five sessions of therapy. RESULTS: In comparison to controls, patients were impaired in both ToM and ER. Patients with deficits in ER experienced more severe delusional distress, whereas ToM problems were not related to delusions. In addition, deficits in ER predicted a less favorable therapeutic relationship and interactional problems viewed by the therapist. Impaired ER also moderated (increased) the negative influence of delusions on the therapeutic relationship and interactional difficulties viewed by the therapist. CONCLUSIONS: Cognitive models on the formation and maintenance of delusions should consider ER as a potential candidate that might be related to the formation and maintenance of delusional distress, whereas problems in ToM might not be directly related to delusions and secondary dimensions of delusions. In addition, problems in ER in patients with psychosis might have an impact on the quality of the therapeutic relationship and patients with problems in ER are more likely to be viewed as problematic by their therapists. Nevertheless, training ER might be a way to improve the quality of the therapeutic relationship and potentially the effectiveness of CBT or other interventions for patients with psychosis.

Problems in measuring the JTC-bias in patients with psychotic disorders with the fish task: a secondary analysis of a baseline assessment of a randomized controlled trial.

BACKGROUND: The jumping to conclusions bias (JTC) is considered to be an important causal factor in theoretical models for the formation and maintenance of delusions. However, recent meta-analytic findings show a rather equivocal pattern of results regarding associations between JTC and delusions. Thus, the present study aims to investigate in a large sample whether the JTC-bias is more pronounced in patients with psychotic disorders in comparison to controls and whether the JTC bias is associated with a more severe delusional conviction, persecutory delusions, and positive symptoms in general. METHODS: Patients with psychotic disorders (n = 300) enrolled in a therapy trial and healthy controls (n = 51) conducted a variant of the beads task (fish task) as a measure for the JTC-bias at the start of the trial. Further, clinical interviews were used to assess patients' delusional severity and delusional conviction. RESULTS: There were no statistically significant differences between patients with psychotic disorders (with 53% displaying the JTC-bias) and controls (41%). Furthermore, there were no statistically significant correlations between JTC measures and persecutory delusions, delusional conviction, and positive symptoms. CONCLUSIONS: We found no differences in JTC between patients with psychotic disorders and healthy controls, which is in part in line with meta-analytic findings using a wide range of JTC task variants. Interestingly, patients with psychotic disorders displayed JTC rates commonly found in the literature, while healthy control subjects showed an unexpectedly high level of JTC. The task variant we used in the present study (fish task) is discussed as a potential reason for our results, as it may induce a more deliberative reasoning style in controls as compared to the traditional beads task. Furthermore, possible implications for the measurement of the JTC-bias, in general, are discussed. TRIAL REGISTRATION: ISRCTN29242879 ( isrctn.com ), date of registration: April 12th 2006, retrospectively registered.

Cognitive behavioral therapy in adolescents with early-onset psychosis: a randomized controlled pilot study.

Cognitive behavioral therapy for psychosis (CBT) is an effective treatment in adult patients with schizophrenia. However, no randomized controlled and blinded trial in adolescents with early-onset psychosis (EOP) has been conducted. Therefore, the present pilot study explores the acceptance, tolerability, feasibility, and safety of a modified CBT in adolescents with EOP. Twenty-five adolescents with EOP were randomized to either 9 months (20 sessions) of CBT + treatment as usual (TAU) or TAU alone. The primary endpoint was the PANSS-positive subscale (P1-7). Secondary endpoints included psychopathology, global functioning, and quality of life (QoL). Acceptance, tolerability, feasibility, and safety were assessed. Blinded assessments took place by the end of the treatment (9 months) and at 24-month follow-up. Despite improvements in both groups and lack of statistical significance between CBT + TAU and TAU regarding the primary endpoint, we observed between-group effect sizes of at least d = 0.39 in favor of CBT + TAU at post-treatment for delusions, negative symptoms, functioning and QoL after the intervention and effect sizes of at least d = 0.35 after 24 months. CBT in EOP was highly acceptable (73.5% agreed to randomization), well-tolerated (83.1% attendance rate, no drop-outs), and safe (one serious adverse event (SAE) in CBT + TAU in comparison with six SAEs in TAU). These findings suggest that CBT adapted to the needs of adolescents with EOP is a promising approach regarding negative symptoms, functioning, and QoL. CBT is a safe and tolerable treatment. However, due to the small sample size and the pilot character of the study, these conclusions are limited, and should be tested in a larger, adequately powered randomized controlled trial.

The precuneus and the insula in self-attributional processes.

Attributions are constantly assigned in everyday life. A well-known phenomenon is the self-serving bias: that is, people's tendency to attribute positive events to internal causes (themselves) and negative events to external causes (other persons/circumstances). Here, we investigated the neural correlates of the cognitive processes implicated in self-serving attributions using social situations that differed in their emotional saliences. We administered an attributional bias task during fMRI scanning in a large sample of healthy subjects (n = 71). Eighty sentences describing positive or negative social situations were presented, and subjects decided via buttonpress whether the situation had been caused by themselves or by the other person involved. Comparing positive with negative sentences revealed activations of the bilateral posterior cingulate cortex (PCC). Self-attribution correlated with activation of the posterior portion of the precuneus. However, self-attributed positive versus negative sentences showed activation of the anterior portion of the precuneus, and self-attributed negative versus positive sentences demonstrated activation of the bilateral insular cortex. All significant activations were reported with a statistical threshold of p ≤ .001, uncorrected. In addition, a comparison of our fMRI task with data from the Internal, Personal and Situational Attributions Questionnaire, Revised German Version, demonstrated convergent validity. Our findings suggest that the precuneus and the PCC are involved in the evaluation of social events with particular regional specificities: The PCC is activated during emotional evaluation, the posterior precuneus during attributional evaluation, and the anterior precuneus during self-serving processes. Furthermore, we assume that insula activation is a correlate of awareness of personal agency in negative situations.

Cultural adaptation and psychometric properties of the family questionnaire in a Brazilian sample of relatives of schizophrenia outpatients.

AIMS AND OBJECTIVES: To evaluate the internal reliability and validity of the Brazilian Portuguese version of the Family Questionnaire among families of schizophrenia outpatients. BACKGROUND: The main studies about the family environment of schizophrenia patients are related to the concept of Expressed Emotion. There is currently no instrument to evaluate this concept in Brazil that is easily applicable and comparable with studies from other countries. DESIGN: Methodological and cross-sectional research design. METHOD: A convenience sample of 130 relatives of schizophrenia outpatients was selected. The translation and cultural adaptation of the instrument involved experts in mental health and experts in the German language and included back translation, semantic evaluation of items and pretesting of the instrument with 30 relatives of schizophrenia outpatients. The psychometric properties of the instrument were studied with another 100 relatives, which fulfilled the requirements for the Brazilian Portuguese version of the instrument. The psychometric properties of the instrument were assessed by construct validity (using an analysis of its key components, comparisons between distinct groups-convergent validity with the Antonovsky's Sense of Coherence Scale) and reliability (checking the internal consistency of its items and its test-retest reproducibility). RESULTS: The analysis of main components confirmed dimensionality patterns that were comparable between the original and adapted versions. In two domains of the instrument, critical comments and emotional over-involvement had moderate and significant correlations, respectively, with Antonovsky's Sense of Coherence Scale, appropriate values of Cronbach's alpha and strong and significant correlations, respectively, in test-retest reproducibility. We observed significant differences between distinct groups of parents in the category of emotional over-involvement. CONCLUSION: We conclude that the Portuguese-adapted version of the Family Questionnaire is valid and reliable for the study sample. RELEVANCE TO CLINICAL PRACTICE: This study provided evidence that the Family Questionnaire is a reliable and valid instrument for assessing expressed emotion. It is easy and practical to use and is acceptable for use in a Brazilian cultural population.

Adverse effects of cognitive behavioral therapy and cognitive remediation in schizophrenia: results of the treatment of negative symptoms study.

This study examined the frequency and extent of detrimental effects of cognitive behavioral therapy (CBT) for psychosis. In a randomized clinical trial, we investigated the efficacy of CBT for the reduction of negative symptoms as compared with cognitive remediation (CR) in schizophrenia patients (n = 198). Safety was addressed through assessment of severe adverse events (SAEs), which were defined as suicides, suicide attempts, suicidal crises, and severe symptom exacerbations over a period of 12 months after inclusion in the study. Monthly assessments with Positive and Negative Syndrome Scale and Scale for the Assessment of Negative Symptoms allowed for the analysis of symptom increases during the treatment. There were no suicides in the trial. SAEs were observed in 10 CBT and 5 CR patients. Increases in negative symptoms occurred in 64 CBT and 58 CR patients. These differences were not significant. The maximum increase in negative symptoms under treatment, as compared with the baseline, was equal to an effect size of -0.66 in CBT patients and -0.77 in CR patients. Thus, the SAE rate was comparable between both interventions and was relatively low, given the severity of the psychotic disorder. Therapists should be aware of a subgroup of patients who show symptom increases with large effect sizes and might require more intensive care.

Quetiapine and norquetiapine in plasma and cerebrospinal fluid of schizophrenic patients treated with quetiapine: correlations to clinical outcome and HVA, 5-HIAA, and MHPG in CSF.

This study investigated concentrations of quetiapine and norquetiapine in plasma and cerebrospinal fluid (CSF) in 22 schizophrenic patients after 4-week treatment with quetiapine (600 mg/d), which was preceded by a 3-week washout period. Blood and CSF samples were obtained on days 1 and 28, and CSF levels of homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations were measured at baseline and after 4 weeks of quetiapine, allowing calculations of differences in HVA (ΔHVA), 5-HIAA (Δ5-HIAA), and MHPG (ΔMHPG) concentrations. Patients were assessed clinically, using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale at baseline and then at weekly intervals. Plasma levels of quetiapine and norquetiapine were 1110 ± 608 and 444 ± 226 ng/mL, and the corresponding CSF levels were 29 ± 18 and 5 ± 2 ng/mL, respectively. After the treatment, the levels of HVA, 5-HIAA, and MHPG were increased by 33%, 35%, and 33%, respectively (P < 0.001). A negative correlation was found between the decrease in PANSS positive subscale scores and CSF ΔHVA (r(rho) = -0.690, P < 0.01), and the decrease in PANSS negative subscale scores both with CSF Δ5-HIAA (r(rho) = -0.619, P = 0.02) and ΔMHPG (r(rho) = -0.484, P = 0.038). Because, unfortunately, schizophrenic patients experience relapses even with the best available treatments, monitoring of CSF drug and metabolite levels might prove to be useful in tailoring individually adjusted treatments.

Quality and correlates of specific self-esteem at the beginning stabilisation phase of schizophrenia.

In view of the potential importance of self-esteem in schizophrenia, there is a considerable lack of knowledge about the characteristics of specific self-esteem. The literature suggests that the experience of the self might be particularly destabilised in the transition phase between acute and remission points of the illness. Thus, the present study aims at examining the quality and correlates of different self-concepts at the beginning stabilisation phase of schizophrenia. In this study, 135 patients with schizophrenia were assessed 3 weeks after admission to inpatient treatment. Four central self-concepts were measured by the Frankfurt Self-Concept Scales (FSKN; Deusinger, I.M., 1986, Die Frankfurter Selbstkonzeptskalen (FSKN), Göttingen, Hogrefe). Clinical psychopathologic, neuropsychological and sociodemographic factors were analysed in two-step exploratory correlation and regression analyses to determine their relative contribution to self-concepts. The median of the four self-concepts ranged between -0.9 and -1.4 standard deviations below normative level. The relationship between negative symptoms and self-concepts was consistently significant, even when the contribution of depression was partialed out. In the multivariate analyses, these two symptom clusters explained up to 39% of the variances in our patients' self-evaluation. Neuropsychological dysfunctions were of relatively subordinate relevance for the patients' self-concepts. Thus, our results suggest that specific self-esteem at the point of beginning stabilisation of schizophrenia is significantly confounded not only by depression but also by negative symptoms.

Does the cognitive dispute of psychotic symptoms do harm to the therapeutic alliance?

We examined whether the cognitive dispute of psychotic symptoms has a negative impact on the course of the therapeutic alliance. Sixty-seven patients with persistent psychotic symptoms received either cognitive behavioral therapy (CBT) or supportive therapy. Questionnaire-based alliance ratings were repeatedly obtained throughout the course of therapy. Patient and therapist alliance ratings were examined separately. Data analyses comprised repeated measurement analyses of variance and cluster analytic procedures. Neither patient nor therapist alliance ratings showed a differential course throughout the treatments. This was despite the implementation of disputing strategies in later stages of CBT. Irrespective of the treatment condition a cluster with a positive alliance rating and a cluster with a poorer rating were found for therapist and patient ratings, respectively. Baseline symptoms and insight differentiated between the types of clusters. In conclusion, CBT-specific interventions that challenge psychotic symptoms do not necessarily negatively influence the course of the alliance.

Cognitive behavioural treatment of negative symptoms in schizophrenia patients: study design of the TONES study, feasibility and safety of treatment.

Currently, there are no convincing treatment strategies for negative symptoms of schizophrenia. On this background, we are conducting the treatment of negative symptoms (TONES) study which addresses the question whether cognitive behavioural therapy (CBT) is efficacious for the reduction of negative symptoms in schizophrenia. The present paper aims at presenting the design of the clinical trial of the study as well as the treatment concept. Further, we investigate the feasibility and the safety of our study treatment. The TONES study is a multicentric, prospective, single-blind, randomised, and controlled trial (RCT). The clinical trial compares CBT (test condition) and cognitive remediation (CR; control condition) with respect to the efficacy in reducing negative symptoms. In order to systematically assess aspects of adherence and feasibility therapists filled in session reports after each session. The safety analysis is performed using the sequential method of Whitehead (The design and analysis of sequential clinical trials, Ellis Horwood, Chichester, 1983). We were able to conduct a systematic recruitment and to include a sample of N = 198 patients which is characterised by negative symptoms of medium severity. The majority of patients accepted the format of a 50-min treatment session. The manualised treatment content seemed to be adequate and the cooperation between patients and therapists was excellent or adequate in approximately 80% of the treatment sessions. Of the 15 severe adverse events 10 occurred in the CBT and 5 in the CR. This difference between the groups was not significant. The study presented here is presumably the first high quality RCT which evaluates CBT with negative symptoms as primary endpoint. On the background of the data presented we conclude that CBT for the reduction of negative symptoms is feasible and can be conducted safely.

The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia.

BACKGROUND: The consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia. OBJECTIVE: The study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied. METHODS: Eighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately. RESULTS: Patient and therapist alliance ratings were not significantly correlated (r=0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d=0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings. CONCLUSION: The findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.

[Research into the feasibility of cognitive behavioural therapy in the treatment of psychotic disorders]. / Psychotherapieforschung zur Kognitiven Verhaltenstherapie bei Positiv-Symptomen psychotischer Störungen.

Psychotherapy in psychotic disorders is a rare condition and is confronted with much scepticism. On the background of intensive research - in particular in Great Britain, sufficient empirical evidence is available from randomised clinical trials to recommend Cognitive Behavioural Treatment for routine care. However, many research questions are open. In particular, the specific efficacy compared to supportive treatment is unclear and the mechanisms of action as well as economical aspects should be investigated more intensively. The psychotherapy research network "psychotherapy of psychotic syndromes" conducts research projects on these issues. The present paper gives an overview over the treatment and the scientific concept of this network.

Course of cognitive functioning during the stabilization phase of schizophrenia.

The present study aimed at examining the longitudinal course of neuropsychological impairments in schizophrenia patients during the stabilization phase of the illness. Cognitive functioning of 151 schizophrenia patients was assessed at baseline, 9-month, and 15-month follow-up with a comprehensive battery of cognitive tests. Cognitive performance of 40 matched controls was also examined at baseline and follow-up in order to control for effects of repeated testing. We found significant improvements in memory, attention, and global cognitive functioning from baseline to 9-month follow-up. Abstraction was stable at a relatively normal level. Global cognitive functioning remained at 9-month follow-up one standard deviation below normative level. Improvements in patients' cognitive performance between the 9-month and the 15-month follow-up were fewer and less pronounced. The present study implies that schizophrenia is a static encephalopathy with trait and state dependent cognitive components particularly in the attention and memory domain. The statistically and clinically significant cognitive improvements should be ground for clinical optimism.

Collaboration in outpatient antipsychotic drug treatment: analysis of potentially influencing factors.

Knowledge of factors relevant for medication adherence and patient collaboration is still limited. Our study aims at exploring the contribution of a variety of factors to collaboration in outpatients with schizophrenia and schizoaffective disorder. We obtained self-rated and observer-rated data from 108 outpatients during an interview 6 months after hospital discharge. The compliance rating scale (CRS) classified 76% of the patients as collaborative. Factors related to the patient, illness, treatment, and social environment were analysed in two-step explorative correlation and regression analyses in order to determine their relative contribution to collaboration. Only trust in medication and lack of insight were associated with collaboration, and they accounted for 38% of the variance. Neither medication side effects nor neuropsychological functioning correlated with collaboration. The conceptualisation of medication adherence is complex, and there are a number of unresolved methodological problems. The data indicate that illness and treatment-related subjective attitudes may be more relevant than side effects, cognitive functioning or any sociodemographic variable.

Negative schemata about the self and others and paranoid ideation in at-risk states and those with persisting positive symptoms.

BACKGROUND: The objective of this study is to test the conflicting theories concerning the association of negative self and other schemata and paranoid ideation. METHODS: A risk-based approach, including risk stratification, is used to gain insight into the association of the negative self and other schemata that may be shared by individuals or differentiate between individuals at clinical high risk (CHR) for a first-episode psychosis and those with full-blown psychosis. The dataset includes a sample of individuals at CHR (n = 137) and a sample of individuals with persisting positive symptoms (PPS, n = 211). The CHR sample was subdivided according to a prognostic index yielding 4 CHR sub-classes with increasing risk for transition to psychosis. RESULTS: Negative beliefs about the self were associated with paranoid ideation in CHR and a lower risk state. In the highest risk state and full-blown psychosis, there is an association with negative beliefs about others. CONCLUSION: These findings are in line with theories suggesting a switch from a predominantly activated negative self-schema to a malevolent others-schema in association with paranoid ideation along the risk-continuum. However, due to methodological limitations these results should be replicated by future studies.

Virtual reality for the psychophysiological assessment of phobic fear: responses during virtual tunnel driving.

An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research.

Stability and cause of anxiety in patients with an implantable cardioverter-defibrillator: a longitudinal two-year follow-up.

OBJECTIVE: Several investigations have found that anxiety disorders often develop in patients with an implantable cardioverter-defibrillator (ICD). This study investigated the inter--and intraindividual stability of anxiety and its relation to ICD activity in patients with an ICD. METHODS: Changes in the psychopathology of 35 patients with an ICD were assessed at the beginning of the trial period and 2.5 years later. Psychometric measures of anxiety were collected. During this period, shocks and antitachycardia pacing were assessed. RESULTS: Anxiety was found to be interindividually stable. We also found a slight, but statistically significant, reduction in trait anxiety and avoidance behavior over time. Patients who experienced shocks or antitachycardia pacing did not differ on psychometric or demographic variables from patients without those events. CONCLUSIONS: Anxiety seems to be interindividually stable in patients with an ICD. We found no connection between anxiety and tachycardia episodes in patients with an ICD.

Predictive Validity of the Brazilian Portuguese Version of the Family Questionnaire for Relapse in Patients With Schizophrenia.

BACKGROUND AND PURPOSE: The Family Questionnaire-Brazilian Portuguese Version (FQ-BPV) has been preliminarily validated in the Brazilian population. This study assessed the predictive validity of the FQ-BPV for relapse in patients with schizophrenia. METHODS: Ninety-four dyads (patients with schizophrenia and their relatives) were recruited from three mental health clinics. Expressed emotion was assessed using the FQ-BPV. Presence of relapse was assessed at 6-, 9-, 12-, and 18-month follow-ups and analyzed through logistic regressions. RESULTS: The critical comments (CC) domain of the FQ-BPV was statistically significant at 18 months. However, the model was not sufficiently robust to classify individuals correctly into relapse or no relapse categories. CONCLUSION: The FQ-BPV did not predict relapse well and we cannot recommend it for that purpose in Brazil without further studies.

Phylo- and ontogenetic fears and the expectation of danger: differences between spider- and flight-phobic subjects in cognitive and physiological responses to disorder-specific stimuli.

To compare specific phobias with an assumed phylogenetic or ontogenetic origin in responses to fear-relevant (FR) stimuli, 17 spider- and 17 flight-phobic participants were exposed to pictures of spiders, flight accidents, or mushrooms randomly followed by either a startling noise or nothing else. While both groups showed a disorder-specific expectancy bias, only spider-phobic participants exhibited a disorder-specific covariation bias. Spider-phobic participants also showed enhanced skin conductance responses (SCRs), event-related brain potentials (ERPs), and startle responses triggered by disorder-specific FR pictures while flight-phobic participants showed only disorder-specific enhanced SCRs. In sum, our direct comparison between ontogenetic and phylogenetic phobias revealed that the former is characterized by biased and enhanced responses triggered by disorder-specific FR stimuli presumably based on a biological preparedness.

Altered processing of pain-related information in patients with fibromyalgia.

Pressure pain thresholds (PPTs) and event-related potentials (ERPs) elicited by emotional words were analyzed in 12 patients with fibromyalgia (FM) and 12 matched healthy subjects. PPTs were assessed at the middle finger of both hands, before and after the experiment. Overall, FM patients and healthy subjects did not differ in PPT. Nevertheless, FM patients as compared with healthy controls were characterized by a significant enhancement of pain sensitivity from the beginning to the end of the experiment indicating a long lasting sensitization due to repeated stimulation. ERPs were recorded during a language decision task where subjects had to react to unpleasant pain-related and emotionally neutral words depending on syntactic or orthographic cues. An emotional category effect was observed on N400 and P300 components of the ERP, indicating that unpleasant words elicited more positive amplitudes than neutral words. A significant group effect was observed on P200 amplitudes, showing reduced amplitudes in FM patients as compared to healthy controls. Furthermore, unpleasant pain-related compared to neutral words triggered significantly enhanced late positive slow waves in healthy controls, while a comparable effect was not found in FM patients. The ERP and PPT data suggest that FM patients are characterized by an altered cognitive processing of pain-related information and by an abnormal adaptation to mechanical pain stimuli, respectively.