Impaired perception of temporal contiguity between action and effect is associated with disorders of agency in schizophrenia.

Delusions of control in schizophrenia are characterized by the striking feeling that one's actions are controlled by external forces. We here tested qualitative predictions inspired by Bayesian causal inference models, which suggest that such misattributions of agency should lead to decreased intentional binding. Intentional binding refers to the phenomenon that subjects perceive a compression of time between their intentional actions and consequent sensory events. We demonstrate that patients with delusions of control perceived less self-agency in our intentional binding task. This effect was accompanied by significant reductions of intentional binding as compared to healthy controls and patients without delusions. Furthermore, the strength of delusions of control tightly correlated with decreases in intentional binding. Our study validated a critical prediction of Bayesian accounts of intentional binding, namely that a pathological reduction of the prior likelihood of a causal relation between one's actions and consequent sensory events-here captured by delusions of control-should lead to lesser intentional binding. Moreover, our study highlights the import of an intact perception of temporal contiguity between actions and their effects for the sense of agency.

[APPS-Study 2020 - On outpatient psychotherapeutic care for people with psychotic disorders]. / APPS-Studie 2020 ­ Zur ambulanten psychotherapeutischen Versorgung von Menschen mit psychotischen Störungen.

BACKGROUND: Although patients with psychotic disorders (PPS) are indicated for outpatient psychotherapy at any stage of their illness, they are rarely treated in this way. For this purpose, structural conditions, the experience of competence of therapists, as well as content-related aspects of training and further education of psychotherapists are analyzed. METHODS: Based on a qualitative preliminary study, an online survey was conducted among 487 psychological psychotherapists. RESULTS: Half of the respondents indicated a high willingness to treat PPS. In the acute phase of the disease only 20% are willing to do so. In the studies as well as in the theoretical part of the education and further education, there is hardly any preparation for a corresponding treatment. In contrast, practical experience in psychiatric clinics is considered very important. With regard to structural framework conditions, low hourly quotas and inflexible billing modalities are criticized. With regard to patients, in addition to sufficient motivation for treatment, low reliability, low cognitive ability, low insight into the illness, and frequent discontinuation of therapy are stated. Contrary to some prejudices, patients are characterized as "peaceful" in their interactions. The reduction of psychotic relapses, social integration and reduction of comorbid symptoms are mainly mentioned as achievable outcomes. The reduction of psychotic symptoms is rated less optimistically. Psychotherapists from psychiatric outpatient clinics (PIA) differ from other outpatient psychotherapists by better competence experience and correspondingly more frequent work with PPS, also in the acute stage. DISCUSSION: Although every second therapist does not feel well trained, the willingness to treat PPS seems to be higher than the pure supply figures suggest. There is potential for optimization in education and training as well as in networking with other professional groups/relatives. This could be responsible for the fact that in the acute psychotic stage there are fears of contact and competence concerns. Psychotherapists in PIAs, where there is closer networking with other professional groups for structural reasons, experience corresponding deficits to a lesser extent. With regard to other structural barriers, the question arises as to whether these represent disorder-specific or rather general problems in psychotherapy.

[Current evidence for various inpatient psychotherapy programs in the treatment of psychoses-A narrative review article]. / Aktuelle Evidenz verschiedener stationärer Psychotherapieprogramme in der Behandlung von Psychosen ­ ein narrativer Übersichtsartikel.

BACKGROUND: The analysis of the efficacy of evidence-based psychotherapy for patients with psychotic disorders has mostly been carried out in the outpatient field. In the inpatient field the efficacy is sometimes difficult to assess due to different healthcare systems. OBJECTIVE: The aim of this narrative review is to summarize international guidelines and meta-analyses on the efficacy of inpatient psychotherapeutic treatment strategies for patients with psychotic disorders. Based on this, recommendations for disorder-specific ward concepts for acute and postacute fields are formulated. METHODS: The German S3 guidelines, international guidelines, current meta-analyses and primary studies on psychological interventions in the treatment of psychotic disorders were included. Based on the results, recommendations for the inpatient psychotherapeutic treatment in various phases of treatment were formulated (acute phase and postacute phase). RESULTS: In the acute phase a combination of cognitive behavioral therapy (CBTp) in the individual setting and family interventions in the group setting as well as metacognitive training (MCT acute) is effective and recommended. In the postacute phase, in addition to individual and group CBTp and family interventions, psychoeducation, social skills training and cognitive remediation have been shown to be effective and are recommended. DISCUSSION: The suggested recommendations for concrete interventions in various treatment phases and the evidence base are critically discussed and recommendations for the structure of wards are presented.

Promoting stigma coping and empowerment in patients with schizophrenia and depression: results of a cluster-RCT.

There is a need for interventions supporting patients with mental health conditions in coping with stigma and discrimination. A psycho-educational group therapy module to promote stigma coping and empowerment (STEM) was developed and tested for efficacy in patients with schizophrenia or depression. 30 clinical centers participated in a cluster-randomized clinical trial, representing a broad spectrum of mental health care settings: in-patient (acute treatment, rehabilitation), out-patient, and day-hospitals. As randomized, patients in the intervention group clusters/centers received an illness-specific eight sessions standard psychoeducational group therapy plus three specific sessions on stigma coping and empowerment ('STEM'). In the control group clusters the same standard psychoeducational group therapy was extended to 11 sessions followed by one booster session in both conditions. In total, N = 462 patients were included in the analysis (N = 117 with schizophrenia spectrum disorders, ICD-10 F2x; N = 345 with depression, ICD-10 F31.3-F31.5, F32-F34, and F43.2). Clinical and stigma-related measures were assessed before and directly after treatment, as well as after 6 weeks, 6 months, and 12 months (M12). Primary outcome was improvement in quality of life (QoL) assessed with the WHO-QOL-BREF between pre-assessment and M12 analyzed by mixed models and adjusted for pre-treatment differences. Overall, QoL and secondary outcome measures (symptoms, functioning, compliance, internalized stigma, self-esteem, empowerment) improved significantly, but there was no significant difference between intervention and control group. The short STEM module has proven its practicability as an add-on in different settings in routine mental health care. The overall increase in empowerment in both, schizophrenia and depression, indicates patients' treatment benefit. However, factors contributing to improvement need to be explored.The study has been registered in the following trial registers. ClinicalTrials.gov: https://register.clinicaltrials.gov/ Registration number: NCT01655368. DRKS: https://www.drks.de/drks_web/ Registration number: DRKS00004217.

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.

Self-assessment of negative symptoms - Critical appraisal of the motivation and pleasure - Self-report's (MAP-SR) validity and reliability.

OBJECTIVE: The negative symptom domain remains a major challenge concerning treatment. A valid self-report measure could assist clinicians and researchers in identifying patients with a relevant subjective burden. The Motivation and Pleasure - Self Report (MAP-SR) derives from the CAINS and is supposed to reflect the "amotivation" factor of negative symptoms. We evaluated different aspects of the scale's reliability and validity. This is the first factorial analysis as well as the first analysis of test-retest reliability. METHODS: We assessed three samples of subjects with schizophrenia or schizoaffective disorder (n = 93) and a broad spectrum of related domains. RESULTS: We explored a 3-, 2- and 1-factor solution (explaining 50.93, 44.85 and 36.18% of variance, respectively). The factor "pleasure and hedonic activity" consists of eight items and was most robust; the factors "social motivation" and "motivation for work" were problematic. Test-retest reliability of the scale was adequate (rS = 0.63, p = .005). Neither the MAP-SR nor the "pleasure and hedonic activities" factor are associated with the PANSS negative symptom scale. There are significant associations with the observer-rated CAINS-MAP scale, experiences of pleasure, and social cognition but none with functional outcome. Discriminant validity could not be established with regards to depression and extrapyramidal symptoms. CONCLUSIONS: We found that the MAP-SR is adequate to assess anhedonia but is less suitable when assessing motivation. Therefore, we propose using the "pleasure and hedonic activity scale" to cover the "anhedonia" subdomain. We think the "motivation" part of the instrument requires reconstruction.

[Psychosis: Cognitive Behavioral Treatment Strategies]. / Psychotische Störungen: Kognitiv-verhaltens-therapeutische Behandlungsstrategien.

Cognitive behavioral therapy (CBT) is an established treatment for the patients with psychosis including schizophrenia. The evidence for the efficacy of CBT is proved by randomized clinical trials and meta-analyses. Evidence-based treatment guidelines recommend CBT for routine treatment. The aim of this paper is to give a short practical guideline for different cognitive behavioral treatment strategies. Cognitive Behavior Therapy for psychosis (CBTp) is an adaptation of general principles of CBT modified for patients with psychotic disorders. Basis of CBT are cognitive models of symptoms to identify treatment targets. The major goal is to foster every-day functioning by realizing a self-management approach. A caring, genuine and real-life oriented therapeutic attitude can help to establish a therapeutic alliance. An individualized functional analysis should be the core for every intervention. Basic strategies like psychoeducation and crisis plans are briefly described. Relatives and close friends of patients should be involved in order to improve crisis management and problem solving. Behavioral and cognitive treatment strategies for delusions, hallucinations and negative symptoms are outlined. Metacognitive treatment as well as social competence training is presented.

Effectiveness of a brief psychoeducational group intervention for relatives on the course of disease in patients after inpatient depression treatment compared with treatment as usual--study protocol of a multisite randomised controlled trial.

BACKGROUND: Relapses and rehospitalisations are common after acute inpatient treatment in depressive disorders. Interventions for stabilising treatment outcomes are urgently needed. Psychoeducational group interventions for relatives were shown to be suitable for improving the course of disease in schizophrenia and bipolar disorders. A small Japanese monocentre randomised controlled trial also showed promising results for depressive disorders. However, the evidence regarding psychoeducation for relatives of patients with depressive disorders is unclear. METHODS/DESIGN: The study is conducted as a two-arm multisite randomised controlled trial to evaluate the incremental effect of a brief psychoeducational group intervention for relatives as a maintenance treatment on the course of disease compared to treatment as usual. Primary outcome is the estimated number of depression-free-days in patients within one year after discharge from inpatient treatment. 180 patients diagnosed with unipolar depressive disorders as well as one key relative per patient will be included during inpatient treatment and randomly allocated to the conditions at discharge. In the intervention group, relatives will participate in a brief psychoeducational group intervention following the patient's discharge. The intervention consists of four group sessions lasting 90 to 120 min each. Every group session contains informational parts as well as structured training in problem-solving. In both study conditions, patients will receive treatment as usual. Patients as well as relatives will be surveyed by means of questionnaires at discharge and three, six, nine and twelve months after discharge. In addition to the primary outcome, several patient-related and relative-related secondary outcomes will be considered and health economics will be investigated. DISCUSSION: Our study will provide evidence on the incremental effect of a brief psychoeducational intervention for relatives as a maintenance treatment after inpatient depression treatment. Positive results may have a major impact on health care for depression. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00006819; Trial registration date: 2014 Oktober 31; Universal Trial Number (UTN): U1111-1163-5391.

Cerebrospinal fluid findings in patients with psychotic symptoms-a retrospective analysis.

In current international classification systems (ICD-10, DSM5), the diagnostic criteria for psychotic disorders (e.g. schizophrenia and schizoaffective disorder) are based on symptomatic descriptions since no unambiguous biomarkers are known to date. However, when underlying causes of psychotic symptoms, like inflammation, ischemia, or tumor affecting the neural tissue can be identified, a different classification is used ("psychotic disorder with delusions due to known physiological condition" (ICD-10: F06.2) or psychosis caused by medical factors (DSM5)). While CSF analysis still is considered optional in current diagnostic guidelines for psychotic disorders, CSF biomarkers could help to identify known physiological conditions. In this retrospective, partly descriptive analysis of 144 patients with psychotic symptoms and available CSF data, we analyzed CSF examinations' significance to differentiate patients with specific etiological factors (F06.2) from patients with schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F2). In 40.3% of all patients, at least one CSF parameter was out of the reference range. Abnormal CSF-findings were found significantly more often in patients diagnosed with F06.2 (88.2%) as compared to patients diagnosed with F2 (23.8%, p < 0.00001). A total of 17 cases were identified as probably caused by specific etiological factors (F06.2), of which ten cases fulfilled the criteria for a probable autoimmune psychosis linked to the following autoantibodies: amphiphysin, CASPR2, CV2, LGl1, NMDA, zic4, and titin. Two cases presented with anti-thyroid tissue autoantibodies. In four cases, further probable causal factors were identified: COVID-19, a frontal intracranial tumor, multiple sclerosis (n = 2), and neurosyphilis. Twenty-one cases remained with "no reliable diagnostic classification". Age at onset of psychotic symptoms differed between patients diagnosed with F2 and F06.2 (p = 0.014), with the latter group being older (median: 44 vs. 28 years). Various CSF parameters were analyzed in an exploratory analysis, identifying pleocytosis and oligoclonal bands (OCBs) as discriminators (F06.2 vs. F2) with a high specificity of > 96% each. No group differences were found for gender, characteristics of psychotic symptoms, substance dependency, or family history. This study emphasizes the great importance of a detailed diagnostic workup in diagnosing psychotic disorders, including CSF analysis, to detect possible underlying pathologies and improve treatment decisions.

Measurement of negative and depressive symptoms: Discriminatory relevance of affect and expression.

There is conceptual overlap between negative and depressive symptoms: Mainly the 'avolition' factor of negative symptoms also encompasses main symptoms of depression. However, whereas in depression mood is low, mainly anticipatory anhedonia can be found in negative symptoms. Moreover, patients with schizophrenia (SCZ) show greater expressive deficits than those with Major Depressive Episode (MDE). We investigated if measures of depressive and negative symptoms differentiate SCZ subjects, subjects with MDE, and healthy controls (HC). 21 SCZ, 22 MDE, and 25 HC subjects were examined with a rater assessment and a self-rating for negative symptoms (Clinical Assessment Interview for Negative Symptoms (CAINS); Motivation and Pleasure - Self-Report (MAP-SR)) and depressive symptoms (Hamilton Rating Scale for Depression (HAMD-17); Beck Depression Inventory (BDI)). All measures differentiated the psychiatric samples from HC (all p's < 0.01). The ratings of depressive symptoms (HAMD-17, BDI) and rater assessment of negative symptoms (CAINS) - specifically its sub scale measuring expressive deficits - managed to discriminate between subjects with schizophrenia and those with MDE (SCZ > MDE > HC for negative, MDE > SCZ > HC for depressive symptoms, all p's < 0.05). The self-rating of negative symptoms (MAP-SR) did not. To differentiate negative symptoms and depression clinicians might look for (self-)reported low mood and observer-rated reduction in speech as well as in gestures and facial expression. Reduced expression and moderate levels of depression point towards a negative syndrome, whereas mostly unimpaired expression and high scores of self-reported depressive symptoms are more likely to indicate a depressive syndrome.

Evidence for two distinct domains of negative symptoms: Confirming the factorial structure of the CAINS.

Negative symptoms are an important predictor of course of illness as well as social and occupational functioning. Clinically effective interventions are scarce. For negative symptoms to become a reliable primary endpoint in treatment studies, clear operationalization and construct validation is needed. Recent factor analyses mostly find two main factors for negative symptoms: diminished expression und amotivation/anhedonia. The Clinical Assessment Interview for Negative Symptoms (CAINS) consists of the subscales "motivation and pleasure" and "expression". We assessed three samples of subjects with schizophrenia (n = 105) for different aspects of the scale's reliability and validity. A confirmatory factor analysis (CFA) of the CAINS confirmed its two-factorial structure. The subscales had distinct correlational profiles: "Motivation and pleasure" was strongly associated with functional outcome and depression and further with neurocognition, positive symptoms and social cognition. "Expression" seems independent of sources of secondary negative symptoms and neurocognition. We found good internal consistency and interrater agreement. Test-retest reliability (two-week interval) was moderate for the CAINS and its "expression" subscale and low for the "motivation and pleasure" subscale. Our findings indicate that the CAINS differentiates reliably between the two main domains of negative symptoms with some questions remaining concerning the validity of the "motivation and pleasure" subscale.

Emotion and self in psychotic disorders: Behavioral evidence from an emotional evaluation task using verbal stimuli varying in emotional valence and self-reference.

BACKGROUND AND OBJECTIVES: Psychotic disorders are accompanied by changes in emotional and self-referential processing. This behavioral study investigates the link between emotional and self-referential processing in 21 psychotic patients with and without symptoms of disordered self-processing and 21 healthy age-matched controls during emotional evaluation of words varying in emotional valence and self-reference. METHODS: Emotional and neutral words related to the self of the reader (e.g., "my fear", "my happiness", "my books"), to the self of another person, unknown to the reader (e.g., "his fear", "his happiness", "his books") or without person reference (e.g., "the fear", "the happiness", "the books") had to be judged in reference to one's own feelings as positive, negative or neutral. RESULTS: Compared to healthy controls (HC) psychotic patients with symptoms of self-disorders (PwSD) showed significantly reduced valence congruent judgments in response to self-related (particularly positive and negative) words and no difference between self-, other-, and personally unreferenced positive words. These differences between PwSD and HC were also reflected in post-experimental ratings of subjective experience. Additionally, no reaction time or memory advantage for self-related or emotional words could be found in psychotic patients irrespective of the presence of self-disorders. LIMITATIONS: The results may be preliminary due to the small sample sizes. CONCLUSIONS: Taken together, the results argue in favor of a differentiated view regarding changes in emotional experience in psychotic disorders. They provide preliminary evidence that in psychotic disorders changes in emotion and self-processing may be related to the severity of self-disorders thought to underlie disordered thinking and feeling in psychotic patients.

[What Determines Treatment Recommendations of Relatives: The Role of Expectations, Negative Consequences and Control Attributions for the Treatment of Patients with Psychosis]. / Was führt zu Behandlungsempfehlungen von Angehörigen: Die Rolle von Erfolgserwartung, negativen Folgen und Kontrollattributionen bei der Behandlung von Patienten mit Psychosen.

Objective Therapy recommendations of relatives of individuals with psychotic disorders. Method A total of n = 52 inpatient relatives were interviewed about their attitude towards psychotherapy and antipsychotics. Results Over 80 % of the relatives recommended psycho- and pharmacotherapy. Concerns reduced recommendations for pharmacotherapy, poor/lack of hope for improvement reduced recommendations for psychotherapy. Conclusion The relatives' therapy recommendations could be influenced by discussing their concerns and expectations of success.

Experimental variation of social stress in virtual reality - Feasibility and first results in patients with psychotic disorders.

BACKGROUND AND OBJECTIVES: Social interaction might lead to increased stress levels in patients with psychotic disorders. Impaired social stress tolerance is critical for social functioning and closely linked with symptom relapse and hospitalization. We present an interactive office built-up in virtual reality (VR). METHODS: Patients with psychotic disorders (PP, N = 26 including N = 5 dropouts) and matched healthy controls (HC, N = 20) were examined with a VR simulating an open-plan office. In a randomized, controlled cross-over design, participants were introduced to virtual co-workers (avatars) and requested to ask them for task assistance. Social feedback in each of the two sessions was either cooperative or rejective in randomized order. RESULTS: The office environment was tolerable for most PP and all HC, five PP and none of the HC dropped out for any reason. Drop-outs reported simulator sickness, influence on thoughts and symptom exacerbations. Statistical trends indicated heightened paranoid ideations for PP after social rejection. State measures of paranoid ideations showed high convergent validity with conventional measures of delusions. Of note, measures of presence were higher for PP than for HC. LIMITATIONS: The exploratory design limits the robustness of the findings. Only statistical trends on paranoid ideation were found. CONCLUSION: The use of VR to assess the effects of social rejection is feasible and tolerable for most PP (87%). However, its implementation for PP is challenged by increased simulator sickness and an additional stress load for some patients. Further studies continuing on these first results that point towards an increased paranoid ideation evoked by negative social feedback and generally higher subjective presence are needed.

Longitudinal relations between symptoms, neurocognition, and self-concept in schizophrenia.

OBJECTIVE: Cognitive models suggest that the self-concept of persons with psychosis can be fundamentally affected. Self-concepts were found to be related to different symptom domains when measured concurrently. Longitudinal investigations to disentangle the possible causal associations are rare. METHOD: We examined a sample of 160 people with a diagnosis of schizophrenia who took part in a psychotherapy study. All participants had the DSM-IV diagnosis of a schizophrenia and pronounced negative symptoms. Neurocognition, symptoms, and self-concepts were assessed at two time points 12 months apart. Structural equation modeling was used to test whether symptoms influence self-concepts (scar-model) or self-concepts affect symptoms (vulnerability model). RESULTS: Negative symptoms correlated concurrently with self-concepts. Neurocognitive deficits are associated with more negative self-concepts 12 months later. Interpersonal self-concepts were found to be relevant for paranoia. CONCLUSION: The findings implicate that if deficits in neurocognition are present, fostering a positive self-concept should be an issue in therapy. Negative interpersonal self-concept indicates an increased risk for paranoid delusions in the course of 1 year. New aspects for cognitive models in schizophrenia and clinical implications are discussed.

The Vicious Cycle of Family Atmosphere, Interpersonal Self-concepts, and Paranoia in Schizophrenia-A Longitudinal Study.

Recent cognitive models of paranoid delusions highlight the role of self-concepts in the development and maintenance of paranoia. Evidence is growing that especially interpersonal self-concepts are relevant in the genesis of paranoia. In addition, negative interpersonal life-experiences are supposed to influence the course of paranoia. As dysfunctional family atmosphere corresponds with multiple distressing dyadic experiences, it could be a risk factor for the development and maintenance of paranoia. A total of 160 patients with a diagnosis of schizophrenia were assessed twice within 12 months. Standardized questionnaires and symptom rating scales were used to measure interpersonal self-concepts, perceived family atmosphere, and paranoia. Data were analyzed using longitudinal cross-lagged structural equation models. Perceived negative family atmosphere was associated with the development of more pronounced negative interpersonal self-concepts 12 months later. Moreover, paranoia was related to negative family atmosphere after 12 months as well. As tests revealed that reversed associations were not able to explain the data, we found evidence for a vicious cycle between paranoia, family atmosphere, and interpersonal self-concepts as suggested by theoretical/cognitive model of paranoid delusions. Results suggest that broader interventions for patients and their caretakers that aim at improving family atmosphere might also be able to improve negative self-concepts and paranoia.

Examining the cognitive model of caregiving--a structural equation modelling approach.

The study tests assumptions from the "cognitive model of caregiving" (Kuipers et al., 2010), which aims to inform interventions for carers of people with psychoses. The sample comprised 61 relatives of patients with schizophrenia. Standardized psychological assessments were conducted twice within 6 months including Involvement Evaluation Questionnaire (IEQ-EU), a short form of the Symptom Checklist 90-R (SCL K9), the Family Questionnaire (FQ), scales measuring control attributions of the Illness Perception Questionnaire for Schizophrenia (IPQS-R) and emotions toward the ill relative. Structural equation modelling was used to analyse data. We identified two pathways: (a) from "attributing control to relatives" to distress, intermediated by anxiety for the patient and emotional overinvolvement (EOI), and (b) from "attribution control to patient" to distress, intermediated by anger about the patient and criticism. The model provided a good fit to the data and was successfully replicated at a second point in time. We were able to find supporting evidence for a cognitive model of caregiving. Control attributions and emotions of informal caregivers are important when interventions are planned reducing expressed emotion and burden of caregivers.