Assessing responsiveness to direct verbal suggestions in depersonalization-derealization disorder.

The dissociative disorders and germane conditions are reliably characterized by elevated responsiveness to direct verbal suggestions. However, it remains unclear whether atypical responsiveness to suggestion is similarly present in depersonalization-derealization disorder (DDD). 55 DDD patients and 36 healthy controls completed a standardised behavioural measure of direct verbal suggestibility that includes a correction for compliant responding (BSS-C), and psychometric measures of depersonalization-derealization (CDS), mindfulness (FFMQ), imagery vividness (VVIQ), and anxiety (GAD-7). Relative to controls, patients did not exhibit elevated suggestibility (g = 0.26, BF10 = .11) but displayed significantly lower mindfulness (g = 1.38), and imagery vividness (g = 0.63), and significantly greater anxiety (g = 1.39). Although suggestibility did not correlate with severity of depersonalization-derealization symptoms in controls, r = -.03 [95% CI: -.36, .30], there was a weak tendency for a positive association in patients, r = .25, [95% CI: -.03, .48]. Exploratory analyses revealed that patients with more severe anomalous bodily experiences were also more responsive to suggestion, an effect not seen in controls. This study demonstrates that DDD is not characterized by elevated responsiveness to direct verbal suggestions. These results have implications for the aetiology and treatment of this condition, as well as its classification as a dissociative disorder in psychiatric nosology.

Vitamin D and clinical symptoms in First Episode Psychosis (FEP): A prospective cohort study.

BACKGROUND: There is a paucity of longitudinal research investigating vitamin D in people with early psychosis. METHOD: Vitamin D levels were measured in 168 patients (64% (n = 108) male, mean age 29.3 (9.8) years) with first episode psychosis (FEP), along with measures of clinical state at baseline and at 12 months follow up. We assessed the a) cross sectional, and; b) longitudinal relationships between continuous and categorical 25-hydroxyvitamin D (25(OH)D) levels and clinical symptoms at first contact for psychosis and at 12 months. RESULTS: In FEP, 80% (n = 134) at baseline, and 76% at 12 months follow up, had suboptimal vitamin D levels (<20 ng/ml). Suboptimal levels of 25 (OH) D at baseline were not cross-sectionally associated with clinical symptoms. Higher vitamin D levels at baseline (n = 77) were significantly associated with better visual reproduction-immediate recall (ß = 0.249, 95%CI = -0.012-0.871, p = 0.044). Higher baseline vitamin D levels were prospectively associated with lower total PANSS (ß = -0.24, 95%CI = -0.47-0.01, p = 0.04) and PANSS negative symptom scores (ß = -0.12, 95%CI = -0.23-0.01, p = 0.04) at 12 months. CONCLUSION: We identified a prospective association between higher baseline serum Vitamin D levels and lower total psychotic symptoms and negative symptoms of psychosis at 12 months after first contact for psychosis. The results of this study require replication in larger prospective studies, and highlight the need for large randomised trials to assess the effect of vitamin D supplementation on symptoms of psychosis in FEP.

Randomised control trial of the effectiveness of an integrated psychosocial health promotion intervention aimed at improving health and reducing substance use in established psychosis (IMPaCT).

BACKGROUND: People with psychosis have a reduced life expectancy of 10-20 years, largely due to cardiovascular disease. This trial aimed to determine the effectiveness of a modular health promotion intervention (IMPaCT Therapy) in improving health and reducing cardiovascular risk in psychosis. METHODS: A multicentre, two arm, parallel cluster RCT was conducted across five UK mental health NHS trusts. Community care coordinators (CC) were randomly assigned to training and supervision in delivering IMPaCT Therapy or treatment as usual (TAU) to current patients with psychosis (cluster). The primary outcome was the physical and mental health subscales of the Short form-36 (SF-36) questionnaire. RESULTS: Of 104 care coordinators recruited, 52 (with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with 193 patients) randomised to TAU. Of 406 patients, 318 (78%) and 301 (74%) attended 12- and 15-month follow-up respectively. IMPaCT therapy showed no significant effect on the physical or mental health component SF-36 scores versus TAU at 12 or 15 months. No effect was observed for cardiovascular risk indicators, except for HDL cholesterol, which improved more with IMPACT therapy than TAU (Treatment effect (95% CI); 0.085 (0.007 to 0.16); p = 0.034). The 22% of patients who received >180 min of IMPACT Therapy in addition to usual care achieved a greater reduction in waist circumference than did controls, which was clinically significant. CONCLUSION: Training and supervising community care coordinators to use IMPaCT therapy in patients with psychosis is insufficient to significantly improve physical or mental health quality of life. The search for effective, pragmatic interventions deliverable in health care services continues. TRIAL REGISTRATION: The trial was retrospectively registered with ISRCTN registry on 23/4/2010 at ISRCTN58667926 ; recruitment started on 01/03/2010 with first randomization on 09.08.2010 ISRCTN58667926 .

Real-time fMRI neurofeedback in adolescents with attention deficit hyperactivity disorder.

Attention Deficit Hyperactivity Disorder (ADHD) is associated with poor self-control, underpinned by inferior fronto-striatal deficits. Real-time functional magnetic resonance neurofeedback (rtfMRI-NF) allows participants to gain self-control over dysregulated brain regions. Despite evidence for beneficial effects of electrophysiological-NF on ADHD symptoms, no study has applied the spatially superior rtfMRI-NF neurotherapy to ADHD. A randomized controlled trial tested the efficacy of rtfMRI-NF of right inferior prefrontal cortex (rIFG), a key region that is compromised in ADHD and upregulated with psychostimulants, on improvement of ADHD symptoms, cognition, and inhibitory fMRI activation. To control for region-specificity, an active control group received rtfMRI-NF of the left parahippocampal gyrus (lPHG). Thirty-one ADHD boys were randomly allocated and had to learn to upregulate their target brain region in an average of 11 rtfMRI-NF runs over 2 weeks. Feedback was provided through a video-clip of a rocket that had to be moved up into space. A transfer session without feedback tested learning retention as a proximal measure of transfer to everyday life. Both NF groups showed significant linear activation increases with increasing number of runs in their respective target regions and significant reduction in ADHD symptoms after neurotherapy and at 11-month follow-up. Only the group targeting rIFG, however, showed a transfer effect, which correlated with ADHD symptom reductions, improved at trend level in sustained attention, and showed increased IFG activation during an inhibitory fMRI task. This proof-of-concept study demonstrates for the first time feasibility, safety, and shorter- and longer-term efficacy of rtfMRI-NF of rIFG in adolescents with ADHD. Hum Brain Mapp 38:3190-3209, 2017. © 2017 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.

Substance use, medication adherence and outcome one year following a first episode of psychosis.

Both substance use and poor medication adherence are associated with poor outcome in psychosis. To clarify the contributions of substance use and poor medication adherence to poor outcome in the year following a first episode of psychosis, 205 patients were evaluated for use of tobacco, alcohol, cannabis and stimulants at their psychosis onset, and in a 1-year follow-up. Data on medication adherence and symptom remission were also collected. Patients had high rates of overall substance use before (37-65%) and after psychosis onset (45-66%). 44% showed poor medication adherence and 55% did not reach remission from psychosis. Nicotine dependence and cannabis use after psychosis onset significantly predicted both poor medication adherence and non-remission, and poor medication adherence mediated the effects of these substances on non-remission. In conclusion, medication adherence lies on the causal pathway between nicotine dependence and cannabis on the one hand and non-remission on the other.

Biofeedback for psychiatric disorders: a systematic review.

Biofeedback potentially provides non-invasive, effective psychophysiological interventions for psychiatric disorders. The encompassing purpose of this review was to establish how biofeedback interventions have been used to treat select psychiatric disorders [anxiety, autistic spectrum disorders, depression, dissociation, eating disorders, schizophrenia and psychoses] to date and provide a useful reference for consultation by clinicians and researchers planning to administer a biofeedback treatment. A systematic search of EMBASE, MEDLINE, PsycINFO, and WOK databases and hand searches in Applied Psychophysiology and Biofeedback, and Journal of Neurotherapy, identified 227 articles; 63 of which are included within this review. Electroencephalographic neurofeedback constituted the most investigated modality (31.7%). Anxiety disorders were the most commonly treated (68.3%). Multi-modal biofeedback appeared most effective in significantly ameliorating symptoms, suggesting that targeting more than one physiological modality for bio-regulation increases therapeutic efficacy. Overall, 80.9% of articles reported some level of clinical amelioration related to biofeedback exposure, 65.0% to a statistically significant (p < .05) level of symptom reduction based on reported standardized clinical parameters. Although the heterogeneity of the included studies warrants caution before explicit efficacy statements can be made. Further development of standardized controlled methodological protocols tailored for specific disorders and guidelines to generate comprehensive reports may contribute towards establishing the value of biofeedback interventions within mainstream psychiatry.

Self-regulation of the anterior insula: Reinforcement learning using real-time fMRI neurofeedback.

The anterior insula (AI) plays a key role in affective processing, and insular dysfunction has been noted in several clinical conditions. Real-time functional MRI neurofeedback (rtfMRI-NF) provides a means of helping people learn to self-regulate activation in this brain region. Using the Blood Oxygenated Level Dependant (BOLD) signal from the right AI (RAI) as neurofeedback, we trained participants to increase RAI activation. In contrast, another group of participants was shown 'control' feedback from another brain area. Pre- and post-training affective probes were shown, with subjective ratings and skin conductance response (SCR) measured. We also investigated a reward-related reinforcement learning model of rtfMRI-NF. In contrast to the controls, we hypothesised a positive linear increase in RAI activation in participants shown feedback from this region, alongside increases in valence ratings and SCR to affective probes. Hypothesis-driven analyses showed a significant interaction between the RAI/control neurofeedback groups and the effect of self-regulation. Whole-brain analyses revealed a significant linear increase in RAI activation across four training runs in the group who received feedback from RAI. Increased activation was also observed in the caudate body and thalamus, likely representing feedback-related learning. No positive linear trend was observed in the RAI in the group receiving control feedback, suggesting that these data are not a general effect of cognitive strategy or control feedback. The control group did, however, show diffuse activation across the putamen, caudate and posterior insula which may indicate the representation of false feedback. No significant training-related behavioural differences were observed for valence ratings, or SCR. In addition, correlational analyses based on a reinforcement learning model showed that the dorsal anterior cingulate cortex underpinned learning in both groups. In summary, these data demonstrate that it is possible to regulate the RAI using rtfMRI-NF within one scanning session, and that such reward-related learning is mediated by the dorsal anterior cingulate.

Psychophysiological investigations in depersonalization disorder and effects of electrodermal biofeedback.

Previous studies investigating depersonalization disorder (DPD) report a lower baseline skin conductance level (SCL) and attenuated skin conductance response (SCR) to emotive stimuli. We hypothesized that increasing physiological arousal levels via electrodermal biofeedback may ameliorate disembodiment and emotional numbing symptomatology. Real-time versus sham biofeedback yielded a significant SCL increase after just 3 real-time biofeedback sessions in healthy volunteers. Subsequently, a randomized controlled biofeedback trial was administered with DPD patients. Findings were not replicated as SCL tended to fall, curiously more substantially in the real-time condition, concomitant with increased low- and high-frequency heart rate variability. To further investigate abnormal autonomic regulation in DPD, we compared basal autonomic activity between patients and healthy volunteers and found the former to be significantly more labile, indexed by greater nonspecific SCRs and higher resting SCLs. Rather than low sympathetic arousal, DPD might be better characterized by abnormal autonomic regulation affecting emotional and physiological responsivity.

Serial and semantic encoding of lists of words in schizophrenia patients with visual hallucinations.

Previous research has suggested that visual hallucinations in schizophrenia are associated with abnormal salience of visual mental images. Since visual imagery is used as a mnemonic strategy to learn lists of words, increased visual imagery might impede the other commonly used strategies of serial and semantic encoding. We had previously published data on the serial and semantic strategies implemented by patients when learning lists of concrete words with different levels of semantic organisation (Brébion et al., 2004). In this paper we present a re-analysis of these data, aiming at investigating the associations between learning strategies and visual hallucinations. Results show that the patients with visual hallucinations presented less serial clustering in the non-organisable list than the other patients. In the semantically organisable list with typical instances, they presented both less serial and less semantic clustering than the other patients. Thus, patients with visual hallucinations demonstrate reduced use of serial and semantic encoding in the lists made up of fairly familiar concrete words, which enable the formation of mental images. Although these results are preliminary, we propose that this different processing of the lists stems from the abnormal salience of the mental images such patients experience from the word stimuli.

Belief models in first episode schizophrenia in South India.

BACKGROUND: Existing evidence indicates that dissonance between patients' and professionals' explanatory models affects engagement of patients with psychiatric services in Western and non-Western countries. AIMS: To assess qualitatively the explanatory models (EMs) of psychosis and their association with clinical variables in a representative sample of first episode patients with schizophrenia in South India. METHOD: One hundred and thirty one patients with schizophrenia presenting consecutively were assessed. Measures included the patient's explanatory models, and clinician ratings of insight, symptoms of psychosis, and functioning on standard scales. RESULTS: The majority of patients (70%) considered spiritual and mystical factors as the cause of their predicament; 22% held multiple models of illness. Patients who held a biomedical concept of disease had significantly higher scores on the insight scale compared to those who held non-medical beliefs. Multivariate analyses identified three factors associated with holding of spiritual/mystical models (female sex, low education and visits to traditional healers); and a single factor (high level of insight) for the endorsement of biological model. CONCLUSIONS: Patients with schizophrenia in this region of India hold a variety of non-medical belief models, which influence patterns of health seeking. Those holding non-medical explanatory models are likey to be rated as having less insight.

Assessing insight in schizophrenia: East meets West.

BACKGROUND: Lack of insight has been observed in people with schizophrenia across cultures but assessment of insight must take into account prevailing illness models. AIMS: To determine whether culturally specific and Western biomedical interpretations of insight and psychosis can be reconciled. METHOD: Patients with schizophrenia (n=131) were assessed during their first contact with psychiatric services in Vellore, South India. Patients' explanatory models, psychopathology and insight were investigated using a standard schedule translated into Tamil. RESULTS: Supernatural explanations of symptoms were frequent. Some insight dimensions were weakly associated (inversely) with severity of symptoms whereas preserved insight was associated with anxiety, help-seeking and perception of change. Willingness to attribute symptoms to disease, in others and in one's self, but not to supernatural forces was strongly associated with insight. CONCLUSIONS: The relationship between insight, awareness of illness and other clinical variables is similar in South India to elsewhere. However, the assessment of insight might have failed to capture locally accepted explanatory frameworks. An inclusive conceptual model which emphasises help-seeking is recommended.

Deriving meaning: Distinct neural mechanisms for metaphoric, literal, and non-meaningful sentences.

In this study, we used a novel cognitive paradigm and event-related functional magnetic resonance imaging (ER-fMRI) to investigate the neural substrates involved in processing three different types of sentences. Participants read either metaphoric (Some surgeons are butchers), literal (Some surgeons are fathers), or non-meaningful sentences (Some surgeons are shelves) and had to decide whether they made sense or not. We demonstrate that processing of the different sentence types relied on distinct neural mechanisms. Activation of the left inferior frontal gyrus (LIFG), BA 47, was shared by both non-meaningful and metaphoric sentences but not by literal sentences. Furthermore, activation of the left thalamus appeared to be specifically involved in deriving meaning from metaphoric sentences despite lack of reaction times differences between literals and metaphors. We assign this to the ad hoc concept construction and open-endedness of metaphoric interpretation. In contrast to previous studies, our results do not support the view the right hemispheric is specifically involved in metaphor comprehension.