Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial.

Importance: Persistent paranoia is common among patients with psychosis. Cognitive-behavioral therapy for psychosis can be effective. However, challenges in engagement and effectiveness remain. Objective: To investigate the effects on paranoia and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only. Design, Setting, and Participants: This parallel-arm, assessor-blinded, randomized clinical trial recruited participants at UK community health services from May 1, 2017, to May 14, 2019. Eligible participants consisted of a referral sample with schizophrenia-spectrum psychosis and distressing, persistent (≥3 months) paranoia. Interventions: Individuals were randomized 1:1 to SlowMo, consisting of 8 digitally supported face-to-face sessions and a mobile app, plus usual care (n = 181) and usual care only (n = 181). Main Outcomes and Measures: The primary outcome was paranoia, measured by the Green et al Paranoid Thoughts Scale (GPTS) total score at 24 weeks. Secondary outcomes included GPTS total score at 12 weeks and GPTS Part A (reference) and Part B (persecutory) scores, the Psychotic Symptom Rating Scales (PSYRATS Delusion subscale), reasoning (belief flexibility, possibility of being mistaken [Maudsley Assessment of Delusions, rated 0%-100%]), and jumping to conclusions (Beads Task). Results: A total of 361 participants were included in intention-to-treat analysis, of whom 252 (69.8%) were male and 249 (69.0%) were White; the mean (SD) age was 42.6 (11.6) years. At 24 weeks, 332 participants (92.0%) provided primary outcome data. Of 181 participants in the SlowMo group, 145 (80.1%) completed therapy. SlowMo plus usual care was not associated with greater reductions than usual care in GPTS total score at 24 weeks (Cohen d, 0.20; 95% CI, -0.02 to 0.40; P = .06). There were significant effects on secondary paranoia outcomes at 12 weeks, including GPTS total score (Cohen d, 0.30; 95% CI, 0.09-0.51; P = .005), Part A score (Cohen d, 0.22; 95% CI, 0.06-0.39; P = .009), and Part B score (Cohen d, 0.32; 95% CI, 0.08-0.56; P = .009), and at 24 weeks, including Part B score (Cohen d, 0.25; 95% CI, 0.01-0.49; P = .04) but not Part A score (Cohen d, 0.12; 95% CI, -0.05 to 0.28; P = .18). Improvements were observed in an observer-rated measure of persecutory delusions (PSYRATS delusion) at 12 weeks (Cohen d, 0.47; 95% CI, 0.17-0.78; P = .002) and 24 weeks (Cohen d, 0.50; 95% CI, 0.20-0.80; P = .001) and belief flexibility at 12 weeks (Cohen d, 0.29; 95% CI, 0.09-0.49; P = .004) and 24 weeks (Cohen d, 0.28; 95% CI, 0.08-0.49; P = .005). There were no significant effects on jumping to conclusions. Improved belief flexibility and worry mediated paranoia change (range mediated, 36%-56%). Conclusions and Relevance: SlowMo did not demonstrate significant improvements in the primary measure of paranoia at 24 weeks; however, a beneficial effect of SlowMo on paranoia was indicated by the results on the primary measure at an earlier point and on observer-rated paranoia and self-reported persecution at 12 and 24 weeks. Further work to optimize SlowMo's effects is warranted. Trial Registration: isrctn.org Identifier: ISRCTN 32448671.

Do cognitive schema mediate the association between childhood trauma and being at ultra-high risk for psychosis?

Exposure to childhood trauma has been associated with psychotic symptoms, being at ultra-high risk for psychosis (UHR), and psychotic disorders such as schizophrenia. Negative self-beliefs have been shown to partially mediate the relationship between childhood trauma and paranoia and have been shown to be characteristic of patients with psychosis. However, whether the association between childhood trauma and being at high risk of developing psychosis (e.g., UHR) and paranoia symptoms is mediated by altered cognitive schema is unknown and warrants investigation to inform preventive interventions. Data was collected on 30 UHR patients from Outreach and Support in South London about exposure to childhood trauma, cognitive schema, paranoia and cannabis use. Relative to healthy controls (n = 38), UHR patients were significantly more likely to report exposure to various types of childhood trauma (emotional and sexual abuse, and emotional and physical neglect), had more negative schema and less positive schema about themselves and others, and were more likely to use cannabis more than once a month. Emotional neglect was found to be significantly associated with UHR status even after controlling for the effects of previous exposure to cannabis use (b = 0.262, 95% CI: 0.115-0.408), and this association was partially mediated by negative self-schema (b = 0.045, 95% CI: 0.004-0.159). Similarly, emotional neglect was significantly associated with paranoia (b = 1.354, 95% CI: 0.246-2.462), and this association was partially mediated by negative self-schema (b = 0.988, 95% CI: 0.323-1.895). These findings provide preliminary evidence about the cognitive mechanisms that may underlie the association between childhood trauma and later risk for psychosis.

Paraphrenia: paranoid states of late life. I. European research.

American psychiatry has traditionally viewed late-life paranoid states either as rare or not part of the schizophrenic syndrome. European psychiatry has not subscribed to this view. The literature (chiefly European) is reviewed from the standpoints of history of the disorder, diagnostic reliability, pre-onset sensory loss, the multiple determinants of paranoia, and the response of paraphrenic patients to treatment with phenothiazines. The evidence leads to the conclusion that late-life paranoid states are not rare, and that the diagnosis "paraphrenia" has real clinical utility. Moreover, there seems to be a substantial relationship between schizophrenia and paraphrenia.

Time trends in first admissions for schizophrenia and paranoid psychosis in Stockholm County, Sweden.

Several studies have reported decreasing time trends in first diagnosed schizophrenia patients. The aim of this study was to analyze time trends for first admissions with a diagnosis of schizophrenia or a diagnosis of either schizophrenia or paranoid psychosis during 1978-1994 in Stockholm County, Sweden, with a population of around 1.8million. Information about first psychiatric admission with the diagnosis schizophrenia or paranoid psychosis for residents of Stockholm County was obtained from the Swedish population-based psychiatric inpatient register. Age-adjusted average yearly changes in first hospitalization rates were estimated in a Poisson regression model. Time trends in first admission rates were calculated from 1978 to 1994, while admissions during 1971 to 1977 were observed only to eliminate later re-admissions. First admissions for schizophrenia declined by 1.9% annually for females and by 1.3% for males, while first admissions for schizophrenia and paranoid psychosis together were unchanged over the study period for both genders. Our results indicate that the incidence of schizophrenia and paranoid psychosis taken together was essentially the same over the studied time period in Stockholm County, and that the apparent decline in first admission rates for schizophrenia may be an effect of changes in clinical diagnosis over time.

Nonschizophrenic paranoid syndromes.

After presenting their model for the description of delusions, the authors report some results of two catamnestic studies in patients with delusional syndromes. There is evidence for the hypothesis that the usual classification of such patients as paranoid schizophrenics is frequently not justified. A reasonable number of the cases might belong to cyclothymia or at least approach it. Disappearance of delusions and complete restitution frequently occur in this group, while chronicity seems connected with persistent psychopathological signs in the accompanying symptomatology supposed to represent--in part--organic brain syndromes or congenital or acquired psychopathic personalities.

Outcome in schizophrenic and similar paranoid psychoses.

A 5-year followup study of patients with schizophrenic or paranoid psychoses was performed using standardized instruments. Less than half of the patients had a poor global outcome. Several findings from other recent outcome studies were replicated. Besides data on occupational history and psychiatric hospitalization, psychopathological characteristics assessed at discharge by psychiatrists' ratings and patients' self-ratings proved to have predictive value.

Is paranoid status prognostic of good outcomes? It depends.

Better outcomes for psychiatric inpatients classified as paranoid rather than nonparanoid could be due to group differences in disability levels created by traditional classification approaches. Paranoid functioning, per se, may not predict good institutional outcomes. The authors retrieved community outcome data for 469 inpatients from 19 wards, a subsample of participants that had been previously examined during their inpatient stay. Paranoid groups showed better community outcomes as an artifact of differences in disability levels when classifications were based on the traditional approach that requires a predominance of paranoid over nonparanoid behavior. No differential outcomes appeared when classifications were based on dimensionally measured paranoid functioning alone. In fact, dispositions of patients suggest that staff view paranoid behavior as a negative rather than positive prognostic indicator.

The severely mentally ill in general hospital psychiatric units.

Analysis of data from the NIMH Survey of Discharges from Non-Federal General Hospitals found that severely mentally ill patients (those with schizophrenia, other psychoses, paranoia, and major affective disorders) became an increasingly larger proportion of general hospital discharges between 1970 and 1980, with more change observed between 1975 and 1980. This seems to confirm that general hospital care is replacing at least some of the care previously provided in State mental hospitals. There has been an increase in beds in nongovernment-owned general hospitals and a decrease in beds in state hospitals. In addition, while discharge referrals from government general hospitals for severe patients were made predominantly to state hospitals in 1970, in 1980 this was rarely the case.

Intervention in psychosocial decompensation of the elderly in poor neighbourhoods in Jerusalem.

In learning to understand the particular problems of old age, in focusing our attention on losses and decompensation, we developed an approach which was concrete and situational rather than (life-long) developmental. In most cases, brief crisis-orientated interventions were sufficient to reduce symptomatology and restore the patient to a healthier level of functioning. Such interventions involved not only the psychogeriatric team but other health and social agencies as well. More so than in other fields of psychiatry, psychogeriatrics concerns itself with a wide spectrum of psychosocial factors; thus the integration of the pyschogeriatric unit into the existing network of community services becomes and important concern.

[An interesting example of procedural and therapeutic failure]. / Ciekawy przyklad porazki proceduralnej i terapeutycznej.

Forty-eighth-year old woman experienced paranoid syndrome for the first time. Her twenty-seven-year old daughter, living with her, adopted pathological sensations. The patient was hospitalized by order of court. The ruling was based on the patient's husband's application and a psychiatrist's certificate. The daughter of the patient still maintained her pathological beliefs, adopted from her ill mother. What is more, similar beliefs were adopted by the second, twenty-eighth-year old daughter. Hospitalization lasted only 11 days because the husband withdrew his application and, by order of court, the patient was discharged from hospital. She now lives with two psychotically induced daughters and her husband, who is under great psychical pressure in such circumstances.

Lack of motivation for treatment in emergency psychiatry patients.

BACKGROUND: A lack of motivation for treatment on the part of patients is a major problem for emergency psychiatric services. Little is known about its determinants. The aim of this study was to investigate determinants of treatment motivation in emergency psychiatric patients. METHOD: A cross-sectional study of 719 patients was made. Motivation for treatment and other clinical variables were assessed using the Severity of Psychiatric Illness scale and the Brief Psychiatric Rating Scale. RESULTS: In all, 47% of patients were not motivated for treatment and they also had severe clinical problems. Lack of motivation was associated with danger to others [odds ratio (OR) 2.03; confidence interval (CI) 1.21-3.40], substance abuse (OR 1.71; CI 1.09-2.67), suspiciousness (OR 1.4; CI 1.19-1.64), grandiosity (OR 1.19; CI 1.01-1.4), anxiety (OR 0.74; CI 0.64-0.86), and GAF score (OR 0.98; CI 0.96-0.99). CONCLUSIONS: Lack of motivation for treatment is a common phenomenon among severely mentally ill patients seen by emergency psychiatric services. Lack of motivation was associated with danger and paranoid symptoms. Motivational techniques as well as involuntary treatment may help to overcome problems due to lack of motivation in these patients.

[A holiday with psychiatric long-term patients (author's transl)]. / Ein Ferienaufenthalt mit psychiatrischen Langzeitpatienten.

Following predominantly favourable earlier experiences with holiday trips, eleven long-term hospitalized patients of sociopsychiatric ward (an institution concerned with the gradual transition from psychiatric treatment to social rehabilitation) went on a one week's trip together with the ward personnel, emphasis being on the aspect of recreation. The patients themselves took over the organization of the daily schedules. Marked improvements in mood levels, a decrease in disturbances of well-being, and increased activity were clearly noticeable. These were probably due to relief from the clinic's daily routine and to the intensification of interactions within the patient group and with the therapists. Although these changes did not persist in most patients after their return, a positive effect for further therapy planning was seen in at least four of them. This experience report concludes with a suggestion to include such trips in the proposed treatment schedule for long-term patients.

[Dispensary treatment of endogenous psychoses from the viewpoint of the psychiatrist in ambulatory care]. / Dispensairebehandlung endogener Psychosen aus der Sicht des ambulant tätigen Psychiaters.

Reviewing the results of the observation of 72 patients suffering from endogenic psychoses during a period of 11 years the author tries to demonstrate the advantages of a basis-near, i.e. near to the places of living and employment, therapy for psychically sick persons. The necessity of long-term therapy is emphasized.

[Relevant predictors of the 5 year outcome of patients with schizophrenic or similar paranoid psychoses (author's transl)]. / Relevante Merkmale für die 5-Jahres-Prognose von Patienten mit schizophrenen und verwandten paranoiden Psychosen.

In a 5 year follow-up study of 81 patients suffering from schizophrenic or similar psychoses many of the predictors known from the literature concerning the outcome of schizophrenia were confirmed. In accordance with the results of the follow-up study on patients from the International Pilot Study of Schizophrenia (IPSS), long lasting professional disintegration and psychiatric hospitalisation preceding index-admission were of special prognostic importance. However in contrast to this follow-up study, other psychopathological data, especially minus symptoms proved to be of considerable prognostic significance. As a result of stepwise multiple regression analyses, combinations of the 5 best characteristics for each outcome-criterion have been found which explain a significantly greater part of the variance than single characteristics.