How do psychiatrists address delusions in first meetings in acute care? A qualitative study.

BACKGROUND: Communicating about delusions can be challenging, particularly when a therapeutic relationship needs to be established in acute care. So far, no systematic research has explored how psychiatrists address patients' delusional beliefs in first meetings in acute care. The aim of this study was to describe how psychiatrists address patients' delusional experiences in acute in-patient care. METHODS: First meetings between five psychiatrists and 14 patients in acute care were audio-recorded and analysed using thematic content analysis. RESULTS: 296 psychiatrist statements about delusions were identified and coded. Three commonly used approaches (with a total of 6 subthemes) were identified. The most common approaches were eliciting the content (1 subtheme: eliciting content and evidence) and understanding the impact (3 subthemes: identifying emotions, exploring links with dysfunctional behaviour and discussing reasons for hospital admission) while questioning the validity of the beliefs (2 subthemes: challenging content and exploring alternative explanations) was less common. The last approach sometimes put patients in a defensive position. CONCLUSIONS: Psychiatrists commonly use three approaches to address patients' delusions in the first meeting in acute in-patient care. Questioning the patients' beliefs can lead to disagreement which might hinder establishing a positive therapeutic relationship. Future research should explore the impact of such an approach on outcomes and specify to what extent questioning the validity of delusional beliefs is appropriate in the first meeting.

Insight and awareness as related to psychopathology and cognition.

BACKGROUND: Insight affects adherence and treatment outcome and relates to cognitive impairment and psychopathology. We investigated the relationship of insight with cognition in patients with major depression, schizophrenia and bipolar disorder in acute psychiatric care, long-term inpatient, and outpatient settings. METHODS: Eighty-one patients (women, 59.5%; age, 45.9 ± 13.5 years; 27 in each setting group; 33.3% with DSM-IV bipolar disorder, 39.5% with unipolar major depression, and 27.2% with schizophrenia) underwent the Wisconsin Card Sorting Test (WCST) to test flexibility, clinician-rated Scale to Assess Unawareness of Mental Disorder (SUMD), and self-rated Insight Scale (IS) to assess insight/awareness. RESULTS: Poor performance on the WCST correlated with higher SUMD scores such as current psychiatric illness unawareness, impaired symptom attribution, unawareness of medication effect, or of social consequences, but not with IS scores. The latter correlated with days on continuous treatment. Patients receiving psycho-education showed greater symptom awareness compared to patients treated with drugs alone. Cognitive flexibility and diagnostic category did not correlate. Poor insight corresponded with severe mental illness, particularly acute psychosis. CONCLUSIONS: Treatment setting specificity reflects psychopathology and severity. Insight is inversely proportional to illness severity and cognitive flexibility, which is also affected by psychopathology. Limitations comprise group heterogeneity, cross-sectional design, and limited sample size.

[Chronic Koro-like Syndrome (KLS) in recurrent depressive disorder as a variant of Cotard's delusion in an italian male patient. A case report and historical review]. / Un caso di Koro-Like Syndrome (KLS) cronica, come variante di un delirio di Cotard, in un paziente italiano affetto da depressione monopolare cronica. Presentazione del caso clinico con revisione storica della letteratura.

Cotard's syndrome is a delusional syndrome, first described in the 1880ies by Cotard, characterized by a nihilistic delusions about the self and/or the world. In same other cases there is an intense nihilistic belief that the patient's entire body or parts of it are disintegrated or dead. The syndrome is often associated with severe depression, but are also described neurological cases. Koro was described a little later from Asia and consisted in the belief that one's own genitalia are shrinking or disappearing and death will ensue thereafter, but there are many cultural variants and the syndrome may present in an incomplete form. We report on a KLS sharing more features with annihilation delusions, such as Cotard's syndrome. In KLS, the délire de négation may be limited to localized systems or organs. We believe that some complete and incomplete forms of Koro, when embedded in a depressive core, may represent a variant of Cotard's delusion. In fact, our patient did not reach a complete denial of his entire body, but rather focused on sexual identity. We analysed the psychosexual issues of our case according to Kretschmer's 1918 view of a "bipolar setting" between sthenic and asthenic characters of a patient suffering from sensitive delusions of (self-) reference. This view may allow us to relate the personological character to the genetic comprehensibility of the delusion.

Unrealistic self-overconfidence in schizophrenia is associated with left presubiculum atrophy and impaired episodic memory.

The study aimed at investigating the role of the hippocampal subfields in cognitive insight and the clinical and neuropsychological underpinnings of the related two sub-dimensions, Self-Reflectiveness (SR), i.e., openness to external feedback, and Self-Certainty (SC), i.e., unrealistic overconfidence in one's opinions. In order to do this, 45 patients with a diagnosis of schizophrenia and 45 age- and gender-matched healthy control subjects (HC) were administered the Beck Cognitive Insight Scale (BCIS), along with neuropsychological, clinical and psychopathological assessment, and underwent an MRI investigation. Hippocampal segmentation was carried out. Regression analyses were performed for BCIS indexes, volumetric parameters of hippocampal subfields and clinical and neuropsychological variables. Results highlighted that in the schizophrenia group, higher levels of SC were related to reduced volume of the left presubiculum, and worse episodic memory. No significant relationship emerged for the SR index. There was no significant relationship between any of the BCIS indexes and volumetric data of the hippocampal subfields in the HC group. Our data support the hypothesis that unrealistic self-overconfidence in schizophrenia is related to the hippocampal presubiculum atrophy, which is involved in episodic memory and cognitive control and is supposed to be underpinned by difficulty in integrating new memories and thus in generating new hypotheses about the self.