Entrustment decisions and the clinical team: A case study of early clinical students.

PURPOSE: Clinical learning contexts influence how medical students engage with entrustment decisions. However, it is unclear how students and health care team members perceive the entrustment decision process. This study explored which factors students and team members consider relevant to entrustment decisions in early clinical rotations. METHODS: The authors conducted a case study at an academic teaching hospital, interviewing 28 medical students and four health care team members during the clerkship year. Within a social constructivist epistemology, we explored students' and health care team members' perceptions of ad hoc entrustment decisions using semi-structured interviews. Transcripts from the interviews and notes from feedback rounds with students were used for analysis. RESULTS: Medical students in their core clerkship year perceived clinical residents as critical educational gatekeepers and key facilitators of entrustment decisions. Another important theme emerged around students' motivation, initiative and willingness to engage with the health care team and patients. Students actively engaged in trust formation processes with different health care team members. The entrustment decision process was perceived as multilateral and dynamic, involving all health care team members and patients. Multiple entrusting supervisors for clerkship students, including nurses and psychologists, emerged from our interview data. They assumed an active role in negotiating entrustment decisions both with and for clerkship students, either facilitating or hindering opportunities. The entrustment decisions emerged as a result of a multifaceted supervisor network interaction. CONCLUSIONS: Supervising residents' ability to integrate students into clinical teams seems to be a critical factor in facilitating entrustment opportunities for clinical activities. Students' active management of informal supervisor networks of health care team members and these team members' willingness to assume responsibility for the students' education emerged as relevant aspects for ad hoc entrustment. Our data suggest that supervision from different health professionals is beneficial for clinical education of medical students and merits further exploration.

Workplace-based assessments of entrustable professional activities in a psychiatry core clerkship: an observational study.

BACKGROUND: Entrustable professional activities (EPAs) in competency-based, undergraduate medical education (UME) have led to new formative workplace-based assessments (WBA) using entrustment-supervision scales in clerkships. We conducted an observational, prospective cohort study to explore the usefulness of a WBA designed to assess core EPAs in a psychiatry clerkship. METHODS: We analyzed changes in self-entrustment ratings of students and the supervisors' ratings per EPA. Timing and frequencies of learner-initiated WBAs based on a prospective entrustment-supervision scale and resultant narrative feedback were analyzed quantitatively and qualitatively. Predictors for indirect supervision levels were explored via regression analysis, and narrative feedback was coded using thematic content analysis. Students evaluated the WBA after each clerkship rotation. RESULTS: EPA 1 ("Take a patient's history"), EPA 2 ("Assess physical & mental status") and EPA 8 ("Document & present a clinical encounter") were most frequently used for learner-initiated WBAs throughout the clerkship rotations in a sample of 83 students. Clinical residents signed off on the majority of the WBAs (71%). EPAs 1, 2, and 8 showed the largest increases in self-entrustment and received most of the indirect supervision level ratings. We found a moderate, positive correlation between self-entrusted supervision levels at the end of the clerkship and the number of documented entrustment-supervision ratings per EPA (p < 0.0001). The number of entrustment ratings explained 6.5% of the variance in the supervisors' ratings for EPA 1. Narrative feedback was documented for 79% (n = 214) of the WBAs. Most narratives addressed the Medical Expert role (77%, n = 208) and used reinforcement (59%, n = 161) as a feedback strategy. Students perceived the feedback as beneficial. CONCLUSIONS: Using formative WBAs with an entrustment-supervision scale and prompts for written feedback facilitated targeted, high-quality feedback and effectively supported students' development toward self-entrusted, indirect supervision levels.

Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review.

BACKGROUND: Entrustable professional activities (EPAs) are increasingly used in undergraduate medical education (UME). We conducted a scoping review to summarize the evidence for the use of EPAs in clinical rotations in UME. METHODS: We searched multiple databases for scoping reviews based on the PRISMA guidelines for articles reporting qualitative and quantitative research, as well as conceptual and curriculum development reports, on EPAs in UME clinical rotations. RESULTS: We identified 3309 records by searching through multiple databases. After the removal of duplicates, 1858 reports were screened. A total of 36 articles were used for data extraction. Of these, 47% reported on EPA and EPA-based curriculum development for clerkships, 50% reported on implementation strategies, and 53% reported on assessment methods and tools used in clerkships. Validity frameworks for developing EPAs in the context of clerkships were inconsistent. Several specialties reported feasible implementation strategies for EPA-based clerkship curricula, however, these required additional faculty time and resources. Limited exposure to clinical activities was identified as a barrier to relevant learning experiences. Educators used nationally defined, or specialty-specific EPAs, and a range of entrustability and supervision scales. We found only one study that used an empirical research approach for EPA assessment. One article reported on the earlier advancement of trainees from UME to graduate medical education based on summative entrustment decisions. CONCLUSIONS: There is emerging evidence concerning how EPAs can be effectively introduced to clinical training in UME. Specialty-specific, nested EPAs with context-adapted, entrustment-supervision scales might be helpful in better leveraging their formative assessment potential.

Introducing a Psychiatry Clerkship Curriculum Based on Entrustable Professional Activities: an Explorative Pilot Study.

OBJECTIVE: The authors evaluated a reformed psychiatry clerkship curriculum based on entrustable professional activities (EPAs). METHODS: The authors conducted an exploratory pilot study of a reformed clerkship curriculum based on EPAs. A novel workplace-based assessment format including an entrustment-supervision scale and curricular adaptations were introduced. The Kirkpatrick model was used to evaluate outcomes of the reformed clerkship curriculum on three levels (1 = acceptance, 2 = learning, 3 = change of behavior). RESULTS: The pilot student cohort (n = 10) completed a questionnaire, 180 self-assessments (18 per student) on need for supervision, and 63 workplace-based assessments (6.3 per student, in 4 weeks). Level 1: high overall satisfaction with the clerkship (five-point Likert item: average, 4.9; range: 4.0-5.0). Level 2: the overall significant decrease in self-assessed need for supervision before and after the clerkship was two supervision levels (direct to indirect supervision; p < 0.05). The most frequently documented admissions included schizophrenic disorders (n = 11; 28%), affective disorders (n = 10; 25%), substance abuse disorders (n = 5; 13%), and anxiety and stress-related disorders (n = 5; 13%). Level 3: clinical supervisors used history taking, assessing the mental status, and documentation and presentation for workplace-based assessments. According to supervisors' ratings, there was a decreasing need for supervision from the first to last week of the clerkship. CONCLUSIONS: Students reacted positively to the reformed clerkship curriculum. The workplace-based assessments with entrustment ratings appeared to support achievement of competency-based learning objectives. Better understanding of how to cover assessment of all core EPAs in the psychiatry clerkship is needed.

Entrustable Professional Activities in Psychiatry: A Systematic Review.

OBJECTIVE: Entrustable professional activities (EPAs) represent discrete clinical tasks that can be entrusted to trainees in psychiatry. They are increasingly being used as educational framework in several countries. However, the empirical evidence available has not been synthesized in the field of psychiatry. Therefore, the authors conducted a systematic review in order to summarize and evaluate the available evidence in the field of EPAs in undergraduate and graduate medical education in psychiatry. METHODS: The authors searched PubMed, Cochrane Library, ERIC, Embase, PsycINFO, all Ovid journals, Scopus, Web of Science, MedEdPORTAL, and the archives of Academic Psychiatry for articles reporting quantitative and qualitative research as well as educational case reports on EPAs in undergraduate and graduate psychiatry education published since 2005. All included articles were assessed for content (development, implementation, and assessment of EPAs) and quality using the Quality Assessment Tool for Studies with Diverse Designs. RESULTS: The authors screened 2807 records and included a total of 20 articles in the final data extraction. Most studies were expert consensus reports (n = 6, 30%) and predominantly conducted in English-speaking countries (n = 17, 85%). Papers reported mainly EPA development and/or EPA implementation studies (n = 14, 70%), whereas EPA assessment studies were less frequent (n = 6, 30%). Publications per year showed an increasing trend both in quantity (from 1 in 2011 to 7 in 2018) and quality (from a QATSDD score of 27 in 2011 to an average score of 39 in 2018). The main focus of the articles was the development of individual EPAs for different levels of training for psychiatry or on curricular frameworks based on EPAs in psychiatry (n = 10, 50%). The lack of empirical controlled studies does currently not allow for meta-analyses of educational outcomes. CONCLUSIONS: The concept of EPA-based curricula seems to become increasingly present, a focus in the specialty of psychiatry both in UME and GME. The lack of empirical research in this context is an important limitation for educational practice recommendations. Currently there is only preliminary but promising data available for using EPAs with regard to educational outcomes. EPAs seem to be effectively used from a curriculum design perspective for UME and GME in psychiatry.

Glucocorticoid administration restores salience network activity in patients with spider phobia.

BACKGROUND: Glucocorticoids reduce phobic fear in patients with anxiety disorders. Although the neurobiology of anxiety disorders is not fully understood, convergent structural and functional neuroimaging studies have identified abnormalities in various brain regions, including those in the salience network (SN) and default mode network (DMN). Here, we examine the effects of glucocorticoid administration on SN and DMN activity during the processing of phobic stimuli. METHODS: We use functional magnetic resonance imaging to record brain activity in 24 female patients with spider phobia who were administered either 20 mg of cortisol or placebo while viewing pictures of spiders. Fourteen healthy female participants were tested with the same task but without substance administration. Independent component analysis (ICA) performed during stimulus encoding identified the SN and DMN as exhibiting synchronized activation in diverse brain regions; thus, we examined the effects of cortisol on these networks. Furthermore, participants had to rate their level of fear at various time points. RESULTS: Glucocorticoids reduced phobic fear in patients with spider phobia. The ICA performed during stimulus encoding revealed that activity in the SN and DMN was reduced in placebo-treated patients versus healthy controls. Brain activity in the SN, but not the DMN, was altered in cortisol- versus placebo-treated patients to a level that was similar to that observed in healthy controls. CONCLUSIONS: Activity in both the SN and DMN was reduced in patients with spider phobia. Cortisol administration altered the SN activity to a level that was comparable to that found in healthy controls. This alteration in SN activity might reflect the fear-reducing effects of glucocorticoids in phobia.

White matter correlates of the disorganized speech dimension in schizophrenia.

Disorganized speech is related to functional abnormalities in schizophrenia. To test the association between formal thought disorders (FTDs) and white matter microstructure, we applied a behavioral rating and diffusion tensor imaging in 61 patients with schizophrenia spectrum disorders. The Bern Psychopathology Scale was used to rate the dimension of language abnormalities ranging from negative FTDs, basically unaltered speech, to positive FTDs. Tract-based spatial statistics indicated increased fractional anisotropy in left hemispheric pathways of the language system in patients with negative FTDs. Thus, altered white matter properties in relevant fiber tracts may represent vulnerability to specific formal thought disorders.

Psychosis Is Mutable over Time: A Longitudinal Psychopathology Study.

BACKGROUND: A neurobiologically informed, system-specific psychopathological approach has been suggested for use in schizophrenia. However, to our knowledge, such an approach has not been used to prospectively describe the course of schizophrenia. SAMPLING AND METHODS: We assessed psychopathology in a well-described sample of 100 patients with schizophrenia or schizoaffective disorder with the Bern Psychopathology Scale (BPS) at 6-month intervals for up to 18 months. The BPS groups symptoms into the 3 domains language, affectivity and motor behaviour; each domain is rated as being normal, inhibited or disinhibited. In addition, we collected qualitative psychopathological data in the form of case reports. RESULTS: Forty-eight patients completed at least 2 assessments over the course of at least 1 year. Of these, 16 patients (33.3%) showed a bipolar course pattern (i.e., a switch from inhibited to disinhibited or vice versa) in 1 domain and 6 patients (12.5%) in more than 1 domain. Shifts from 1 dominant domain to another were seen frequently (n = 20, 41.7%), but shifts between 1 dominant domain and a combination of dominant domains were more common (n = 33, 68.8%). CONCLUSIONS: The course of schizophrenia is heterogeneous and shows frequent changes in psychopathology. This should be taken into account in the communication with patients and in the research on underlying illness mechanisms and treatment. A major limitation of this study is the small sample size.

Systems Neuroscience of Psychosis: Mapping Schizophrenia Symptoms onto Brain Systems.

Schizophrenia research has been in a deadlock for many decades. Despite important advances in clinical treatment, there are still major concerns regarding long-term psychosocial reintegration and disease management, biological heterogeneity, unsatisfactory predictors of individual course and treatment strategies, and a confusing variety of controversial theories about its etiology and pathophysiological mechanisms. In the present perspective on schizophrenia research, we first discuss a methodological pitfall in contemporary schizophrenia research inherent in the attempt to link mental phenomena with the brain: we claim that the time-honored phenomenological method of defining mental symptoms should not be contaminated with the naturalistic approach of modern neuroscience. We then describe our Systems Neuroscience of Psychosis (SyNoPsis) project, which aims to overcome this intrinsic problem of psychiatric research. Considering schizophrenia primarily as a disorder of interindividual communication, we developed a neurobiologically informed semiotics of psychotic disorders, as well as an operational clinical rating scale. The novel psychopathology allows disentangling the clinical manifestations of schizophrenia into behavioral domains matching the functions of three well-described higher-order corticobasal brain systems involved in interindividual human communication, namely, the limbic, associative, and motor loops, including their corticocortical sensorimotor connections. The results of several empirical studies support the hypothesis that the proposed three-dimensional symptom structure, segregated into the affective, the language, and the motor domain, can be specifically mapped onto structural and functional abnormalities of the respective brain systems. New pathophysiological hypotheses derived from this brain system-oriented approach have helped to develop and improve novel treatment strategies with noninvasive brain stimulation and practicable clinical parameters. In clinical practice, the novel psychopathology allows confining the communication deficits of the individual patient, shifting attention from the symptoms to the intact resources. We have studied this approach and observed important advantages for therapeutic alliances, personalized treatment, and de-escalation strategies. Future studies will further conjoin clinical definitions of psychotic symptoms with brain structures and functions, and disentangle structural and functional deficit patterns within these systems to identify neurobiologically distinct subsyndromes. Neurobiologically homogeneous patient groups may provide new momentum for treatment research. Finally, lessons learned from schizophrenia research may contribute to developing a comprehensive perspective on human experience and behavior that integrates methodologically distinct, but internally consistent, insights from humanities and neuroscience.

Gesture Performance in First- and Multiple-Episode Patients with Schizophrenia Spectrum Disorders.

BACKGROUND/AIM: Gesturing plays an important role in social behavior and social learning. Deficits are frequent in schizophrenia and may contribute to impaired social functioning. Information about deficits during the course of the disease and presence of severity and patterns of impairment in first-episode patients is missing. Hence, we aimed to investigate gesturing in first- compared to multiple-episode schizophrenia patients and healthy controls. METHODS: In 14 first-episode patients, 14 multiple-episode patients and 16 healthy controls matched for age, gender and education, gesturing was assessed by the comprehensive Test of Upper Limb Apraxia. Performance in two domains of gesturing - imitation and pantomime - was recorded on video. Raters of gesture performance were blinded. RESULTS: Patients with multiple episodes had severe gestural deficits. For almost all gesture categories, performance was worse in multiple- than in first-episode patients. First-episode patients demonstrated subtle deficits with a comparable pattern. CONCLUSIONS: Subjects with multiple psychotic episodes have severe deficits in gesturing, while only mild impairments were found in first-episode patients independent of age, gender, education and negative symptoms. The results indicate that gesturing is impaired at the onset of disease and likely to further deteriorate during its course.

Disturbances of Agency and Ownership in Schizophrenia: An Auditory Verbal Event Related Potentials Study.

A 'sense of self' is essentially the ability to distinguish between self-generated and external stimuli. It consists of at least two very basic senses: a sense of agency and a sense of ownership. Disturbances seem to provide a basic deficit in many psychiatric diseases. The aim of our study was to manipulate those qualities separately in 28 patients with schizophrenia (14 auditory hallucinators and 14 non-hallucinators) and 28 healthy controls (HC) and to investigate the effects on the topographies and the power of the event-related potential (ERP). We performed a 76-channel EEG while the participants performed the task as in our previous paper. We computed ERPs and difference maps for the conditions and compared the amount of agency and ownership between the HC and the patients. Furthermore, we compared the global field power and the topographies of these effects. Our data showed effects of agency and ownership in the healthy controls and the hallucinator group and to a lesser degree in the non-hallucinator group. We found a reduction of the N100 during the presence of agency, and a bilateral temporal negativity related to the presence of ownership. For the agency effects, we found significant differences between HC and the patients. Contrary to the expectations, our findings were more pronounced in non-hallucinators, suggesting a more profoundly disturbed sense of agency compared to hallucinators. A contemporary increase of global field power in both patient groups indicates a compensatory recruitment of other mechanisms not normally associated with the processing of agency and ownership.

Catatonia.

One of the most exciting psychiatric conditions is the bizarre psychomotor syndrome called catatonia, which may present with a large number of different motor signs and even vegetative instability. Catatonia is potentially life threatening. The use of benzodiazepines and electroconvulsive therapy (ECT) has been efficient in the majority of patients. The rich clinical literature of the past has attempted to capture the nature of catatonia. But the lack of diagnostic clarity and operationalization has hampered research on catatonia for a long time. Within the last decades, it became clear that catatonia had to be separated from schizophrenia, which was finally accomplished in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In DSM-5, catatonia syndrome may be diagnosed as a specifier to major mood disorders, psychotic disorders, general medical conditions, and as catatonia not otherwise specified. This allows diagnosing the syndrome in a large variety of psychiatric disorders. Currently, the pathobiology remains widely unknown. Suspected neurotransmitter systems include gamma-aminobutyric acid (GABA) and glutamate. Neuroimaging reports pointed to reduced resting state activity and reduced task activation in motor areas of the frontal and parietal cortex. The new classification of catatonia will foster more clinical research and neuroscientific approaches by testing catatonia in various populations and applying stringent criteria. The scarce number of prospective trials will hopefully increase, as more trials will be encouraged within a more precise concept of catatonia.

Psychopathological Course Typology in Schizophrenia Spectrum Disorders: A Heuristic Approach in a Sample of 100 Patients.

BACKGROUND: Despite several previous attempts at subtyping schizophrenia, a typology that reflects neurobiological knowledge and reliably predicts course and outcome is lacking. We applied the system-specific concept of the Bern Psychopathology Scale (BPS) to generate a course typology based on three domains: language, affectivity, and motor behaviour. SAMPLING AND METHODS: A cohort of 100 patients with schizophrenia or schizoaffective disorders according to DSM-IV criteria underwent psychopathological assessment, and all their available medical records were retrospectively analysed on the basis of the BPS. RESULTS: Overall, 39% of the patients showed dominant abnormalities in only one domain, 37% in two domains, and 24% in all three domains. The motor domain was affected in the majority of patients (76%), followed by affectivity (63%) and language (46%). Eighty-six percent of patients showed a bipolar course pattern in at least one domain. CONCLUSIONS: In a retrospective analysis of 100 patient records we described system-specific course patterns of schizophrenia by using a neurobiologically informed psychopathological assessment. The results showed a surprisingly high proportion of bipolar courses and a pattern of pure and mixed subtypes, which speaks for an overlap of domains with regards to psychopathological symptoms. A limitation of this heuristic and retrospective approach is that it was largely based on clinical judgement. Prospective studies with more rigorous threshold definitions are needed to clarify the neurobiological and clinical implications of the proposed reorganization of psychotic disorders.

Rivalry of homeostatic and sensory-evoked emotions: Dehydration attenuates olfactory disgust and its neural correlates.

Neural correlates have been described for emotions evoked by states of homeostatic imbalance (e.g. thirst, hunger, and breathlessness) and for emotions induced by external sensory stimulation (such as fear and disgust). However, the neurobiological mechanisms of their interaction, when they are experienced simultaneously, are still unknown. We investigated the interaction on the neurobiological and the perceptional level using subjective ratings, serum parameters, and functional magnetic resonance imaging (fMRI) in a situation of emotional rivalry, when both a homeostatic and a sensory-evoked emotion were experienced at the same time. Twenty highly dehydrated male subjects rated a disgusting odor as significantly less repulsive when they were thirsty. On the neurobiological level, we found that this reduction in subjective disgust during thirst was accompanied by a significantly reduced neural activity in the insular cortex, a brain area known to be considerably involved in processing of disgust. Furthermore, during the experience of disgust in the satiated condition, we observed a significant functional connectivity between brain areas responding to the disgusting odor, which was absent during the stimulation in the thirsty condition. These results suggest interference of conflicting emotions: an acute homeostatic imbalance can attenuate the experience of another emotion evoked by the sensory perception of a potentially harmful external agent. This finding offers novel insights with regard to the behavioral relevance of biologically different types of emotions, indicating that some types of emotions are more imperative for behavior than others. As a general principle, this modulatory effect during the conflict of homeostatic and sensory-evoked emotions may function to safeguard survival.

Magnetic resonance spectroscopy investigations of functionally defined language areas in schizophrenia patients with and without auditory hallucinations.

BACKGROUND: Cerebral dysfunction occurring in mental disorders can show metabolic disturbances which are limited to circumscribed brain areas. Auditory hallucinations have been shown to be related to defined cortical areas linked to specific language functions. Here, we investigated if the study of metabolic changes in auditory hallucinations requires a functional rather than an anatomical definition of their location and size to allow a reliable investigation by magnetic resonance spectroscopy (MRS). METHODS: Schizophrenia patients with (AH; n=12) and without hallucinations (NH; n=8) and healthy controls (HC; n=11) underwent a verbal fluency task in functional MRI (fMRI) to functionally define Broca's and Wernicke's areas. Left and right Heschl's gyri were defined anatomically. RESULTS: The mean distances in native space between the fMRI-defined regions and a corresponding anatomically defined area were 12.4±6.1 mm (range: 2.7-36.1 mm) for Broca's area and 16.8±6.2 mm (range: 4.5-26.4 mm) for Wernicke's area, respectively. Hence, the spatial variance was of similar extent as the size of the investigated regions. Splitting the investigations into a single voxel examination in the frontal brain and a spectroscopic imaging part for the more homogeneous field areas led to good spectral quality for almost all spectra. In Broca's area, there was a significant group effect (p=0.03) with lower levels of N-acetyl-aspartate (NAA) in NH compared to HC (p=0.02). There were positive associations of NAA levels in the left Heschl's gyrus with total (p=0.03) and negative (p=0.006) PANSS scores. In Broca's area, there was a negative association of myo-inositol levels with total PANSS scores (p=0.008). CONCLUSION: This study supports the neurodegenerative hypothesis of schizophrenia only in a frontal region whereas the results obtained from temporal regions are in contrast to the majority of previous studies. Future research should test the hypothesis raised by this study that a functional definition of language regions is needed if neurochemical imbalances are expected to be restricted to functional foci.

Rapid tranquilization of severely agitated patients with schizophrenia spectrum disorders: a naturalistic, rater-blinded, randomized, controlled study with oral haloperidol, risperidone, and olanzapine.

INTRODUCTION: Agitation is a major problem in acute schizophrenia. Only a few studies have tested antipsychotic agents in severely agitated patients, mainly because of legal issues. Furthermore, most studies were limited to the first 24 hours. We aimed to investigate the efficacy of oral haloperidol, risperidone, and olanzapine in reducing psychotic agitation in severely agitated patients with schizophrenia or schizophreniform or schizoaffective disorder over 96 hours using a prospective, randomized, rater-blinded, controlled design within a naturalistic treatment regimen. METHODS: In total, 43 severely agitated patients at acute care psychiatric units were enrolled. Participants were randomly assigned to receive either daily haloperidol 15 mg, olanzapine 20 mg, or risperidone 2 to 6 mg over 5 days. Positive and Negative Syndrome Scale psychotic agitation subscale score was the primary outcome variable. A mixed-model analysis was applied. RESULTS: All drugs were effective for rapid tranquilization within 2 hours. Over 5 days, the course differed between agents (P < 0.001), but none was superior. Dropouts occurred only in the risperidone and olanzapine groups. Men responded better to treatment than did women during the initial 2 hours (P = 0.046) as well as over the 5-day course (P < 0.001). No difference between drug groups was observed regarding diazepam or biperiden use. CONCLUSIONS: Oral haloperidol, risperidone, and olanzapine seem to be suitable for treating acute severe psychotic agitation in schizophrenia spectrum disorders. Response to oral antipsychotics demonstrated a gender effect with poorer outcome in women throughout the study.

Glucocorticoids enhance in vivo exposure-based therapy of spider phobia.

BACKGROUND: Preclinical and clinical studies indicate that the administration of glucocorticoids may promote fear extinction processes. In particular, it has been shown that glucocorticoids enhance virtual reality based exposure therapy of fear of heights. Here, we investigate whether glucocorticoids enhance the outcome of in vivo exposure-based group therapy of spider phobia. METHODS: In a double blind, block-randomized, placebo-controlled, between-subject study design, 22 patients with specific phobia of spiders were treated with two sessions of in vivo exposure-based group therapy. Cortisol (20 mg) or placebo was orally administered 1 hr before each therapy session. Patients returned for a follow-up assessment one month after therapy. RESULTS: Exposure-based group therapy led to a significant decrease in phobic symptoms as assessed with the Fear of Spiders Questionnaire (FSQ) from pretreatment to immediate posttreatment and to follow-up. The administration of cortisol to exposure therapy resulted in increased salivary cortisol concentrations and a significantly greater reduction in fear of spiders (FSQ) as compared to placebo at follow-up, but not immediately posttreatment. Furthermore, cortisol-treated patients reported significantly less anxiety during standardized exposure to living spiders at follow-up than placebo-treated subjects. Notably, groups did not differ in phobia-unrelated state-anxiety before and after the exposure sessions and at follow-up. CONCLUSIONS: These findings indicate that adding cortisol to in vivo exposure-based group therapy of spider phobia enhances treatment outcome.

Agency and ownership are independent components of 'sensing the self' in the auditory-verbal domain.

'Sensing the self' relies on the ability to distinguish self-generated from external stimuli. It requires functioning mechanisms to establish feelings of agency and ownership. Agency is defined causally, where the subjects action is followed by an effect. Ownership is defined by the features of the effect, independent from the action. In our study, we manipulated these qualities separately. 13 right-handed healthy individuals performed the experiment while 76-channel EEG was recorded. Stimuli consisted of visually presented words, read aloud by the subject. The experiment consisted of six conditions: (a) subjects saw a word, read it aloud, heard it in their own voice; (b) like a, but the word was heard in an unfamiliar voice; (c) subject heard a word in his/her own voice without speaking; (d) like c, but the word was heard in an unfamiliar voice; (e) like a, but subjects heard the word with a delay; (f) subjects read without hearing. ERPs and difference maps were computed for all conditions. Effects were analysed topographically. The N100 (86-172 ms) displayed significant main effects of agency and ownership. The topographies of the two effects shared little common variance, suggesting independent effects. Later effects (174-400 ms) of agency and ownership were topographically similar, suggesting common mechanisms. Replicating earlier studies, significant N100 suppression was observed, with a topography resembling the agency effect. 'Sensing the self' appears to recruit from at least two very distinct processes: an agency assessment that represents causality and an ownership assessment that compares stimulus features with memory content.

Self-efficacy as a predictor of outcome after residential treatment programs for alcohol dependence: simply ask the patient one question!

BACKGROUND: Self-efficacy has been identified as one of the most consistent variables that predict the outcome of alcohol treatment. However, many previous studies in this field failed to control for other important predictors (e.g., dependences severity, psychiatric symptoms, and treatment goal). Our study's first goal was to evaluate the predictive value of self-efficacy when most other relevant variables were statistically controlled. The second goal was to compare the predictive values of self-efficacy assessed with the Situational Confidence Questionnaire (SCQ), and general self-efficacy assessed with a single question. METHODS: Four hundred and fifteen patients with alcohol dependence from 12 residential alcohol use disorder (AUD) treatment programs were assessed at treatment admission, discharge, and the 1-year follow-up. A stepwise logistic regression for abstinence was calculated using all predictors. For those predictors that were significant, a Cox survival regression analysis was performed to predict the time to the first drink after discharge. RESULTS: Only abstinence as treatment goal, alcohol use during treatment, and general self-efficacy as measured by 1 question were revealed to be significant predictors in the stepwise regression, whereas all other variables, including self-efficacy as measured by the SCQ, were not significantly associated with abstinence at the 1-year follow-up. Cox survival regression analysis showed a significant difference in the time to first alcohol use between patients with maximum general self-efficacy and those with lower general self-efficacy, when the other 2 significant variables were controlled for. CONCLUSIONS: General self-efficacy, that is, the patients' own prognosis of his success in remaining abstinent, was a central variable in predicting residential alcohol dependence treatment outcome. Self-efficacy showed a more accurate prognosis of outcome when it was assessed with just 1 question, than when assessed with the SCQ. With this simplified assessment, knowledge of the prognostic value of self-efficacy could be made applicable for everyday practice.

Computational analysis on verbal fluency reveals heterogeneity in subjective language interests and brain structure.

Language is an essential higher cognitive function in humans and is often affected by psychiatric and neurological disorders. Objective measures like the verbal fluency test are often used to determine language dysfunction. Recent applications of computational approaches broaden insights into language-related functions. In addition, individuals diagnosed with a psychiatric or neurological disorder also often report subjective difficulties in language-related functions. Therefore, we investigated the association between objective and subjective measures of language functioning, on the one hand, and inter-individual structural variations in language-related brain areas, on the other hand. We performed a Latent Semantic analysis (LSA) on a semantic verbal fluency task in 101 healthy adult participants. To investigate if these objective measures are associated with a subjective one, we examined assessed subjective natural tendency of interest in language-related activity with a study-specific questionnaire. Lastly, a voxel-based brain morphometry (VBM) was conducted to reveal associations between objective (LSA) measures and structural changes in language-related brain areas. We found a positive correlation between the LSA measure cosine similarity and the subjective interest in language. Furthermore, we found that higher cosine similarity corresponds to higher gray matter volume in the right cerebellum. The results suggest that people with higher interests in language access semantic knowledge in a more organized way exhibited by higher cosine similarity and have larger grey matter volume in the right cerebellum, when compared to people with lower interests. In conclusion, we demonstrate that there is inter-individual diverseness of accessing the semantic knowledge space and that it is associated with subjective language interests as well as structural differences in the right cerebellum.