Assessing the special need for protection of vulnerable refugees: testing the applicability of a screening method (RHS-15) to detect traumatic disorders in a refugee sample in Germany.

Objectives: Although EU member states are obligated to take special account of the situation of particularly vulnerable refugees, appropriate and specific measures to detect affected asylum seekers are not yet available. This study tries to pave the way for the implementation of an adequate instrument which at the same time assesses these needs of suffering people whilst responding to the need for mental health assessments specifically designed for refugees. This was done by testing the implementation of a screening method (Refugee Health Screener RHS-15) for trauma related mental health problems in refugees. Design: Two refugee samples in Germany (differing in arrival time: 126 applicants for asylum residing in the initial reception center and 116 living in long term communal accommodations) were assessed with the culturally sensitive Refugee Health Screener (RHS-15) to detect the incidence of mental health problems amongst them. Test fairness, reasonableness, susceptibility, transparency, acceptance, external design, utility and economy of the instrument were examined to check the applicability of the RHS-15 standardization test. Results: The RHS-15 indicates a good practical feasibility as the examination of the focused psychometric characteristics suggests. It became apparent, that implementing a screening procedure depends on political, legal and medical context factors that need to be considered. 2/3 of the participants had a positive screening result, which needs further diagnostic clarification in a second step. Conclusion: The RHS-15 seems to be practicable, economical, and rapidly deployable for the widespread detection of traumatic disorders in refugees living in Europe. The tool proved useful to aid diagnostic assessments and provide treatment to individuals in need, however the time of examination (resp. the duration of staying in the target land) influences the results.

Cognitive remediation for depressed inpatients: Results of a pilot randomized controlled trial.

OBJECTIVE: Neurocognitive deficits that persist despite antidepressive treatment and affect social and vocational functioning are well documented in major depressive disorder. Cognitive training approaches have proven successful in ameliorating these deficits in other psychiatric groups, but very few studies have been conducted in unipolar depressive patients by now. In contrast to previous studies solely including outpatients, effects of a cognitive remediation intervention on neurocognitive functioning of depressed inpatients were assessed by the present study. METHOD: A randomized controlled trial was carried out with 46 depressed inpatients of a psychiatric hospital. Patients were randomly assigned to either a control group that received standard drug and non-drug (cognitive behavioural, occupational, sports, relaxation and music therapy) antidepressive treatment or a remediation group that additionally received 12 sessions of cognitive training for a total of 4 weeks (three sessions per week). An intent to treat analysis and a last observation carried forward method was used for data analyses. RESULTS: Patients of the remediation group demonstrated greater improvements in neurocognitive measures of verbal and nonverbal memory, working memory and executive function (Cohen's d effect sizes between .52 and .98). CONCLUSIONS: These results provide preliminary evidence that cognitive remediation interventions can be successfully applied also in psychiatric inpatients experiencing an acute depressive episode.

Temporal unpredictability of a stimulus sequence affects brain activation differently depending on cognitive task demands.

Within cognitive neuroscience, in nearly every experimental setting, subjects are presented with stimuli that appear at either constant or variable points in time, referred to as interstimulus intervals (ISIs). These temporal patterns differ in the degree to which an exact stimulus onset may be predicted. We investigated whether this experimental feature affects brain and behavior, and whether the impact is modulated by the cognitive demands of a task. Subjects (N=26) were assessed via fMRI while solving three different tasks under either temporally predictable (constant ISI) or unpredictable (variable ISI) conditions. The tasks differed with regard to demands on working memory and response uncertainty. Compared to constant ISIs, variable (i.e., less predictable) ISIs led to a general increase in reaction time and in right amygdala activation. Depending on the cognitive demands required by the specific task, the left amygdala, the parietal cortex, the supplementary motor area, and the dorsolateral prefrontal cortex were engaged as well. The results indicate that the temporal structure in a stimulus sequence affects both overt and covert behaviors. Implicit temporal uncertainty increases activation in several brain regions depending on cognitive demands. Thus, an often-overlooked basic design feature, the application of constant or variable ISIs, may contribute to heterogeneity in cognitive neuroscience findings.

Relapse (number of detoxifications) in abstinent male alcohol-dependent patients as related to personality traits and types of tolerance to frustration.

BACKGROUND: Personality traits like depression on the one hand and aggression and impulsivity on the other are assumed to be predisposing factors for different types of alcohol dependence. Both types are associated with sensitivity to frustration, but this may be different for the two types of personality according to whether they are confronted with frustrations caused by withdrawal from positive or infliction of negative events. It has not been shown so far if both types of personality factors and the two different sources of frustration are differently relevant for the propensity of relapse. This was investigated here in a study on 60 abstinent male alcohol-dependent patients. METHODS: Correlations between the number of previous detoxifications reflecting liability to relapse and questionnaire scores on personality factors and on reactions to frustration were computed. RESULTS: Bonferroni-corrected correlations yielded significant relationships between the number of detoxifications and the personality factor of aggression as well as pronounced depressive reactions to frustrating conditions of non-reward caused by humans. Controlling for impulsivity, aggression and depression revealed that depressive reactions to frustration are genuine predictors for probability of relapse independent of underlying personality factors. Persons particularly sensitive to frustrations from human denial of positive reinforcers are liable to relapse which fits the theory of sensitivity to reward in drug-addicted individuals. CONCLUSION: Results demonstrate that relapse is clearly more related to aggression than to impulsivity, depression and anxiety and may be facilitated if persons are sensitive to frustrating conditions of non-reward caused by social partners.

Cognitive remediation improves cognition and good cognitive performance increases time to relapse--results of a 5 year catamnestic study in schizophrenia patients.

BACKGROUND: Cognitive deficits are stable features of schizophrenia that are linked to functional outcome. Cognitive remediation approaches have been proven successful in ameliorating these deficits, although effect sizes vary considerably. Whether cognitive deficits are serious predictors of clinical outcome is less clear. METHODS: Sixty patients suffering from schizophrenia were included in our sample, thirty of them received computer-assisted cognitive training, and thirty received occupational therapy. For a subsample of 55 patients, who could be traced over a period of five years after the end of the cognitive remediation intervention, time until first relapse and time in psychosis were determined retrospectively from their medical records. RESULTS: Cognitive remediation significantly improved problem solving, memory and attention with high effect sizes. Employment status, a post test verbal memory performance measure and a measure of executive functioning outperformed all other measures in the prediction of time to relapse, while allocation to treatment group outperformed all other variables in the prediction of both cognitive measures. CONCLUSIONS: Cognitive remediation of neurocognitive deficits thus makes sense in a twofold fashion: It enhances cognition directly and positively acts on clinical course indirectly via improved neurocognition. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00004880.

Functional connectivity in a monetary and social incentive delay task in medicated patients with schizophrenia.

Introduction: Numerous studies indicate impaired reward-related learning in individuals with schizophrenia, with various factors such as illness duration, medication, disease severity, and level of analysis (behavioral or neurophysiological data) potentially confounding the results. Patients with schizophrenia who are treated with second-generation antipsychotics have been found to have a less affected reward system. However, this finding does not explain the neural dysfunctions observed in previous studies. This study aimed to address the open question of whether the less impaired reward-related behavior is associated with unimpaired task-related functional connectivity or altered task-related functional connectivity. Methods: The study included 23 participants diagnosed within the schizophrenia spectrum and 23 control participants matched in terms of age, sex, and education. Participants underwent an MRI while performing a monetary incentive delay task and a social incentive delay task. The collected data were analyzed in terms of behavior and functional connectivity. Results: Both groups exhibited a main effect of reward type on behavioral performance, indicating faster reaction times in the social incentive delay task, but no main effect of reward level. Altered functional connectivity was observed in predictable brain regions within the patient group, depending on the chosen paradigm, but not when compared to healthy individuals. Discussion: In addition to expected slower response times, patients with schizophrenia demonstrated similar response patterns to control participants at the behavioral level. The similarities in behavioral data may underlie different connectivity patterns. Our findings suggest that perturbations in reward processing do not necessarily imply disturbances in underlying connectivities. Consequently, we were able to demonstrate that patients with schizophrenia are indeed capable of exhibiting goal-directed, reward-responsive behavior, although there are differences depending on the type of reward.

QLiS--development of a schizophrenia-specific quality-of-life scale.

BACKGROUND: The aim of the project was to develop an instrument for the assessment of subjective quality of life specific to schizophrenic persons on the basis of patients' views on their own life and on sound psychometric principles. METHODS: The project applied a six-step multiphase development process with six distinct studies. (1) The elicitation of schizophrenic persons' views on their quality of life was based on open-ended interviews with interviewees from different settings (acute ward inpatients, long-term care patients, community care patients; n = 268). (2) A cross-sectional study with schizophrenic and healthy persons was conducted to quantify the relative importance of the various aspect of quality of life that emerged from the qualitative study (n = 143). (3) We conducted an empirical comparison of response formats with schizophrenic persons (n = 32). (4) A scale construction- and reliability-testing study was performed (n = 203) as well as (5) a test-retest reliability study (n = 49). (6) The final questionnaire (QLiS, quality of life in schizophrenia) was tested in an additional study on convergent and discriminant validity (n = 135). RESULTS: The QLiS comprises 52 items (plus 2 optional items related to work) in 12 subscales: social contacts, appreciation by others, relationship to family, appraisal of pharmacotherapy, appraisal of psychopathological symptoms, cognitive functioning, abilities to manage daily living, appraisal of accommodation/housing, financial situation, leading a 'normal' life, confidence, general life-satisfaction. An item response format with four response categories was preferred by the schizophrenic persons. The mean values of the subscales clustered around the theoretical mean of the subscales and only minimal ceiling effects were found. The reliability (test-retest-reliability and internal consistency) was with one exception > .70 for all subscales. CONCLUSION: Taking the low numbers of items per subscale into account, the QLiS can be regarded as an accurate assessment instrument of subjective quality of life in schizophrenia with good content validity.

Sensory and motor encoding strategies in n-back tasks: a simulation of schizophrenic working memory deficits in healthy subjects.

AIMS: Different patterns of intact and disturbed working memory function can be observed in schizophrenic patients depending on the type of n-back task. We investigated whether these patterns can be induced in healthy subjects by experimentally preventing a motor encoding strategy. METHODS: Thirty-two healthy subjects were asked to solve 2 types of n-back task. In the continuous matching task, the subjects had to compare the present stimulus with the one occurring n stimuli back. In the continuous delayed response task (CDRT), the subjects had to select a response depending on the stimulus n stimuli back. Both types of n-back task are assumed to differ with respect to the encoding strategies that can be used to solve the tasks. The use of a motor strategy was prevented by a random arrangement of the target buttons. RESULTS: When the position of the target buttons was predictable, CDRT was solved faster and with higher accuracy than the continuous matching task. However, CDRT was solved more slowly and less accurately when the arrangement of the target buttons varied between the trials. This resulted in a comparable performance in both types of the n-back task. CONCLUSIONS: The behavioural alteration in schizophrenic patients in n-back tasks can be induced in healthy subjects by experimentally preventing the use of a motor encoding strategy.

Superior 'theory of mind' in borderline personality disorder: an analysis of interaction behavior in a virtual trust game.

To gain further insight into interpersonal dysfunction in Borderline Personality Disorder (BPD) we investigated the effects of emotional cues and the fairness of a social partner on the ability to infer other peoples' intentions in a virtual social exchange. 30 BPD patients and 30 nonpatients were asked to play a multiround trust game with four virtual trustees. The trustees varied in regard to fairness and presence of emotional facial cues which were both linked to repayment ratio. BPD patients adjusted their investment to the fairness of their partner. In contrast, nonpatients disregarded the trustees' fairness in the presence of emotional facial expressions. Both groups performed equally in an emotion recognition task and assessed the trustees' fairness comparably. When the unfair trustee provided emotional cues, BPD patients assessed their own behavior as more fair, while the lack of cues led patients to assess their own behavior as unfair. BPD patients are superior in the attribution of mental states to interaction partners when emotional cues are present. While the emotional expressions of a partner dominated the exchange behavior in nonpatients, BPD patients used the objective fairness of their social counterparts to guide their own behavior despite the existence of emotional cues.

Different Patterns of Mental Health Problems in Unaccompanied Refugee Minors (URM): A Sequential Mixed Method Study.

Unaccompanied refugee minors (URM) represent one of the most vulnerable refugee groups due to their young age, developmental status, and insufficient coping strategies. Clinical observations indicate that the frequency of mental health problems varies between different URM subgroups. In the present research project, clinical interviews as a source of qualitative data were combined with quantitative psychometric information in a mixed-method approach in order to study the patterns of mental health problems in 561 URM from four different language groups (Arabic, Farsi, Somali, and Tigrinya) immediately after arrival in the host country (Germany). Qualitative analysis obtained as differentiating categories "language, countries of origin, age, and gender"; quantitatively, the Refugee Health Screener (RHS-15) was applied. According to the positive screening results, the highest number of mental complaints was returned by children and adolescents speaking Farsi (65.9%) and Somali (65.8%). They were followed by URM speaking Arabic (49.4%) and Tigrinya (43.3%). The results were influenced not only by origin, but also by age (with higher burden among older Farsi-speaking URM) and gender (with higher burden among male URM). Although the prevalences in URM subgroups differ, the observed high rates of positive screening results in our sample of URM from Germany substantiate the need for early detection of mental complaints and appropriate mental health care for at least every second URM.

Executive functions and cognitive subprocesses in patients with obstructive sleep apnoea.

In recent years, special interest has been focused on impairments of executive functions in patients with obstructive sleep apnoea syndrome (OSAS). However, the majority of studies have not clearly separated deficits in executive functions from impairments in other cognitive processes involved in task solving. In the present study, working memory (WM) functions of 20 patients with OSAS were compared with those of 10 age-, sex- and education-matched healthy subjects. Cognitive functions were measured four times a day; each of these measurements was accompanied by an assessment of subjective and objective daytime sleepiness. To separate dysfunctions of WM from those of additionally involved processes, n-back tasks were applied embedded in a reaction-time-decomposition approach. Deficits in n-back tasks could be observed in OSAS patients in accuracy and reaction times. However, the slowing could already be observed in simple reaction time tasks. The drop in 1-back accuracy in the morning was related to daytime sleepiness. During the afternoon, accuracy of OSAS patients dropped in 2-back tasks, an effect which correlated neither with sleepiness nor with the extent of sleep apnoea or oxygen desaturation. In conclusion, our data reflect a complex perspective upon cognitive deficits in OSAS. Cross-group differences in processing time on the higher level WM task appeared to be attributable to slowing at a more elementary cognitive processing level. In contrast, reduced accuracy during the WM task in the OSAS group could not be explained by deficits in more elementary cognitive processes.

Perceived Intensity of Emotional Point-Light Displays is Reduced in Subjects with ASD.

One major characteristic of autism spectrum disorder (ASD) is problems with social interaction and communication. The present study explored ASD-related alterations in perceiving emotions expressed via body movements. 16 participants with ASD and 16 healthy controls observed video scenes of human interactions conveyed by point-light displays. They rated the valence of the depicted emotions in terms of their intensity and judged their confidence in their ratings. Results showed that healthy participants rated emotional interactions displaying positive emotionality as being more intense and were more confident about their ratings than ASD subjects. Results support the idea that patients with ASD have an altered perception of emotions. This extends research on subjective features (intensity, confidence) of emotion perception to the domain of emotional body movements and kinematics.

Activation-flow coupling differentiates between vascular and Alzheimer type of dementia.

The activation-flow coupling describes a mechanism, which adapts local cerebral blood flow in accordance with the underlying neuronal activity. It was suggested that the mechanism helps in differentiation between Alzheimer and vascular type of dementia. We combined EEG and Doppler techniques and assessed integrity of the activation-flow coupling in the occipital cortex utilizing a visual stimulation task. Alzheimer patients (MMSE: 18+/-8 points, DemTect 5+/-4 points) without signs of vascular lesions on a MRI scan and vascular demented patients (MMSE: 20+/-6 points, DemTect 6+/-3 points; MRI Fazekas score 7+/-3 points) were compared with data from an age-matched control group. Evoked flow velocity responses in the posterior cerebral artery were analysed according to a control system model specifying the parameters gain, attenuation, natural frequency and rate time. Evoked potentials were analysed for the N(75)-P(100) amplitude difference. Vascular demented patients exhibited a significant decreased gain parameter and increased attenuation parameter indicating severe cerebrovascular dysfunction. Also, the potential amplitudes were significantly decreased indicating neuronal damage due to the vascular disease process. Alzheimer patients did not differ in parameters as compared to the control group supporting other reports of intact occipital function at this stage of disease. Simultaneous assessment of electrical as well as vascular integrity might help in differentiating the most frequent forms of dementia.

Influence of vigilance and learning on prefrontal activation in schizophrenia.

BACKGROUND: Executive functions, which are neuroanatomically associated with the frontal lobe, are known to be impaired in schizophrenia. It is, however, still unclear whether the underlying functional disturbance is due to a hyper- or a hypoactivation of the dorsolateral prefrontal cortex (DLPFC) or neither. METHODS: To address this question, we examined the brain activation of 21 schizophrenic patients on atypical antipsychotic medication and 21 healthy control subjects during a mental maze task by means of fMRI. RESULTS: We found no significant overall difference in cerebral activation between the groups, but differences in the change in DLPFC activation from the first to the second half of the experiment. In the maze compared to the control task, there was a decrease in activation in the DLPFC in the patients and an almost significant increase in the controls. The change in activation in the patient group correlated with a change in subjective sleepiness, while the increase in activation in the controls could be attributed to learning processes. CONCLUSION: We hypothesized that differential temporal influences on brain activation could lead to either hyper- or hypoactivation of the DLPFC in schizophrenia.

Oxytocin modulates neural circuitry for social cognition and fear in humans.

In non-human mammals, the neuropeptide oxytocin is a key mediator of complex emotional and social behaviors, including attachment, social recognition, and aggression. Oxytocin reduces anxiety and impacts on fear conditioning and extinction. Recently, oxytocin administration in humans was shown to increase trust, suggesting involvement of the amygdala, a central component of the neurocircuitry of fear and social cognition that has been linked to trust and highly expresses oxytocin receptors in many mammals. However, no human data on the effects of this peptide on brain function were available. Here, we show that human amygdala function is strongly modulated by oxytocin. We used functional magnetic resonance imaging to image amygdala activation by fear-inducing visual stimuli in 15 healthy males after double-blind crossover intranasal application of placebo or oxytocin. Compared with placebo, oxytocin potently reduced activation of the amygdala and reduced coupling of the amygdala to brainstem regions implicated in autonomic and behavioral manifestations of fear. Our results indicate a neural mechanism for the effects of oxytocin in social cognition in the human brain and provide a methodology and rationale for exploring therapeutic strategies in disorders in which abnormal amygdala function has been implicated, such as social phobia or autism.

Acetylcholine esterase inhibitor donepezil improves dynamic cerebrovascular regulation in Alzheimer patients.

BACKGROUND: Alzheimer's disease (AD) leads to a degeneration of the nucleus basalis of Meynert and thus to decreased cholinergic tonus in the brain. The transcription of endothelial nitric oxide synthase depends on an adequate cholinergic innervation of microvessels and vasoregulative abnormalities have been reported in AD. We investigated activation-flow coupling to study the role of acetylcholine esterase inhibition (AChEI) on vasoregulative function. METHODS: A functional transcranial Doppler approach was used to measure the visually evoked flow velocity response in the posterior cerebral artery in AD patients who had no vascular risk factors. The diagnosis of AD was made according to the ICD10/DSMIIIR-criteria. After baseline recording the effect of four weeks 5mg donepezil and then four weeks 10 mg was investigated. Doppler data were evaluated with a control system approach to obtain dynamic properties of vasoregulation and were compared with a healthy control group. RESULTS: AD patients showed an increased damping (0.64 +/- 0.2; p = 0.007 vs. control) in evoked responses and lower resting flow velocity levels (40 +/- 13 cm/s; p = 0.06 vs. control), which were restored in a dose-dependent manner under AChEI (0.4 +/- 0.2; 44 +/- 11 cm/s). CONCLUSIONS: AD is associated with a functional vasoregulative deficit possibly due to decreased levels of the endothelial nitric oxide synthase. Augmenting levels with AChEI normalized flow regulation possibly leading to a better blood supply to active neurons.

Imaging gene-substance interactions: the effect of the DRD2 TaqIA polymorphism and the dopamine agonist bromocriptine on the brain activation during the anticipation of reward.

Dopamine is known as the main neurotransmitter modulating the activation of the reward system of the brain. The DRD2 TaqIA polymorphism is associated with dopamine D2 receptor density which plays an important role in the context of reward. Persons carrying an A1 allele have a lower D2 receptor density and a higher risk to show substance abuse. The present study was designed to investigate the influence of the DRD2 TaqIA polymorphism and the selective D2 receptor agonist bromociptine on the activation of the reward system by means of functional magnetic resonance imaging (fMRI). In a double-blind crossover study with 24 participants we found an increase of reward system activation from placebo to bromocriptine only in subjects carrying the A1 allele. Furthermore, only A1 carrier showed an increase of performance under bromocriptine. The results are interpreted as reflecting a specific sensitivity for dopamine agonists in persons carrying an A1 allele and may complement actual data and theories of the development of addiction disorders postulating a higher genetic risk for substance abuse in carrier of the A1 allele.

The bimodal P300 oddball component is decreased in patients with an adjustment disorder: An event-related potentials study.

OBJECTIVE: We found previously that use of a bimodal oddball design with synchronized pairs of audio-visual stimuli increased the sensitivity of the P300 wave to detect subclinical anxiety-depression in otherwise healthy subjects. Here, we wished to determine whether these P300 modulations would also be encountered when a clinical population comprised of patients with an adjustment disorder (AJD) was compared to healthy controls. METHOD: Two groups, each comprised of twenty-five participants (AJD patients, and controls; N=50) had to detect deviant stimuli among frequent stimuli in an oddball task by clicking on a button. Separate blocks involving audio (A), visual (V) or bimodal congruent (AV) stimuli were used and compared. RESULTS: P300 amplitudes of the control group were higher than those displayed by AJD patients, but only in the bimodal AV oddball task, while unimodal (visual or auditory) oddball tasks did not reveal any significant differences. CONCLUSIONS: The increased sensitivity of the bimodal P300 that we observed previously in subclinical anxiety-depression was also observed in AJD patients. SIGNIFICANCE: The impaired "bimodal congruence effect" in AJD suggests that these patients have altered integrative processes, which has potential implications for cognitive therapy.

[Asylum Law and Mental Health: An Interdisciplinary Analysis of the Coaction of Medical and Legal Aspects]. / Asylrecht und psychische Gesundheit: Eine interdisziplinäre Analyse des Zusammenwirkens medizinischer und juristischer Aspekte.

OBJECTIVE: Interdisciplinary analysis of the consequences of laws and legal practice for mental health conditions of asylum seekers and psychiatric care. METHODS: Based on the case study of a Kurdish woman with complex trauma-related psychiatric disorder, who had been in psychiatric hospital care for 25 months, the legal and medical facts are exposed, followed by a discussion referring to theoretical approaches from medical anthropology. RESULTS: Immigration laws and legal practice can have harmful consequences, which can be interpreted as "structural violence". CONCLUSION: In case of traumatized refugees, the coaction of legal and medical aspects has to be acknowledged seriously by the medical, legal and political parts involved.

Social Interaction Behavior in ADHD in Adults in a Virtual Trust Game.

OBJECTIVE: Social cognitive functions in adults with ADHD were investigated in a virtual social exchange game. METHOD: The sample consisted of 40 participants (20 adult ADHD participants, 20 healthy controls). Participants played a multiround trust game with virtual trustees who differed in regard to fairness and presence of emotional facial cues. RESULTS: Investments were higher in ADHD participants than in healthy participants except for partners who played fair with constant neutral expressions. ADHD patients did not adapt their behavior to the fairness of the trustee. In the presence of emotional facial cues, ADHD and healthy participants transferred more monetary units to happy rather than angry-looking trustees. Differences in investment behavior were not linked to deficits in emotion-recognition abilities or cognitive dysfunctions. CONCLUSION: Alterations in interaction behavior and in the formation of a general attitude toward social partners could be shown in adults with ADHD.