Associations of thalamocortical networks with reduced mindfulness in alcohol use disorder.

Background: Increased mindfulness is associated with reduced alcohol consumption in patients with alcohol use disorder (AUD) after residential treatment. However, the underlying neurobiological mechanism of mindfulness in AUD is unclear. Therefore, we investigate the structural and functional alterations of the thalamocortical system with a focus on the mediodorsal thalamic nucleus (MD-TN), the default mode and the salience network (DMN/SN) which has previously been associated with mindfulness in healthy subjects. We hypothesized lower mindfulness and reduced structural and functional connectivity (FC) of the thalamocortical system, particularly in the DMN/SN in AUD. We assumed that identified neurobiological alterations in AUD are associated with impairments of mindfulness. Methods: Forty-five abstinent patients with AUD during residential treatment and 20 healthy controls (HC) were recruited. Structural and resting-state functional MRI-scans were acquired. We analysed levels of mindfulness, thalamic volumes and network centrality degree of the MD-TN using multivariate statistics. Using seed-based whole brain analyses we investigated functional connectivity (FC) of the MD-TN. We performed exploratory correlational analyses of structural and functional DMN/SN measurements with levels of mindfulness. Results: In AUD we found significantly lower levels of mindfulness, lower bilateral thalamic and left MD-TN volumes, reduced FC between MD-TN and anterior cingulum/insula and lower network centrality degree of the left MD-TN as compared to HC. In AUD, lower mindfulness was associated with various reductions of structural and functional aspects of the MD-TN. Conclusion: Our results suggest that structural and functional alterations of a network including the MD-TN and the DMN/SN underlies disturbed mindfulness in AUD.

Effects of Sustained Competitive Employment on Psychiatric Hospitalizations and Quality of Life.

OBJECTIVE: There is extensive evidence for the effectiveness of supported employment among people with severe mental illness. However, less research has been conducted to evaluate the effects of sustained competitive employment on nonvocational outcomes. The aim of this study was to evaluate the effects of sustained competitive work on quality of life and psychiatric hospitalizations. METHODS: As part of a randomized controlled trial, a mediation analysis was used to compare the direct and indirect effects of supported employment versus a traditional vocational program on sustained competitive employment, days of psychiatric hospitalization, and quality of life among 85 participants over five years. RESULTS: The five-year follow-up indicated that the effects of supported employment on reduced days of hospitalization and increased quality of life were fully mediated by the program's effects on increasing sustained competitive employment. CONCLUSIONS: The rehabilitative and therapeutic dimensions of functional health conditions are interrelated in the long term. The achievement of sustained competitive employment may be a key factor in improving social and psychiatric outcomes for people with severe and persistent mental disorders.

Nonverbal Synchrony in Social Interactions of Patients with Schizophrenia Indicates Socio-Communicative Deficits.

BACKGROUND: Disordered interpersonal communication can be a serious problem in schizophrenia. Recent advances in computer-based measures allow reliable and objective quantification of nonverbal behavior. Research using these novel measures has shown that objective amounts of body and head movement in patients with schizophrenia during social interactions are closely related to the symptom profiles of these patients. In addition to and above mere amounts of movement, the degree of synchrony, or imitation, between patients and normal interactants may be indicative of core deficits underlying various problems in domains related to interpersonal communication, such as symptoms, social competence, and social functioning. METHODS: Nonverbal synchrony was assessed objectively using Motion Energy Analysis (MEA) in 378 brief, videotaped role-play scenes involving 27 stabilized outpatients diagnosed with paranoid-type schizophrenia. RESULTS: Low nonverbal synchrony was indicative of symptoms, low social competence, impaired social functioning, and low self-evaluation of competence. These relationships remained largely significant when correcting for the amounts of patients' movement. When patients showed reduced imitation of their interactants' movements, negative symptoms were likely to be prominent. Conversely, positive symptoms were more prominent in patients when their interaction partners' imitation of their movements was reduced. CONCLUSIONS: Nonverbal synchrony can be an objective and sensitive indicator of the severity of patients' problems. Furthermore, quantitative analysis of nonverbal synchrony may provide novel insights into specific relationships between symptoms, cognition, and core communicative problems in schizophrenia.

Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial.

OBJECTIVE: The individual placement and support model of supported employment has been shown to be more effective than other vocational approaches in improving competitive work over 1-2 years in persons with severe mental illness. The authors evaluated the longer-term effects of the model compared with traditional vocational rehabilitation over 5 years. METHOD: A randomized controlled trial compared supported employment to traditional vocational rehabilitation in 100 unemployed persons with severe mental illness. Competitive work and hospital admissions were tracked for 5 years, and interviews were conducted at 2 and 5 years to assess recovery attitudes and quality of life. A cost-benefit analysis compared program and total treatment costs to earnings from competitive employment. RESULTS: The beneficial effects of supported employment on work at 2 years were sustained over the 5-year follow-up period. Participants in supported employment were more likely to obtain competitive work than those in traditional vocational rehabilitation (65% compared with 33%), worked more hours and weeks, earned more wages, and had longer job tenures. Reliance on supported employment services for retaining competitive work decreased from 2 years to 5 years for participants in supported employment. Participants were also significantly less likely to be hospitalized, had fewer psychiatric hospital admissions, and spent fewer days in the hospital. The social return on investment was higher for supported employment participants, whether calculated as the ratio of work earnings to vocational program costs or of work earnings to total vocational program and mental health treatment costs. CONCLUSIONS: The results demonstrate that the greater effectiveness of supported employment in improving competitive work outcomes is sustained beyond 2 years and suggest that supported employment programs contribute to reduced hospitalizations and produce a higher social return on investment.

Time-series panel analysis (TSPA): multivariate modeling of temporal associations in psychotherapy process.

OBJECTIVE: Processes occurring in the course of psychotherapy are characterized by the simple fact that they unfold in time and that the multiple factors engaged in change processes vary highly between individuals (idiographic phenomena). Previous research, however, has neglected the temporal perspective by its traditional focus on static phenomena, which were mainly assessed at the group level (nomothetic phenomena). To support a temporal approach, the authors introduce time-series panel analysis (TSPA), a statistical methodology explicitly focusing on the quantification of temporal, session-to-session aspects of change in psychotherapy. TSPA-models are initially built at the level of individuals and are subsequently aggregated at the group level, thus allowing the exploration of prototypical models. METHOD: TSPA is based on vector auto-regression (VAR), an extension of univariate auto-regression models to multivariate time-series data. The application of TSPA is demonstrated in a sample of 87 outpatient psychotherapy patients who were monitored by postsession questionnaires. Prototypical mechanisms of change were derived from the aggregation of individual multivariate models of psychotherapy process. In a 2nd step, the associations between mechanisms of change (TSPA) and pre- to postsymptom change were explored. RESULTS: TSPA allowed a prototypical process pattern to be identified, where patient's alliance and self-efficacy were linked by a temporal feedback-loop. Furthermore, therapist's stability over time in both mastery and clarification interventions was positively associated with better outcomes. CONCLUSIONS: TSPA is a statistical tool that sheds new light on temporal mechanisms of change. Through this approach, clinicians may gain insight into prototypical patterns of change in psychotherapy.

Video-based quantification of body movement during social interaction indicates the severity of negative symptoms in patients with schizophrenia.

In schizophrenia, nonverbal behavior, including body movement, is of theoretical and clinical importance. Although reduced nonverbal expressiveness is a major component of the negative symptoms encountered in schizophrenia, few studies have objectively assessed body movement during social interaction. In the present study, 378 brief, videotaped role-play scenes involving 27 stabilized outpatients diagnosed with paranoid-type schizophrenia were analyzed using Motion Energy Analysis (MEA). This method enables the objective measuring of body movement in conjunction with ordinary video recordings. Correlations between movement parameters (percentage of time in movement, movement speed) and symptom ratings from independent PANSS interviews were calculated. Movement parameters proved to be highly reliable. In keeping with predictions, reduced movement and movement speed correlated with negative symptoms. Accordingly, in patients who exhibited noticeable movement for less than 20% of the observation time, prominent negative symptoms were highly probable. As a control measure, the percentage of movement exhibited by the patients during role-play scenes was compared to that of their normal interactants. Patients with negative symptoms differed from normal interactants by showing significantly reduced head and body movement. Two specific positive symptoms were possibly related to movement parameters: suspiciousness tended to correlate with reduced head movement, and the expression of unusual thought content tended to relate to increased movement. Overall, a close and theoretically meaningful association between the objective movement parameters and the symptom profiles was found. MEA appears to be an objective, reliable and valid method for quantifying nonverbal behavior, an aspect which may furnish new insights into the processes related to reduced expressiveness in schizophrenia.

Lack of concordance between subjective improvement and symptom change in psychotic episodes.

OBJECTIVES: Subjective, self-rated improvement in patients with schizophrenia spectrum disorders can carry significance as a first-person account of treatment outcome, and can be of importance for the individual patient's acceptance of further treatment, including psychological treatments. This study assessed the concordance between post-treatment subjective improvement and the observed symptom change after a psychotic episode. DESIGN: Longitudinal study based on daily symptom ratings. METHOD: The study sample consisted of 43 younger, primarily first- or second-episode patients. Observed symptom change was calculated as both pre-post differences and symptom trajectories. Subjective improvement was assessed at the end of treatment by using the 'Emotional and Behavioural Changes in Psychotherapy Questionnaire' (VEV), a retrospective measure of subjective change. RESULTS: The findings indicated no significant concordance between pre-post differences in symptoms and self-rated improvement, nor were final levels of symptoms related to subjective improvement. Higher initial and mean symptom levels for positive symptoms were related to a lower degree of subjective improvement. A shorter duration of an initial trend-like improvement in psychosis was shown to be associated with greater subjective improvement. CONCLUSIONS: Subjective assessment of improvement may differ markedly from symptom change. In psychotic episodes, more severe initial positive symptoms as well as a delayed improvement of positive symptoms may be related to a reduced subjective experience of improvement for the duration of the entire episode. The treatment of psychosis should take a possible discordance between subjective and objective change into account.

Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods.

The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.

Perception of causality in schizophrenia spectrum disorder.

Patients with schizophrenia spectrum disorders often maintain deviating views on cause-effect relationships, especially when positive and disorganization symptoms are manifest. Altered perceived causality is prominent in delusional ideation, in ideas of reference, and in the mentalizing ability (theory of mind [ToM]) of patients. Perceiving causal relationships may be understood either as higher order cognitive reasoning or as low-level information processing. In the present study, perception of causality was investigated as a low-level, preattentional capability similar to gestalt-like perceptual organization. Thirty-one patients (24 men and 7 women with mean age 27.7 years) and the same number of healthy control subjects matched to patients with respect to age and sex were tested. A visual paradigm was used in which 2 identical discs move, from opposite sides of a monitor, steadily toward and then past one another. Their coincidence generates an ambiguous, bistable percept (discs either "stream through" or "bounce off" one another). The bouncing perception, ie, perceived causality, is enhanced when auditory stimuli are presented at the time of coincidence. Psychopathology was measured using the Positive and Negative Syndrome Scale. It was found that positive symptoms were strongly associated with increased perceived causality and disorganization with attenuated perceived causality. Patients in general were not significantly different from controls, but symptom subgroups showed specifically altered perceived causality. Perceived causality as a basic preattentional process may contribute to higher order cognitive alterations and ToM deficiencies. It is suggested that cognitive remediation therapy should address both increased and reduced perception of causality.

[Predictive factors of successful vocational re-integration in patients with chronic schizophrenia]. / Prädiktive Faktoren einer erfolgreichen beruflichen Wiedereingliederung von schizophrenen Patienten.

OBJECTIVE: Vocational re-integration of patients with chronic schizophrenia remains even with the help of comprehensive integration programs a very ambitious aim. Therefore, a profound and up-to-date knowledge of vocational outcome predictors is imperative. The objective of the present study was, while minimizing the influence of the instruments used, to generate factors, which predict best the re-integration outcome. METHOD: In a sample of 76 chronic schizophrenia patients ten relevant factors were derived from a factor analysis including 32 variables. In a second step the predictive value of these ten factors centering on vocational outcome were tested by logistic regression analysis. RESULTS: Participants who had a successful outcome showed a good vocational capacity before and during the two-week assessment phase, had no social deficits and no depressive-resignative coping strategies. Schizophrenia symptoms and cognitive deficits, however, were of minor relevance. CONCLUSIONS: The results of our factor-analytic approach confirm earlier findings that vocational functioning observed in a sheltered setting and social competence are the best predictors for successful vocational rehabilitation. Moreover, they serve to substantiate the necessity of developing therapeutic programs that enhance patients' hopefulness and self-confidence.

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program.

BACKGROUND: Vocational rehabilitation is a central issue in the rehabilitation of patients with chronic schizophrenia. However, even with the help of comprehensive integration programs, achieving this objective remains a very ambitious and difficult undertaking. Therefore, a profound and up-to-date knowledge of vocational functioning and outcome predictors in patients who have the goal to return into competitive employment is imperative. The objective of the present study was to test the predictors summarized in the recent review of Cook and Razzano, as well as to test those predictors specified in the nine hypotheses put forward by Anthony and Jansen in schizophrenia patients enrolled in a vocational rehabilitation program. METHODS: The predictive value of ten hypotheses centering on vocational functioning and outcome were consecutively tested in a sample of 53 schizophrenia patients. Those predictors identified as significant were then taken into a 'winner take all' regression in order to determine which of them were the best. RESULTS: The overall work performance observed in a workshop proved to be the best predictor of vocational functioning. Contrary to the pivotal claim in Anthony and Jansen's review, in our sample, negative symptoms indeed influenced vocational functioning, outcome and functional skills. Cognitive impairments, social competence and fatalistic control beliefs also had predictive value for vocational functioning and outcome. CONCLUSIONS: These results reflect the accumulated findings of the past decade as summarized by Cook and Razzano. Moreover, they serve to substantiate the necessity of promoting the concept of cognitive remediation and associated programs designed to transform fatalistic beliefs into feelings of hopefulness, thereby enhancing the readiness of schizophrenia patients to enroll in rehabilitation programs.

Time series models of symptoms in schizophrenia.

The symptom courses of 84 schizophrenia patients (mean age: 24.4 years; mean previous admissions: 1.3; 64% males) of a community-based acute ward were examined to identify dynamic patterns of symptoms and to investigate the relation between these patterns and treatment outcome. The symptoms were monitored by systematic daily staff ratings using a scale composed of three factors: psychoticity, excitement, and withdrawal. Patients showed moderate to high symptomatic improvement documented by effect size measures. Each of the 84 symptom trajectories was analyzed by time series methods using vector autoregression (VAR) that models the day-to-day interrelations between symptom factors. Multiple and stepwise regression analyses were then performed on the basis of the VAR models. Two VAR parameters were found to be associated significantly with favorable outcome in this exploratory study: 'withdrawal preceding a reduction of psychoticity' as well as 'excitement preceding an increase of withdrawal'. The findings were interpreted as generating hypotheses about how patients cope with psychotic episodes.

Symptom trajectories in psychotic episodes.

Whereas the cross-sectional structure of schizophrenic symptoms has been studied extensively, little is known about the development of symptoms during acute episodes. In this study, symptom trajectories of 46 schizophrenia spectrum patients were examined based on daily observation during an average treatment period of 104 days. A novel time series approach was used to identify initial phases of response and other descriptive features of the trajectories. The results yielded five dynamical factors: (1) overall level of positive symptoms, (2) duration of nonspecific response, (3) slope of response in all symptom domains, (4) enduring negative symptoms, and (5) duration of response regarding psychoticity. Compared to patients with an acute schizophrenia-like psychotic disorder, schizophrenia and schizoaffective disorder patients ranked higher in factor 4 (enduring negative symptoms). They tended towards a lower level of positive symptoms and showed a less prominent response to treatment. The examination of a subsample of 19 patients with relapse indicated a prolonged duration of initial treatment response regarding psychoticity. The results support the validity of this approach for the description of symptom trajectories.