Alternation in functional connectivity within default mode network after psychodynamic psychotherapy in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is characterized by impairments in emotion regulation, impulse control, and interpersonal and social functioning along with a deficit in emotional awareness and empathy. In this study, we investigated whether functional connectivity (FC) within the default mode network (DMN) is affected by 1-year psychodynamic psychotherapy in patients with BPD. METHODS: Nine BPD patients filled out the demography, Interpersonal Reactive Index (IRI), Toronto Alexithymia Scale 20 (TAS 20), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and the Borderline Evaluation Severity over Time (BEST) questionnaire. The BPD group (9F) and the control group (9F) had a mean ± SD age of 28.2 ± 5.3 years and 30.4 ± 6.1 years, respectively. BPD subjects underwent longitudinal resting-state fMRI before psychodynamic psychotherapy and then every 4 months for a year after initiating psychotherapy. FC in DMN was characterized by calculating the nodal degree, a measure of centrality in the graph theory. RESULTS: The results indicated that patients with BPD present with aberrant DMN connectivity compared to healthy controls. Over a year of psychotherapy, the patients with BPD showed both FC changes (decreasing nodal degree in the dorsal anterior cingulate cortex and increasing in other cingulate cortex regions) and behavioral improvement in their symptoms and substance use. There was also a significant positive association between the decreased nodal degree in regions of the dorsal cingulate cortex and a decrease in the score of the TAS-20 indicating difficulty in identifying feelings after psychotherapy. CONCLUSION: In BPD, there is altered FC within the DMN and disruption in self-processing and emotion regulation. Psychotherapy may modify the DMN connectivity and that modification is associated with positive changes in BPD emotional symptoms.

COVID-19 vaccination hesitancy is not all a conspiracy theory: A qualitative study from Iran.

BACKGROUND: The COVID-19 pandemic has burdened disastrous mortality and morbidity rates in society all over the world. While vaccination is one of the most effective immunization methods to control infectious diseases globally, some have avoided receiving the vaccine. We have aimed to investigate the reasons behind the hesitancy of vaccination among healthcare workers. METHOD: We performed ten semi-structured interviews with volunteered healthcare workers of Rasoul Akram hospital. Then each interview was anonymized, and Braun and Clarke's thematic analysis method was used to analyze the interviews. RESULTS: Our data analysis revealed thirty-eight different codes as reasons for vaccination hesitancy among our interviewees. All these thirty-eight codes were grouped into ten sub-themes, and these sub-themes were further grouped into our four main themes: 1. Fear of side effects, 2. Distrust, 3. Inefficiency, and 4. Non-necessity. Fear of side effects was the most frequent reason that interviewees mentioned. Also, Half of the interviewees mentioned distrust as a reason for COVID-19 vaccine hesitancy. At least once, all interviewees mentioned that they believed vaccination is inefficient. Some interviewees had beliefs and reasons that made them assume vaccination is simply not necessary. CONCLUSION: Fear of side effects, distrust, inefficiency, and non-necessity were the reasons that our participants refused to get vaccinated. Fear of side effects and distrust were the most common reasons that led to non-vaccination.

Factors associated with pharmacological and psychotherapy treatments adherence in patients with borderline personality disorder.

Background: Borderline personality disorder is a major mental illness characterized by sustained relationship instability, impulsive behavior, and intense affects. Adherence is a complex behavior, from minor refusals to abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and psychotherapy adherence, patients' attitude toward medication, and assessing medication and treatment adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran. Methods: The study was a cross-sectional study. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. Data were collected using the Drug Attitude Inventory-10 (DAI-10) questionnaire and a questionnaire to determine the attitude of patients toward pharmacological and psychotherapy treatment as well as therapeutic adherence. After collecting data, patients' therapeutic adherence was divided into poor, partial, and good compliance. Results: Ninety-four patients were involved in the study, and fifty-four were women. Findings of DAI showed that 54 (57.4%) participants had negative attitudes toward medication, while 38 (40.4%) participants showed a negative attitude toward psychotherapy treatment. Additionally, the percentage of patients with good psychotherapy adherence (44.7%) was higher than that of patients with good medication adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%), and then fear of medication dependence (40%). Patients with higher education levels and a positive history of hospitalization in a psychiatric ward had better adherence to psychotherapy (P < 0.05). Conclusion: Results of the current study show that attitude toward psychotherapy is more favorable than pharmacotherapy among patients with BPD. The rationale may be that medications are mainly prescribed for comorbid conditions and do not have substantial effects on the BPD symptoms, resulting in low medication adherence.

War, immigration and COVID-19: The experience of Afghan immigrants to Iran Amid the pandemic.

Introduction: Afghanistan's domestic upheaval following the Taliban's invasion leads to massive displacement of its population. The number of Afghan refugees in Iran has dramatically increased since the Taliban's takeover of Afghanistan in August 2021. Multiple pre-and post-migratory traumatic experiences affect immigrants' physical, psychological, social, and economic wellbeing. The coronavirus outbreak, considered a traumatic experience in human life in the 21st century, added to their problems in Iran and exposed them to new challenges. This qualitative study aimed to investigate their experiences early before, during, and after immigration and the pandemic's challenges to their lives in Iran. Methods: In the present qualitative study, ten Afghan residents living in Iran who immigrated to Iran legally or illegally since the summer of 2021 and the last year after the second Taliban invasion were selected via purposive sampling. A semi-structured interview was applied to gather the data, and the data were analyzed through Braun and Clarke's thematic analysis method. Results: Ten male participants with a mean age of 26 y/o were interviewed. Their residence in Iran was between 20 days and 8 months. Four main themes were extracted. The first theme, the Tsunami of suffering, represents a disruption of the normal flow of life. Six subthemes, including loss, being near death, insecurity, sudden hopelessness, leaving the country involuntarily, and reluctance to explore underlying emotions, are included in this category. The second one, Lost in space, describes the participant's attempt to leave Afghanistan following the extensive losses and violent death threats. Their experiences are categorized into four subthemes: the miserable trip, encountering death, life-threatening experiences, and being physically and verbally abused. The third theme, with its five subthemes, try to demonstrate the participants' experiences after getting to their destination in Iran. The last one, Challenges of the COVID-19 explained the experience of Taliban return, war trauma, running away, and living as a refugee or immigrant coincided with the COVID pandemic. Discussion: Our interviewees explained multiple and successive traumatic experiences of war, migration, and the pandemic. The central clinical features of survivors are fears of losing control, being overwhelmed, and inability to cope. They felt abandoned because not only lost their family support in their homeland but could not also receive support in Iran due to the pandemic-related social distancing and isolation. They were dissociated and emotionally numb when describing their experience, which is a hallmark of experiencing severe, unprocessed traumas. Conclusion: Gaining a better understanding of Afghan refugees lived experiences may help provide them with better social and health care support. Proper mental and physical healthcare support and de-stigmatization programs may reduce the impact of multiple traumas on their wellbeing.

Online Sexual Activity among Iranian Clients with Borderline Personality Disorder and Its Correlation with Severity of Symptoms.

Objective: Clients with borderline personality disorder (BPD) often engage in high-risk sexual behaviors. Online sexual platforms convey abusive and harmful themes, especially for this group of sexually impulsive patients. We hypothesized a correlation between their online sexual activities and the severity of BPD symptoms. Method : Fifty clients with BPD who were referred to Iran psychiatric hospital and Tehran Psychiatric Institute in 2020 participated in this research. The Borderline Evaluation of Severity over Time (BEST) questionnaire was used to assess the severity of BPD symptoms, and the Internet Sex Screening Test (ISST) was used to evaluate online sexual behaviors. A psychiatric interview considered substance abuse and other confounding factors. Results: The mean ISST and BEST scores were 7.82 ± 5.74 and 41.7 ± 12.5, respectively. There was a positive and significant correlation between the severity of BPD symptoms and online sexual activities (P < 0.001, r = 0.480). There was also a significant relationship between online sexual activities and a history of substance abuse (P = 0.003, F = 25.06). Conclusion: Online sexual activity can harm clients with BPD who are more vulnerable to high-risk sexual behaviors. More severe borderline personality traits were associated with more online sexual activity, which underlines the importance of providing education about and managing such activities in clients with BPD.

Discharge of psychiatric patients against psychiatrist's advice.

Background: Discharge from the hospital against the doctor's advice and refusal of receiving treatment is one of the significant issues at the time of hospitalization, which is especially crucial in relation to psychiatric patients. It can exacerbate the disorder and the subsequent complications and increase further hospital admissions. The present study was designed to evaluate the causes of discharge from the hospital and the refusal of receiving treatment against medical advice in hospitalized patients in Iran Psychiatric Hospital. Methods: The present study was a descriptive cross-sectional study. One hundred patients hospitalized in Iran Psychiatric Hospital discharged with personal consent against medical advice from July to December 2018 were studied. Two methods were used for assessment; the fulfillment of a routine ministry-approved checklist by the dischargers themselves and the face-to-face interview with both the patient and discharger based on a researcher-made checklist. Cohen's Kappa coefficient was used to assess the agreement of the answers of patients to both routine ministry-approved and researcher-made checklists by SPSS software version 16.0 with an overall accuracy of 95%. Results: Based on the results extracted from the researcher-made checklist, 43 (43%) of the discharges were generally based on patient-related factors. The personal insistence to discharge by the patient was cited as the main reason for discharge. Cohen's Kappa coefficient showed no significant agreement between the patient's answers to the interview and what they have previously filled in the routine ministry-approved checklist. More specifically, the measure of agreement for answers of patients to questions in the standard checklist and the questions asked by the interviewer was 0.078 (p=0.167). Conclusion: From the results of this study, it can be concluded that the face-to-face interview based on the researcher-made checklist can more effectively determine the reasons for discharge of patients due to the accuracy of the interview.

Attitude towards migration of psychiatric trainees and early career psychiatrists in Iran.

INTRODUCTION: Migration of medical professionals has been rapidly increasing in the past decades and it strongly affects origin and destination countries. OBJECTIVES: We aimed to explore the extent and the reasons of migration among psychiatric trainees and early career psychiatrists in Iran. METHODS: Our semi-structured 61-items questionnaire inquired participants' demographics, experiences of short-term mobility (from 3 months to 1 year), long-term migration (more than 1 year) and attitudes towards migration (current and future plans). RESULTS: A total of 184 responses were received. Most (73.4 %) participants were female, and within the age range of 25-65 (Mean: 34.9). Only 15.2 % had a short-term mobility experience, mostly due to academic reasons (35.7 %). Most (75 %) stated that this short-term mobility experience influenced them in favor of migration. The majority (83.7 %) had 'ever' considered leaving Iran, and more than half (57.3 %) stated they 'strongly agree' or 'agree' to leaving the country 'now' (at the time of the study). The main reason to migrate from Iran was first political, followed by work, financial, social, religious, academic, and cultural reasons, and the least ranked were personal reasons. In relation to their 5-year plans, 67.3 % saw themselves in the country they currently live in, Iran. The main features reported for an attractive job were 'pleasant work environment' (97.3 %), 'good welfare and social security' (96.7 %) and 'high salary '(96.2 %). CONCLUSIONS: This study calls for more support of psychiatric trainees and early career psychiatrists in Iran. Improvements in the political context, work conditions and finances might lower the rate of migratory intention and brain drain.

Assessment of psychiatrists' approaches regarding disclosure of psychiatric disorders to their patients: a qualitative study.

Background: Diagnosis disclosure is the result of a shift in medical approaches from traditional paternalism to participatory and patient-centered decision making. Disclosure of psychiatric diagnosis remained uncommon and controversial. Giving information about psychiatric illnesses is very complicated, and it is affected by several factors. While clinical guidelines provide a clear pathway for treating patients, in practice, the treatment of patients is influenced by cultural and social factors. The aim of the current study was a qualitative assessment of psychiatrists' approaches regarding the disclosure of psychiatric disorders to their patients. Methods: The current study was conducted with a qualitative approach. The participants were purposefully selected psychiatrists from three medical universities in Tehran, Iran. The data gathered using the semi-structured interview method. Sixteen interviews with 14 psychiatrists were conducted. Data were analyzed using thematic analysis. Results: Psychiatrists decide to disclose the diagnosis based on several factors. We summarized these factors in a central theme, passive situational decision making based on paternalism and displacement of responsibility. It has two subthemes, including "passive and situational decision making" and "paternalism and displacement of responsibility." Each theme presented by detailed quotations. Conclusion: The results of this study showed that psychiatrists did not actively disclose the diagnosis name to patients. Diagnosis disclosure was influenced by several factors, such as the certainty about the diagnosis and the severity of the disease. This passive approach does not respect the patient's rights. The paternalistic nature of this approach mandates psychiatrists to consider themselves as the responsible perosn for their patients' welfare.

The experience of patients with bipolar disorder from diagnosis disclosure: A qualitative study.

Background: Disclosure of the diagnosis is an essential part of the treatment process and an important part of patient rights. However, it can be a very stressful experience, especially in mental health disorders. Patients with bipolar disorder have a unique experience of receiving and managing their diagnosis. The objective of the current study was to explore the experience of patients with bipolar disorder of diagnosis disclosure. Methods: This was a qualitative study. Participants were recruited from patients who knew their disorder's name using purposive sampling method. The inclusion criteria were being diagnosed by a psychiatrist as having bipolar disorder and the disclosure was conducted by a psychiatrist. Sixteen semi-structured, in-depth interviews were conducted with twelve patients. Data were analyzed using thematic content analysis. Results: Patients received their diagnosis name in three steps including Wandering in Unknowns, Limited Brightness and Reaching to a Relative Insight. Patients believed that disclosure of the diagnosis was not accompanied by enough information. Conclusion: The disclosure of diagnosis in patients with bipolar disorder without providing enough information is stressful and is not helpful in empowering these patients. Based on our results, disclosure of diagnosis to patients with bipolar disorder was not conducted with enough information and patients had problems for understanding their symptoms and treatments.

Validity and reliability of Persian translation of the Borderline Evaluation of Severity over Time (BEST) questionnaire.

Background: Borderline Evaluation of Severity over Time (BEST) is one of the self-reported tools for evaluation of the severity and track the response of treatment of borderline personality disorder. The present study evaluated the validity and reliability of Persian Translation of the Borderline Evaluation of Severity over Time (BEST) Questionnaire and to compare it with a semi-structured clinical interview for DSM-IV axis II (SCID-II). Methods: The questionnaire was translated into Persian and then, the content and face validities of the questionnaire were determined. The translated BEST questionnaire and SCID-II were conducted on 33 outpatients and 32 hospitalized patients with diagnosis of borderline personality disorder and 30 patients' companions. Forty-five patients completed the questionnaire again in an interval between 7 to 45 days. The data were analyzed using exploratory factor analysis, paired sample t-test, and the Pearson correlation coefficient and Cronbach's α coefficient. Results: This study evaluates the content validity, face validity, and criterion validity and reliability of the Persian version of the BEST Questionnaire. The mean scores of the BEST questionnaire were 45.6, 39.2, and 24.3 in in-patients, outpatients, and controls, respectively (p=0.001). The mean scores of the BEST questionnaire were 43.7 in the first evaluation, and 41.4 in the second one (r=0.619, p<0.001). Cronbach's α coefficient was 0.761, and it reached to 0.898 after omitting items 13 to 15. The questionnaire had a two-factor structure, including internal turmoil and the disturbance in interpersonal relationships. Conclusion: The Persian version of the BEST Questionnaire has a high face and content validity, high criterion validity, moderate to high reliability, and an acceptable two-factor structure.

Evaluation of psychiatric illness in Iranian stoma patients.

INTRODUCTION: The objective of this study was to assess the nonpsychotic psychiatric disorders of stoma patients in Iran. METHOD: In this cross-sectional study, patients referred to the Iranian Ostomy Association from 2005 to 2006 filled the 28-item General Health Questionnaire (GHQ) in Farsi as a screening instrument to identify cases of nonpsychotic psychiatric morbidity. RESULTS: A total of 155 patients participated in the study, of whom 79 (51%) were female and 76 (49%) were male. Fifty-five percent of the patients (n=86) had psychiatric problems. The females' mean GHQ score was significantly higher than that of males (P=.001). Psychiatric disorder was significantly more frequent among patients with the following specifications: educational level of high school or lower (P=.001), mucosal hemorrhage of the ostomy (P=.03), stomal stenosis (P=.012), and history of psychiatric drug consumption (P=.000). GHQ score decreased as stoma age increased (P=.032; r=-.177). DISCUSSION: Similar to other complications, psychiatric problems are prevalent in Iranian stoma patients. Our findings highlight the need for special support.