Restoring Trust for People With Psychosis Through Psychotherapy.

ABSTRACT: Mistrust is a significant problem for people with psychosis and can interfere with their capacity to engage in psychosocial treatment. In this article, the developmental trajectory of mistrust is outlined, including the impact that attachment disruption, childhood trauma, attributional biases, internalized stigma, and discrimination can have on the person's capacity to form trusting bonds with others. After this review, three elements are described that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. These elements are framed in the context of metacognitive reflection and insight therapy, an integrative therapy that is well suited to address mistrust through its explicit focus on metacognition and intersubjectivity.

Integrating Loss and Processing Grief in Psychotherapy of Psychosis.

Objective: While recovery from psychosis is possible, recovery is a multidimensional construct driven by various factors. One relevant factor to recovery from psychosis that has often been overlooked in the psychotherapy literature is the importance of facing loss and processing grief in relation to psychosis. Methods: A review of the existing empirical literature on grief associated with psychosis was conducted. Clinicians with significant therapeutic experience working with persons with psychosis reviewed cases to examine the losses the patients had suffered and how they responded to these losses. The clinicians considered essential principles that are relevant when helping patients with psychosis integrate loss and process grief. Results: Persons who have experienced psychosis often experience the loss of role functioning, interpersonal relationships, cognition, and self-concept. However, when these losses are not fully integrated into the person's identity, it can result in either more losses due to denial and metacognitive impairments or increased hopelessness and depression due to internalized stigma. Five elements in psychotherapy of psychosis were identified that can facilitate the integration of loss and processing of grief: understand the personal experience of the psychotic episode, attend to feelings of grief and the primary loss, explore the meaning of psychotic symptoms and identity implications, integrate psychotic vulnerabilities into the sense of self, and foster realistic hope in the face of an uncertain future. Conclusion: Psychotherapy can enable persons with psychosis to make meaning of their losses, process their grief, integrate their psychotic vulnerability into their sense of self, and develop realistic hope.

Intent to Understand the Meaning of Psychotic Symptoms During Patient-Psychiatrist Interactions.

Research confirms that although patients experiencing psychosis want to speak about their symptoms with psychiatrists, psychiatrists are often hesitant to engage them directly in such conversations because of their fear of colluding, promoting defensiveness, or rupturing the therapeutic alliance. As a result, patients are often left to contend with confusing psychotic experiences, such as hallucinations and delusions, that they cannot make sense of on their own. In this article, the common barriers that prevent engagement in conversations about psychosis are described, and the conventional wisdom about the futility of talking with patients about delusions is challenged. The article suggests that instead of avoiding conversations about psychotic ideas, psychiatrists should embrace an "intent to understand," an inquisitive state of mind even in the face of seemingly incomprehensible symptoms. Such a stance can promote the therapeutic alliance, deepen an understanding of the patient as a person, and facilitate an integrative recovery style. Finally, the article offers clinical pointers, including the importance of behaving courteously and respectfully, listening to the affect expressed in the symptom, and looking for connections between the symptom and painful life experiences. Maintaining an intent to understand may help psychiatric residents-in-training, as well as experienced clinicians, to foster an empathic understanding that builds a positive therapeutic alliance and contributes to more successful pharmacotherapy and psychotherapeutic interventions.

Longitudinal stability of Social Cognition and Object Relations Scale-Global Rating Method dimensional ratings, score ranges and narrative 'blandness' in a clinical sample.

While understanding how internalized representations of others (i.e., object relations) change over the course of treatment is essential for treatment planning and evaluation of progress, few studies have examined the nature of these changes through repeated psychological assessments. In this study, we applied the SCORS-G to Thematic Apperception Test narratives for 61 adult patients with complex psychiatric problems undergoing residential treatment over an 18-month period. Over the course of treatment, patient representations of self and others became more complex, indicating improvements in mentalization. Further, an analysis of default ratings (i.e., an aspect of story 'blandness') suggested that certain shifts in SCORS-G dimensional scores over time were accounted for by greater degree of scorable content across time points, rather than changes specific to the dimensions themselves. Findings from novel exploratory analyses aimed at evaluating the test-retest reliability of both default rating proportion and several emerging alternative scoring approaches (including changes in minimum, maximum and range of scores on individual dimensions) are reported. While the magnitude of change across mean dimensional scores was found to be lower compared to those previously found in outpatient populations, our results suggest that the SCORS-G remains capable of detecting changes in mentalization capacities in individuals contending with longstanding, severe psychiatric impairment and personality-based psychopathology. Implications for treatment, assessment and future research are discussed.

Promoting an integrating recovery style: A mentalization-informed approach.

How a person recovers after a psychotic episode is known to be a key predictor of treatment response, impacting a person's sense of self and interpersonal relationships. An integrating recovery style, characterized by more curiosity about the psychotic episode and its potential meaning, has been shown to produce better outcomes. A novel therapeutic treatment, mentalization-based therapy for psychosis, targets the potential mechanisms (i.e., curiosity about mental states, affect modulation, and interpersonal awareness) that might foster an integrating recovery style, enabling a person to make meaning of their episode and use others to facilitate exploration. In this case study, we present the treatment of an emerging adult who sought residential treatment following her first psychotic episode and who initially presented with a guarded, dismissive approach to her symptoms and gradually formed a more integrating recovery style.

Assessing Self-Definition and Relatedness in Level of Personality Functioning.

The two polarities model (TPM) of personality organizes psychological assessment and psychotherapy and connects to personality disorder diagnosis using the DSM-5 Alternative Model for Personality Disorders (AMPD). The authors developed scales assessing the TPM from an existing self-report measure for level of personality functioning (LPF), a core component of the AMPD. Iterative content analyses of the LPF measure yielded scales for Autonomy and Communion corresponding to dimensions of the TPM. The scales were refined via internal consistency analyses using a measure of psychological attachment and studied in development and validation samples. Associations with relevant external criteria were explored in a series of multiple regressions. The new content-based LPF scales were illustrated with a case vignette. Although the new Autonomy/Communion scales await further validation prior to clinical use, initial evidence suggests that they may bridge the nomological nets of the TPM and AMPD and potentially offer clinical utility in assessment and treatment planning.

Card pull effects of the Thematic Apperception Test using the Social Cognition and Object Relations-Global Rating Method on complex psychiatric sample.

In recent years, there has been growing interest in examining the stimulus pull effects on respondent narratives to the Thematic Apperception Test (Murray, 1943) using standardized coding methods such as the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011; Westen, 1995). The present study expands on prior work by examining sources of variance in SCORS-G dimensions and card pull effect patterns in an adult clinical sample characterized by high psychiatric comorbidity and clinical severity. A sample of 158 adult psychiatric patients in long-term residential treatment provided narratives to 10 TAT cards (five of which have not previously been studied for pull effects). Cards 2 and 7BM pulled for significantly more adaptive narratives (positive pull), whereas Card 13MF pulled for more pathological stories (negative pull). Like prior studies, variance in cognitive dimensions of the SCORS-G was most explained by person effects, whereas the largest source of variance for all other dimensions was best explained by a combination of the card and the person effects on the narrative. Finally, exploratory analyses of card pull effects within different gender groups were conducted. The implications of these findings for performance-based future studies and possible clinical applications of card pull findings are discussed.

Comparative Content Analysis of Self-Report Scales for Level of Personality Functioning.

Content validity analyses of eight self-report instruments for assessing severity of personality disorder (PD), also known as Level of Personality Functioning (LPF), were conducted using the conceptual scheme of the Alternative Model for Personality Disorders (AMPD; APA, 2013). The item contents of these eight inventories were characterized for the LPF constructs of Identity (ID), Self-Direction (SD), Empathy (EM), and Intimacy (IN) along with the pathological personality trait domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Severity of pathology (SV) reflected in item content was also rated. Raters demonstrated robust agreement for AMPD and SV constructs across instruments. Similarity between instrument AMPD construct profiles was quantified by intraclass correlations (ICC). Results showed the instruments were generally similar in AMPD-construct coverage, but some important differences emerged. The subscales of the instruments also were characterized for the degree to which they reflect the four LPF (ID, SD, EM, IN) domain constructs. Collectively, these content validity comparisons clarify the equivalence of instruments for AMPD constructs and the relative proportions of construct coverage within instrument subscales. These results can inform future research with LPF self-report instruments and guide clinicians in selecting an LPF-related instrument for use in practice.

Evaluating Stable and Situational Expressions of Passive-Aggressive Personality Disorder: A Multimethod Experience Sampling Case Study.

Passive-aggressive (PA) personality traits have received increasing attention in the research literature and are known to interfere with treatment engagement and recovery. Theoretical disagreements about PA, combined with its omission from the DSM-5, have left open many questions regarding its dynamic structure and temporal stability. Our goal in the present case study was to use a multimethod, experience sampling assessment framework for a single research subject enrolled in long-term residential treatment who exhibited significant PA traits to provide a complex portrait of daily interpersonal behaviors and experiences across a range of contexts. We review data gathered over a year of residential treatment to identify changes in self and interpersonal functioning and to deepen our understanding of the dynamic motivational structure of PA over time. Our findings expand understanding of both PA dynamics and provide support for integrating multimethod assessment into routine clinical practice.

Synthesis of Phosphonomethyl Tetrahydrofurans via the Mori-Tamaru Reaction of Phosphonodienes.

Nickel-catalyzed reductive addition of phosphonodienes to aldehydes (the Mori-Tamaru reaction) gives hydroxy vinyl phosphonates in good yields with excellent control of the relative stereochemistry. Base-induced cyclization of the vinyl phosphonates yields phosphonomethyl-substituted tetrahydrofurans. Inversion of the hydroxyl stereochemistry by Mitsunobu reaction and then cyclization yields a different set of phosphonomethyl-substituted tetrahydrofuran diastereoisomers.

From Fragmentation to Coherence: Psychodynamic Psychotherapy for Psychosis through the Lens of Metacognition.

Psychoanalysis has produced important theories that help explain the radical alterations in self-experience central for persons experiencing psychosis. These concepts have led to important clinical developments, case studies, and some research on the efficacy of psychodynamic psychotherapy for psychosis (Gottdiener, 2006). However, psychodynamic psychotherapy has struggled to produce operationalized constructs to measure how it enhances self-development and the therapeutic mechanisms of action that facilitate these changes. Outside of psychoanalysis, some researchers have focused on the construct of metacognition (i.e. thinking about thinking) and its relevance to understanding psychosis. Proponents of this paradigm have created an integrative, exploratory therapy (MERIT, Lysaker & Klion, 2017) that blends various therapeutic traditions that overlap with psychodynamic psychotherapy and mentalization (Ridenour, Knauss, & Hamm, 2019). In this paper, we will present a short-term intensive case study of psychodynamic psychotherapy with a young man experiencing psychosis in residential treatment and then analyze the therapy through the lens of metacognition to provide constructs that illustrate the ways that it promotes recovery and self-integration.

The Integration of EMA and Single-Occasion Multimethod Assessment Data for a Complex Psychiatric Patient.

The utilization of multimethod assessment approaches can provide comprehensive information regarding daily interpersonal and personality functioning, increasing opportunities to guide treatment planning in a more personalized, evidence-based manner. The routine implementation of multimethod assessment within clinical settings, however, remains rare, and there are few studies that have reviewed the clinical utility of multimethod assessment. Our goal in this study was to analyze multimethod data collected from a single research subject enrolled in residential treatment in order to illustrate the process of integrating data across both single-occasion (e.g., self-report, performance-based, and behavioral tests) and multitimepoint (ecological momentary assessment of interpersonal experiences) dimensions. Results revealed both areas of convergence and divergence across measures, enabling the development of a complex clinical formulation that sharpened diagnostic considerations and contributed valuable insights to treatment planning. Our findings provide support for the value of incorporating multimethod assessment into routine clinical practice.

Borderline personality disorder diagnosis in a new key.

BACKGROUND: Conceptualizations of personality disorders (PD) are increasingly moving towards dimensional approaches. The definition and assessment of borderline personality disorder (BPD) in regard to changes in nosology are of great importance to theory and practice as well as consumers. We studied empirical connections between the traditional DSM-5 diagnostic criteria for BPD and Criteria A and B of the Alternative Model for Personality Disorders (AMPD). METHOD: Raters of varied professional backgrounds possessing substantial knowledge of PDs (N = 20) characterized BPD criteria with the four domains of the Level of Personality Functioning Scale (LPFS) and 25 pathological personality trait facets. Mean AMPD values of each BPD criterion were used to support a nosological cross-walk of the individual BPD criteria and study various combinations of BPD criteria in their AMPD translation. The grand mean AMPD profile generated from the experts was compared to published BPD prototypes that used AMPD trait ratings and the DSM-5-III hybrid categorical-dimensional algorithm for BPD. Divergent comparisons with DSM-5-III algorithms for other PDs and other published PD prototypes were also examined. RESULTS: Inter-rater reliability analyses showed generally robust agreement. The AMPD profile for BPD criteria rated by individual BPD criteria was not isomorphic with whole-person ratings of BPD, although they were highly correlated. Various AMPD profiles for BPD were generated from theoretically relevant but differing configurations of BPD criteria. These AMPD profiles were highly correlated and showed meaningful divergence from non-BPD DSM-5-III algorithms and other PD prototypes. CONCLUSIONS: Results show that traditional DSM BPD diagnosis reflects a common core of PD severity, largely composed of LPFS and the pathological traits of anxiousness, depressively, emotional lability, and impulsivity. Results confirm the traditional DSM criterion-based BPD diagnosis can be reliably cross-walked with the full AMPD scheme, and both approaches share substantial construct overlap. This relative equivalence suggests the vast clinical and research literatures associated with BPD may be brought forward with DSM-5-III diagnosis of BPD.

Cyclipostins and Cyclophostin Analogues as Multitarget Inhibitors That Impair Growth of Mycobacterium abscessus.

Twelve new Cyclophostin and Cyclipostins analogues (CyC19-30) were synthesized, thus extending our series to 38 CyCs. Their antibacterial activities were evaluated against four pathogenic mycobacteria (Mycobacterium abscessus, Mycobacterium marinum, Mycobacterium bovis BCG, and Mycobacterium tuberculosis) and two Gram negative bacteria. The CyCs displayed very low toxicity toward host cells and were only active against mycobacteria. Importantly, several CyCs were active against extracellular M. abscessus (CyC17/CyC18ß/CyC25/CyC26) or intramacrophage residing mycobacteria (CyC7(α,ß)/CyC8(α,ß)) with minimal inhibitory concentrations (MIC50) values comparable to or better than those of amikacin or imipenem, respectively. An activity-based protein profiling combined with mass spectrometry allowed identification of the potential target enzymes of CyC17/CyC26, mostly being involved in lipid metabolism and/or in cell wall biosynthesis. Overall, these results strengthen the selective activity of the CyCs against mycobacteria, including the most drug-resistant M. abscessus, through the cumulative inhibition of a large number of Ser- and Cys-enzymes participating in key physiological processes.

The Evolution of Psychological Testing at the Austen Riggs Center: A Theoretical Analysis.

Theoretical perspectives on personality and the development of psychopathology have shifted markedly over the last 7 decades. However, it remains unclear how those changes affect mental health practice. Comprehensive and conscientiously recorded reports of psychological testing provide a clear window on this process because they comprise distinctive records of how patients are assessed and understood. For this study, we conducted an exploratory, qualitative analysis of the narratives of the testing reports over the past 65 years at the Austen Riggs Center, a private psychiatric hospital and residential treatment center, to assess changes over time and to evaluate the influence that various factors had on the reports. The data revealed significant changes in psychologists' ways of assessing and conceptualizing personality and identity, adaptive functioning, and psychological development. Additionally, we evaluated how the evolving theoretical influences, such as institutional, professional, and sociohistorical factors affected the psychologist's model of psychopathology and development. This study raises important questions about how theoretical innovations affect clinical practice over time.

Emerging Psychotherapies for Psychosis.

Recent developments in the research and clinical literatures have highlighted the importance of focusing on higher-order cognitive processes in the treatment of psychotic disorders. A particular emphasis has been placed on how impairments in self-monitoring and the ability to form mental representations of others uniquely manifest in psychosis. At the same time, the recovery movement has influenced clinical innovations by emphasizing the importance of subjective domains of recovery that privilege the individual's phenomenological experience. In this column, we outline 2 emerging approaches to the treatment of psychosis, Metacognitive Reflection and Insight Therapy and Mentalization-based Therapy for Psychosis, highlighting the ways that each approach targets higher-order cognitive processes as a focused point of intervention, while maintaining a collaborative treatment approach that values the patient's agency.

Relay cross metathesis reactions of vinylphosphonates.

Dimethyl (ß-substituted) vinylphosphonates do not readily undergo cross metathesis reactions with Grubbs catalyst and terminal alkenes. However, the corresponding mono- or diallyl vinylphosphonate esters undergo facile cross metathesis reactions. The improved reactivity is attributed to a relay step in the cross metathesis reaction mechanism.