Implementation of guidelines on Family Involvement for persons with Psychotic disorders: a pragmatic cluster randomized trial. Effect on relatives' outcomes and family interventions received.

Background: Family interventions (FI) are recommended as part of the treatment for psychotic disorders, but the implementation in mental health services is generally poor. Recently, The Implementation of guidelines on Family Involvement for persons with Psychotic disorders (IFIP) trial, demonstrated significant improvements in implementation outcomes at cluster-level. This sub-study aims to examine the effectiveness of the IFIP intervention on relatives' outcomes and received FI. Methods: A cluster randomized controlled trial, was conducted in 15 Norwegian Community Mental Health Center (CMHC) units that were randomized to either the IFIP intervention, including implementation interventions and clinical interventions, or treatment as usual (TAU). The clinical interventions consisted of FI: basic family involvement and support (BFIS) to all patients and family psychoeducation (FPE) to as many as possible. Patients with psychotic disorders and their closest relative were invited to fill in questionnaires at inclusion and 6 months and 12 months follow-up. Received FI was reported by both relatives and clinicians. The relatives' primary outcome was satisfaction with health service support, measured by the Carer well-being and support questionnaire part B (CWS-B). The relatives' secondary outcomes were caregiver experiences, expressed emotions and quality of life. Patients' outcomes will be reported elsewhere. Results: In total 231 patient/relative pairs from the CMHC units were included (135 intervention; 96 control).The relatives in the intervention arm received an increased level of BFIS (p=.007) and FPE (p < 0.05) compared to the relatives in the control arm, including involvement in crisis planning. The primary outcome for relatives' satisfaction with health service support, showed a non-significant improvement (Cohen's d = 0.22, p = 0.08). Relatives experienced a significant reduced level of patient dependency (Cohen's d = -0.23, p = 0.03). Conclusion: The increased support from clinicians throughout FI reduced the relatives' perceived level of patient dependency, and may have relieved the experience of responsibility and caregiver burden. The COVID-19 pandemic and the complex and pioneering study design have weakened the effectiveness of the IFIP intervention, underscoring possible potentials for further improvement in relatives' outcomes. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT03869177.

"Existential Catastrophe Anxiety": Phenomenology of Fearful Emotions in a Subset of Service Users With Severe Mental Health Conditions.

A subset of people with severe mental health conditions feels they are on the verge of losing control, even in the absence of external threats or triggers. Some go to extreme ends to avoid affective arousal and associated expectations of a possible, impending catastrophe. We have learned about such phenomenological, emotional challenges in a group of individuals with severe, composite mental health problems and psychosocial disabilities. These individuals have had long treatment histories in the mental health care system. They have been encountered at a specialized inpatient ward offering exposure-based therapy that aims at restoring self-regulation and recovery. We describe the phenomenology of anxiety and fear presented by these service users, a fear we have coined existential catastrophe anxiety (ECa). We also suggest a set of underlying, interacting, psychological mechanisms that may give rise to ECa, before comparing ECa with three other constructs previously described in the literature-annihilation anxiety, ontological insecurity, and affect phobia. These comparisons show several similarities, but also unique qualities with ECa and its suggested underlying mechanisms. The conceptualization of ECa may aid clinicians in addressing extreme experiential turmoil and engage service users in empowering therapeutic projects.

Quantifying auditory impressions in dreams in order to assess the relevance of dreaming as a model for psychosis.

A long noted hypothesis is that mechanisms of dreaming play a role in psychotic hallucinations. One challenge for this hypothesis is that while psychotic hallucinations primarily are auditory, dreaming most characteristically is visual. At the same time, previous studies have not explicitly examined auditory impressions in dreaming. Here, we mapped the prevalence and characteristics of auditory impressions in 130 dreams reported after spontaneous awakenings from sleep in 13 normal, healthy people. We instructed participants to report any dream they could recall and to pay particular attention to possible auditory impressions. The participants reported auditory impressions in 93.9% of their dreams on average. The most prevalent auditory type was other people speaking (83.9% of participants' dreams), followed by the dreamer speaking (60.0%), and other types of sounds (e.g. music, 33.1%). Of altogether 407 instances of auditory impressions in the 130 dreams, auditory quality was judged comparable to waking in 46.4%, indeterminate in 50.6%, and absent or only thought-like in 2.9%. The results suggest that also internally generated auditory (verbal) sensations are a central component of dreaming, typically occurring several times every night in normal, healthy people.

Measuring childhood maltreatment: Psychometric properties of the Norwegian version of the Maltreatment and Abuse Chronology of Exposure (MACE) scale.

PURPOSE: Adverse childhood experiences in sensitive periods of the developing brain render the individual at a life-long risk for a broad spectrum of aberrant health outcomes. However, there is a lack of scales for the comprehensive assessment of adverse childhood experiences providing information of various types and the age of occurrence. Based on the complete, experimental version of the Maltreatment and abuse chronology of exposure (MACE-X) scale, the present study aimed to develop and psychometrically test a Norwegian version of MACE. METHODS: The 75-item MACE-X was translated from German to Norwegian and administered as a self-report measure to 90 outpatients and 145 employees at a Division of specialized mental health care in South-Eastern Norway. The outpatients also completed the Childhood trauma questionnaire (CTQ) and the Symptom checklist 90 (SCL-90) to investigate convergent and predictive validity. To investigate test-retest reliability, outpatients completed MACE once more two weeks later. RESULTS: Rasch analysis and Anderson likelihood ratio tests on the combined outpatient and employee data resulted in a 55 item version of the Norwegian MACE. In the outpatient group, test-retest reliability of the MACE-55 was excellent for total scores (ICC ≥ 0.94) and good to excellent for 10 subscale scores (ICC ≥ 0.82). Convergent validity with the CTQ was moderate to high for both total scores (0.63 ≥ r ≥ 0.86) and subscale scores (0.56 ≥ r ≥ 0.82). As compared to CTQ total scores, a MACE total score that combined severity and duration of exposure was numerically more strongly associated with overall psychiatric symptoms and each of nine symptom domains on the SCL-90. CONCLUSIONS: The newly developed Norwegian MACE comprehensively assesses past exposure to adverse childhood experiences with high psychometric properties. This scale is a useful tool for research questions addressing sensitive periods for childhood adversities and associated health phenotypes.

Strong Associations Between Childhood Victimization and Community Violence in Male Forensic Mental Health Patients.

Background: Childhood abuse and neglect increase the risk of both mental disorders and violent behavior. Associations between child relational adversities and violent behavior have not been extensively investigated in forensic mental health settings. We asked whether the extent of child adversities predicts the extent of violence in the community in forensic mental health patients. Methods: We included 52 male patients at a medium security forensic mental health ward, with diagnoses of predominantly paranoid schizophrenia and other schizophrenia and psychotic disorders. Seventy-five percent had comorbid substance abuse. We extracted information on six types of child adversities based on clinicians' administrations of the Historical Clinical Risk Management 20 version 3 (HCR 20) scale and summary notes in electronic patient journals. These same sources were used to extract information on war trauma and interpersonal violence in the community. We established cumulative scales for exposure to number of types of child adversities and number of incidents of community violence. Results: Physical and emotional abuse, emotional and physical neglect, and bullying were associated with higher levels of community violence. We observed a linear, significant increase in the frequency of community violence with cumulative numbers of child adversity types. Conclusions: Cumulative exposure to child adversities may be associated with higher degrees of violence in forensic mental health patients, with the most violent patients having the most extensive exposures to adversities. An enhanced focus on child adversities in risk assessment and management of violence may be considered in forensic inpatient settings.

Effects of the Collaborative Assessment and Management of Suicidality (CAMS) Model: A Secondary Analysis of Moderation and Influencing Factors.

In a randomized controlled trial, we found that suicidal patients who received Collaborative Assessment and Management of Suicidality (CAMS) reported greater improvements in suicidal ideation and mental health distress compared to participants who received treatment as usual (TAU). Here, we explored moderators and mediators of the effectiveness of CAMS. Compared to TAU, CAMS was more effective in reducing suicidal ideation when the working alliance, in particular its bond subcomponent, was low. In terms of reducing mental health distress, CAMS was superior to TAU only for participants who did not use illicit drugs and, more tentatively, only for patients without borderline personality traits. We suggest that CAMS may repair a difficult vantage point in terms of poor working alliance in patients with suicide ideation. To obtain superior benefits of CAMS upon more general mental health distress in patients with drug abuse or borderline traits, these problems may need to be more explicitly targeted in parallel.

Impact of Psychotherapy in Psychosis: A Retrospective Case Control Study.

Background: The need for psychological therapies for psychosis has become apparent since long-term antipsychotic drug treatment has a range of adverse side effects, with moderate therapeutic effects at best. Aims: To investigate whether the psychotherapeutic approach, dialogue therapy (DT) is associated with improvements of symptoms and functioning beyond standard psychiatric treatment (ST) in both schizophrenia and other psychosis. Methods: A retrospective case-control design, comparing 54 patients with different psychoses who received DT with 54 patients in a control group receiving ST was carried out. The groups were matched on diagnosis, age, sex, and treatment start. Outcome measures were Global assessment of functioning (GAF) scores, medications at follow up, and hospital stays after completed outpatient treatment. Results: Mean time in treatment from inclusion to follow-up was 3 years and 5 months. At follow-up, GAF functioning (GAF-F) and GAF symptom (GAF-S) scores both were significantly higher in the DT group than the ST group. Effect sizes (Cohen's d) were large; 1.8 for GAF-S and 2.1 for GAF-F. At follow-up, the use of psychoactive drugs was significantly reduced despite a shorter time in psychotherapy in the DT group compared to the ST group. Days of hospitalizations after end of treatment in the study period were significantly reduced in both groups compared to the period before start of treatment. Conclusions: The findings from this exploratory study are consistent with the possibility that dialogue therapy may lead to improvements in symptoms and functioning compared to standard treatment in psychosis.

Managing suicidality within specialized care: A randomized controlled trial.

BACKGROUND: Suicide prevention is a core task in mental health services. Our objective was to determine whether Collaborative Assessment and Management of Suicidality (CAMS) reduced suicidal thoughts and behaviors and mental health distress more effectively than treatment as usual (TAU) in a heterogeneous patient population within specialized mental health care services. METHODS: In this observer-blinded pragmatic randomized controlled trial participants who scored 13 or above on Beck's Scale for Suicide Ideation-Current (BSSI-C) were included from seven in- and outpatient units. Primary outcome was suicidal ideation (BSSI-C). Secondary outcomes were mental health distress measured by the Outcome Questionnaire-45, and suicidal behaviors measured by the Suicide Attempt Self-Injury Count. Patients were assessed at baseline and after 6 and 12 months. RESULTS: The final intent-to-treat analyses included 78 participants (mean age 35.9 years, SD = 14.5, 41 females). The majority were depressed (65%), had a secondary diagnosis (73%) and 32% suffered from borderline personality disorder or borderline traits. After 6 months, CAMS participants reported lower levels of suicidal ideation compared to TAU (ß = -4.29, 95% CI = -8.32 to -0.27, p = .036). Larger changes in mental health distress were observed for CAMS participants after 6 months (ß = -11.87, 95% CI = -22.99 to -0.76, p = .036) and 12 months (ß = -13.70, 95% CI = -24.88 to -2.51, p = .017). LIMITATIONS: The modest sample size rendered the trial unable to detect small between-group differences. CONCLUSIONS: CAMS reduced suicidal ideation and mental health distress more efficiently than TAU in a heterogeneous patient population within specialized care.

Drug-free after basal exposure therapy. / Medisinfri etter basal eksponeringsterapi.

BAKGRUNN: Vestre Viken tilbyr basal eksponeringsterapi til døgnpasienter med alvorlige sammensatte psykiske lidelser og lavt funksjonsnivå. I behandlingen kan de som ønsker det få hjelp til å bli medisinfrie. Det sentrale behandlingselementet er eksponering for uønskede indre opplevelser, betegnet som eksistensiell katastrofeangst. Vi undersøkte pasientenes psykososiale fungering etter minst to år etter avsluttet døgnbehandling. MATERIALE OG METODE: Det var tilgjengelige data for 33 av 36 utskrevne pasienter. Vi registrerte psykofarmakabruk, symptom- og funksjonsnivå (Global Assessment of Functioning, GAF), utdanningsnivå, arbeidsevne og boevne ved inntaks- og oppfølgingstidspunktet samt innleggelser året før inntak og oppfølging. Grad av eksponering ble skåret ved utskrivning. RESULTATER: Ved oppfølgingstidspunktet (i gjennomsnitt 5,3 år) var 16 personer medisinfrie, mens 17 fremdeles brukte psykofarmaka. Gjennomsnittlig GAF-skår i den medisinfrie gruppen var ca. 65, noe som tilsvarer milde symptomer og lettere sosiale utfordringer. I psykofarmakagruppen var gjennomgjennomsnittlig GAF-skår ca. 41, noe som indikerer alvorlige problemer og behandlingsbehov. Fire av de medisinfrie og 13 av dem som brukte psykofarmaka, var blitt reinnlagt året før oppfølgingen, og henholdsvis ni og én var i minst 50 % arbeid. Medisinfrie pasienter med høy grad av eksponering hadde best psykososial fungering. De syv som oppnådde full tilfriskning, var alle medisinfrie. FORTOLKNING: De pasientene som i basal eksponeringsterapi valgte å eksponere seg, trappet ned psykofarmakabruken og etter hvert ble medisinfrie, viste ved langtidsoppfølgingen bedre psykososial fungering enn de som fortsatt brukte psykofarmaka.

Predictors of suicide in the patient population admitted to a locked-door psychiatric acute ward.

OBJECTIVE: No prior study appears to have focused on predictors of suicide in the general patient population admitted to psychiatric acute wards. We used a case-control design to investigate the association between suicide risk factors assessed systematically at admission to a locked-door psychiatric acute ward in Norway and subsequent death by suicide. METHOD: From 2008 to 2013, patients were routinely assessed for suicide risk upon admission to the acute ward with a 17-item check list based on recommendations from the Norwegian Directorate of Health and Social Affairs. Among 1976 patients admitted to the ward, 40 patients, 22 men and 18 women, completed suicide within December 2014. RESULTS: Compared to a matched control group (n = 120), after correction for multiple tests, suicide completers scored significantly higher on two items on the check list: presence of suicidal thoughts and wishing to be dead. An additional four items were significant in non-corrected tests: previous suicide attempts, continuity of suicidal thoughts, having a suicide plan, and feelings of hopelessness, indifference, and/or aggression. A brief scale based on these six items was the only variable associated with suicide in multivariate regression analysis, but its predictive value was poor. CONCLUSION: Suicide specific ideations may be the most central risk markers for suicide in the general patient population admitted to psychiatric acute wards. However, a low predictive value may question the utility of assessing suicide risk.

Collaborative Assessment and Management of Suicidality (CAMS) compared to treatment as usual (TAU) for suicidal patients: study protocol for a randomized controlled trial.

BACKGROUND: Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that appears promising to reduce suicidal ideation and suicidal cognition. CAMS has not previously been evaluated in a standard specialized mental health care setting for patients with suicidal problems in general. In this pragmatic randomized controlled trial (RCT) we will investigate if CAMS is more effective than treatment as usual (TAU) in reducing suicidal thoughts and behaviors. Effects will also be investigated on mental health and symptom relief in general and upon readmissions to inpatient units. METHODS/DESIGN: The study is a multicenter, observer-blinded, superiority, two-armed RCT which will include patients from four clinical departments at Vestre Viken Hospital Trust, Norway. We aim to include 100 patients with moderate to strong suicidal problems, as defined by a score of 13 or more on Beck's Scale for Suicide Ideation - Current. Patients are included regardless of diagnosis. Randomization will be performed using a stratified four-block procedure with treatment unit as the stratification variable. The duration of treatment will vary depending on patients' needs and clinical assessments. Patients are interviewed by research staff at four checkpoints: baseline, 2 weeks, 6 months, and 12 months. Central outcome measures are the Beck Scale for Suicide Ideation - Current, Outcome Questionnaire - 45, and Suicide Attempt Self-Injury Count. DISCUSSION: This pragmatic trial is effectuated within the Public Health Care System in Norway, where patients have multiple problems and diagnoses and therapists have a high work load. Results from this trial are highly generalizable to a typical everyday clinical setting, and one should expect similar results if CAMS is implemented in the future as a standard component in specialized mental health care systems. TRIAL REGISTRATION: Open Science Framework: DOI 10.17605/OSF.IO/JHRM2 . Registered 5 July 2015. ClinicalTrials.gov: NCT02685943 . Registered on 8 February 2016.

Basal Exposure Therapy: A New Approach for Treatment-Resistant Patients with Severe and Composite Mental Disorders.

New treatment approaches are needed for patients with severe and composite mental disorders who are resistant to conventional treatments. Such treatment-resistant patients often have diagnoses of psychotic or bipolar disorders or severe personality disorders and comorbid conditions. In this study, we evaluate basal exposure therapy (BET), a novel ward-integrated psychotherapeutic approach for these patients. Central to BET is the conceptualization of undifferentiated existential fear as basic to the patients' problem, exposure to this fear, and the therapeutic platform complementary external regulation, which integrates and governs the totality of interventions throughout the treatment process. BET is administered at a locked-door ward with 6 patient beds and 13.5 full-time employees, including a psychiatrist and 2 psychologists. Thirty-eight patients who had completed BET were included, all but two being female, mean age 29.9 years. Fourteen patients had a diagnosis of schizophrenia or schizoaffective disorder (F20/25), eight had bipolar disorder or recurrent depressive disorder (F31/33), eight had diagnoses in the F40-48 domain (neurotic, stress-related, and somatoform disorders), five were diagnosed with emotionally unstable personality disorder (F60.3), and three patients had other diagnoses. Twenty of the patients (53%) had more than one ICD-10 diagnosis. Average treatment time in BET was 13 months, ranging from 2 to 72 months. Time-series data show significant improvements in symptoms and functioning from enrollment to discharge, with effect sizes at 0.76 for the Dissociation Experience Scale, 0.93 for the Brief Symptom Inventory, 1.47 for the Avoidance and Action Questionnaire, and 1.42 and 1.56, respectively, for the functioning and symptom subscales of the Global Assessment of Functioning Scale. In addition, the patients used significantly less antiepileptic, antipsychotic, anxiolytic, and antidepressant medications at discharge than at treatment enrollment. Patient improvement across treatment was associated with the following duration of time in BET, the successful completions of the exposure component of BET, positive changes in experiential avoidance as measured with the Acceptance and Action Questionnaire, and high symptom levels and low levels of functioning at treatment start. The findings indicate that BET may be a promising inpatient psychotherapeutic approach for previously treatment-resistant patients with severe and comorbid conditions.

A critical assessment of the equal-environment assumption of the twin method for schizophrenia.

The classical twin method (CTM) is central to the view that schizophrenia is ~80% heritable. The CTM rests on the equal-environment assumption (EEA) that identical and fraternal twin pairs experience equivalent trait-relevant environmental exposures. The EEA has not been directly tested for schizophrenia with measures of child social adversity, which is particularly etiologically relevant to the disorder. However, if child social adversity is more similar in identical than fraternal pairs in the general twin population, the EEA is unlikely to be valid for schizophrenia, a question which we tested in this study. Using results from prior twin studies, we tested if intraclass correlations for the following five categories of child social adversity are larger in identical than fraternal twins: bullying, sexual abuse, physical maltreatment, emotional neglect and abuse, and general trauma. Eleven relevant studies that encompassed 9119 twin pairs provided 24 comparisons of intraclass correlations, which we grouped into the five social exposure categories. Fisher's z-test revealed significantly higher correlations in identical than fraternal pairs for each exposure category (z ≥ 3.53, p < 0.001). The difference remained consistent across gender, study site (country), sample size, whether psychometric instruments were used, whether interviewing was proximate or distant to the exposures, and whether informants were twins or third persons. Combined with other evidence that the differential intraclass correlation for child social adversity cannot be explained by evocative gene-environment covariation, our results indicate that the CTM does not provide any valid indication of genomic effects in schizophrenia.

Electroconvulsive Treatment: Hypotheses about Mechanisms of Action.

No consensus has been reached on the mode of action of electroconvulsive treatment (ECT). We suggest that two features may aid in the delineation of the involved mechanisms. First, when effective, ECT would be likely to affect brain functions that are typically altered in its primary recipient group, people with severe depression. Central among these are the frontal and temporal lobes, the hypothalamus-pituitary-adrenal (HPA) stress axis, and the mesocorticolimbic dopamine system. Second, the involved mechanisms should be affected for a time period that matches the average endurance of clinical effects, which is indicated to be several days to a few weeks. To identify effects upon frontal and temporal lobe functioning we reviewed human studies using EEG, PET, SPECT, and fMRI. Effects upon the HPA axis and the dopamine system were assessed by reviewing both human and animal studies. The EEG studies indicate that ECT decelerates neural activity in the frontal and temporal lobes (increased delta and theta wave activity) for weeks to months. Comparable findings are reported from PET and SPECT studies, with reduced cerebral blood flow (functional deactivation) for weeks to months after treatment. The EEG deceleration and functional deactivation following ECT are statistically associated with reduced depression scores. FMRI studies indicate that ECT flattens the pattern of activation and deactivation that is associated with cognitive task performance and alters cortical functional connectivity in the ultra slow frequency range. A common finding from human and animal studies is that ECT acutely activates both the HPA axis and the dopamine system. In considering this evidence, we hypothesize that ECT affects the brain in a similar manner as severe stress or brain trauma which activates the HPA axis and the dopamine system and may compromise frontotemporal functions.

Suicidality before and in the early phases of first episode psychosis.

INTRODUCTION: The suicide risk in psychotic disorders is highest in the early phases of illness. Studies have typically focused on suicidality from treatment start rather than actual onset of psychosis. This study explored the prevalence and characteristics of suicidality in patients with a first episode of psychosis (FEP) in two time intervals: 1) prior to study entry and 2) explicitly in the period of untreated psychosis. METHOD: One hundred seventy FEP-patients were interviewed as soon as possible after treatment start. The interview included assessments of diagnoses, suicidality, symptoms, substance use, and premorbid functioning. RESULTS: Nearly 26% of the patients attempted suicide prior to study entry and 14% made suicide attempts during the period of untreated psychosis. Of the patients who had been suicidal (i.e. experienced suicidal ideation or attempts), 70% were suicidal during the period of untreated psychosis. Suicide attempts prior to study entry were associated with female gender, more depressive episodes, younger age at psychosis onset, and history of alcohol disorder. Suicide attempts during untreated psychosis were also associated with more depressive episodes and younger age at illness onset, in addition to drug use the last six months and longer duration of untreated psychosis (DUP). CONCLUSION: The prevalence of suicidality before and in the early phases of FEP is high, especially during untreated psychosis. As prolonged DUP is associated with suicide attempts during the period of untreated psychosis, reducing the DUP could have the effect of reducing the prevalence of suicide attempts in patients with FEP.

Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms.

Mental health services and research have been dominated for several decades by a rather simplistic, reductionistic focus on biological phenomena, with minimal consideration of the social context within which genes and brains inevitably operate. This 'medical model' ideology, enthusiastically supported by the pharmaceutical industry, has been particularly powerful in the field of psychosis, where it has led to unjustified and damaging pessimism about recovery. The failure to find robust evidence of a genetic predisposition for psychosis in general, or 'schizophrenia' in particular, can be understood in terms of recently developed knowledge about how epigenetic processes turn gene transcription on and off through mechanisms that are highly influenced by the individual's socio-environmental experiences. To understand the emerging evidence of the relationship between adverse childhood events and subsequent psychosis, it is necessary to integrate these epigenetic processes, especially those involving the stress regulating functions of the HPA axis, with research about the psychological mechanisms by which specific types of childhood trauma can lead to specific types of psychotic experiences. The implications, for research, mental health services and primary prevention, are profound.

Thinking and hallucinating: reciprocal changes in sleep.

Internal deliberations (focused thoughts) and endogenous percepts (hallucinations) vary in a reciprocal manner across the states of waking and sleep, paralleling changes in regional brain activation. As subjects go from waking through sleep onset to NREM sleep and then to REM sleep, they report progressively more hallucinoid imagery and progressively less thinking. We have investigated whether this reciprocity in cognition between NREM and REM is maintained throughout the night. To do so, we analyzed 229 REM and 165 NREM reports collected with the Nightcap sleep monitoring system from 16 participants in their homes over 14 nights. The reports were scored for the presence of hallucinations and directed thinking by external judges. As predicted, hallucinations were more frequent in REM than in NREM for each segment of the night, and directed thinking was more frequent in NREM in the first 5 h of the night. Late in the night, directed thinking was equally infrequent in NREM and REM. At the same time, hallucinations increased within both NREM and REM as the night progressed, whereas directed thinking decreased in NREM and remained at a stable, low level in REM. These findings suggest that a reciprocal shift in focused thinking and hallucinating is a general property of cognitive activity across the wake-sleep cycle. Biological evidence supports the hypothesis that these cognitive changes are governed by specific state regulatory and neurocognitive processes at several levels of the brain.