A controlled trial of adaptive disclosure-enhanced to improve functioning and treat posttraumatic stress disorder.

OBJECTIVE: This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types. AD-Enhanced (AD-E) uses letter writing (e.g., to the deceased), loving-kindness meditation, and bolstered homework to facilitate improved functioning to repair TL and MI-related trauma. METHOD: The primary outcomes were the Sheehan Disability Scale (SDS), evaluated at baseline, throughout treatment, and at 3- and 6-month follow-ups (Brief Inventory of Psychosocial Functioning was also administered), the Clinician-Administered PTSD Scale (CAPS-5), the Dimensions of Anger Reactions, the Revised Conflict Tactics Scale, and the Quick Drinking Screen. RESULTS: There were statistically significant between-group differences on two outcomes: The intent-to-treat (ITT) mixed-model analysis of SDS scores indicated greater improvement from baseline to posttreatment in the AD-E group (d = 2.97) compared to the PCT group, d = 1.86; -2.36, 95% CI [-3.92, -0.77], t(1,510) = -2.92, p < .001, d = 0.15. Twenty-one percent more AD-E cases made clinically significant changes on the SDS than PCT cases. From baseline to posttreatment, AD-E was also more efficacious on the CAPS-5 (d = 0.39). These differential effects did not persist at follow-up intervals. CONCLUSION: This was the first psychotherapy of veterans with TL/MI-related PTSD to show superiority relative to PCT with respect to functioning and PTSD, although the differential effect sizes were small to medium and not maintained at follow-up. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Reconsidering research exclusion for serious mental illness: Ethical principles, current status, and recommendations.

BACKGROUND: Historically, individuals managing serious mental illness (SMI) have often been excluded from research, typically because of concern that these individuals may not be able to understand and provide truly informed consent. As treatment has improved, the assumption that individuals managing SMI may not be capable of consent needs to be re-examined. Systematic exclusion from research may limit empirically tested treatments available for people managing SMI, and may contribute to the health care disparities seen in this population. OBJECTIVES: This article examines this issue by documenting current rates of research exclusion for high disease burden conditions, based on empirical review of studies in ClinicalTrials.gov. RESEARCH DESIGN: Current rates of exclusion from studies for psychiatric conditions were assessed through systematic review of relevant clinical trials on ClinicalTrials.gov. SUBJECTS: Subjects in this inquiry are either articles accessed in the literature reviews, or descriptions of studies in public data on ClinicalTrials.gov. MEASURES: The primary measure was a previously published coding system to document the extent and types of research exclusion related to psychiatric status. RESULTS: Among studies of interventions for substance use disorders and chronic pain, individuals managing SMI were more likely to be excluded than those with other psychiatric disorders at statistically significant levels. This was not the case among studies of interventions for ischemic heart disease. In studies of substance use disorders, 9% explicitly excluded SMI and 83% could exclude people with SMI based on broader exclusion criteria. In studies of chronic pain these two categories of exclusion were 16% and 55%, and in studies of ischemic heart disease, these two categories of exclusion were 1% and 20%. CONCLUSIONS: Evidence indicates that it is ethically and scientifically more appropriate to exclude based on capacity to consent than membership in the group of individuals managing SMI. The discussion outlines techniques researchers can use for more equitable and generalizable sampling.

Increases in Intrinsic Thalamocortical Connectivity and Overall Cognition Following Cognitive Remediation in Chronic Schizophrenia.

BACKGROUND: Thalamic projections to the prefrontal cortex (PFC) are critical for cognition, and disruptions in these circuits are thought to underlie the pathophysiology of schizophrenia. Cognitive remediation (REM) is a behavioral intervention that holds promise for improving cognition and functioning in schizophrenia, however the extent to which it affects thalamo-prefrontal connections has not been researched. This study sought to determine whether patients with schizophrenia who undergo a placebo-controlled trial of REM show increased functional connectivity between the thalamus and PFC, and whether these changes correspond to improvements in cognition. METHODS: Twenty-six patients with chronic schizophrenia were randomized to either 48 hours (over 16 weeks) of a drill-and-practice working memory-focused REM or an active placebo condition. All participants underwent cognitive assessment (MATRICS Consensus Cognitive Battery), as well as both resting and task-based fMRI before and after their respective intervention. All clinicians, technicians, and raters were blind to participant condition. RESULTS: We observed changes in resting-state connectivity in the PFC for the REM group but not the placebo group. Increased intrinsic connectivity between the thalamus and right middle frontal gyrus correlated with improvements in overall cognition. Additionally, lower baseline cognition correlated with greater increases in connectivity between the thalamus and PFC. Similar findings were observed when patients were scanned during a working memory task. CONCLUSIONS: These results suggest that increases in thalamo-prefrontal circuitry correspond with training-related improvements of the cognitive deficits associated with schizophrenia.

Neuroplastic changes in patients with schizophrenia undergoing cognitive remediation: triple-blind trial.

BackgroundPatients with schizophrenia have shown cognitive improvements following cognitive remediation, but the neuroplastic changes that support these processes are not fully understood.AimsTo use a triple-blind, placebo-controlled trial to examine neural activation before and after cognitive remediation or a computer skills training (CST) placebo (trial registration: NCT00995553)).MethodTwenty-seven participants underwent functional magnetic resonance imaging before and after being randomised to either cognitive remediation intervention or CST. Participants completed two variants of the N-back task during scanning and were assessed on measures of cognition, functional capacity, community functioning and symptoms.ResultsWe observed a group × time interaction in the left prefrontal cortex, wherein the cognitive remediation group showed increased activation. These changes correlated with improved task accuracy within the cognitive remediation group, whereas there was no relationship between changes in activation in untrained cognitive measures. Significant changes were not observed in other hypothesised areas for the cognitive remediation group.ConclusionsWe replicated the finding that cognitive remediation increases left lateral prefrontal activation during a working memory task in patients with schizophrenia, suggesting this may be an important neural target for these types of interventions.

Effects of the Indianapolis Vocational Intervention Program (IVIP) on defeatist beliefs, work motivation, and work outcomes in serious mental illness.

Defeatist beliefs and amotivation are prominent obstacles in vocational rehabilitation for people with serious mental illnesses (SMI). The CBT-based Indianapolis Vocational Intervention Program (IVIP) was specifically designed to reduce defeatist beliefs related to work functioning. In the current study, we examined the impact of IVIP on defeatist beliefs and motivation for work, hypothesizing that IVIP would be associated with a reduction in defeatist beliefs and greater motivation for work. We also examined the effects of IVIP on these variables as well as work outcomes during a 12-month follow-up. Participants with SMI (n=64) enrolled in a four-month work therapy program were randomized to IVIP or a support therapy group (SG). Assessments were conducted at baseline, post-treatment (4months), and follow-up (1year). Compared to those in SG condition, individuals randomized to IVIP condition reported greater reductions in defeatist beliefs and greater motivation for work at follow-up, along with greater supported employment retention rates. Specifically treating and targeting negative expectations for work therapy improves outcomes, even once active supports of the IVIP program and work therapy are withdrawn.

Inpatient utilization before and after implementation of psychosocial rehabilitation programs: analysis of cost reductions.

Research on psychosocial rehabilitation (PSR) interventions generally indicates that these approaches are effective in facilitating improved functioning for persons with serious mental illness (SMI; schizophrenia, schizoaffective disorder, bipolar disorder, and other psychotic disorders). In this quasi-experimental study, we assessed the effectiveness of PSR interventions through a records review of 311 veterans who received outpatient services for SMI. From 2002 to 2008, a midwestern VA Medical Center implemented a number of PSR interventions. By 2008, veterans who used PSR interventions demonstrated reductions in their use of inpatient psychiatric care, whereas veterans who did not access PSR interventions showed no change in inpatient psychiatric care use. Analyses revealed that the provision of PSR services to veterans with SMI who had been hospitalized was associated with decreased duration of hospitalizations and costs savings of $17,739 per veteran per year in total mental health care. Findings are consistent with implementation of PSR programs within VA Medical Centers yielding the greatest cost savings through creation of effective outpatient services that reduce inpatient service needs for veterans with SMI.

Attribution biases in schizophrenia: relationship to clinical and functional impairments.

BACKGROUND: Patients with schizophrenia exhibit impairment in their ability to accurately recognize facial emotions in others, and the severity of this emotion perception deficit has been associated with poorer functioning. However, the mechanisms underlying facial emotion perception deficits are poorly understood. There is evidence to suggest that patients, particularly those with certain positive symptoms, may misinterpret other people's facial expressions as having an overly negative valence. The present study examined the degree to which attribution biases in facial emotion perception are associated with psychiatric symptomatology and social and occupational impairments. SAMPLING AND METHODS: The error profiles from a facial emotion perception test were analyzed and compared for 67 schizophrenic state hospital inpatients and 21 nonpsychiatric controls. Attribution bias scores were separately computed for each of six types of emotion. RESULTS: The error profiles were remarkably similar for patients as a group and controls. Within the patient group, severity of positive symptoms was associated with more 'fear' misperceptions. Patients with relatively high levels of 'anger' misperceptions tended to have more severe disorganization and negative symptoms and more pronounced functional impairments. Interestingly, patients who erroneously reported seeing relatively high levels of 'shame' and 'happiness' showed better functioning and less severe symptoms. CONCLUSIONS: Attribution biases appear to play a role in contributing to functional impairments in patients with schizophrenia. The lack of an isomorphic attribution bias across patients highlights the importance of considering schizophrenia heterogeneity when attempting to understand and treat social cognitive deficits.

Computerized measurement of negative symptoms in schizophrenia.

Accurate measurement of negative symptoms is crucial for understanding and treating schizophrenia. However, current measurement strategies are reliant on subjective symptom rating scales, which often have psychometric and practical limitations. Computerized analysis of patients' speech offers a sophisticated and objective means of evaluating negative symptoms. The present study examined the feasibility and validity of using widely-available acoustic and lexical-analytic software to measure flat affect, alogia and anhedonia (via positive emotion). These measures were examined in their relationships to clinically-rated negative symptoms and social functioning. Natural speech samples were collected and analyzed for 14 patients with clinically-rated flat affect, 46 patients without flat affect and 19 healthy controls. The computer-based inflection and speech rate measures significantly discriminated patients with flat affect from controls, and the computer-based measure of alogia and negative emotion significantly discriminated the flat and nonflat patients. Both the computer and clinical measures of positive emotion/anhedonia corresponded to functioning impairments. The computerized method of assessing negative symptoms offered a number of advantages over the symptom scale-based approach.

Attentional dysfunction, social perception, and social competence: what is the nature of the relationship?

The aim of this study was to examine the nature of the relationship between attentional dysfunction and social competence deficits in patients with schizophrenia. Attentional functioning, social perception, and social competence were assessed in 56 inpatients. Measures of vigilance and span of apprehension were administered to assess attentional functioning. Social perception was assessed with an audiovisual measure of affect recognition. Social competence was rated from a role-play task. Span of apprehension and auditory vigilance emerged as specific predictors of social competence. Affect recognition was tested as a mediator and a moderator of the relationship between attentional dysfunction and social competence. Affect recognition was found to moderate the relationship between span of apprehension and social competence.

Neurocognitive and social cognitive correlates of formal thought disorder in schizophrenia patients.

The neurocognitive and social cognitive correlates of two types of formal thought disorder (i.e., bizarre-idiosyncratic and concrete thinking) were examined in 47 stable outpatients with schizophrenia. Both types of thinking disturbance were related to impairments in verbal learning, intrusions in verbal memory, immediate auditory memory, sustained attention, and social schema knowledge. Distractibility during an immediate memory task was associated with more frequent bizarre verbalizations but not concreteness. Impaired verbal learning rate and intrusions in verbal memory independently contributed to the prediction of bizarre responses, whereas intrusions in verbal memory and impaired immediate memory independently contributed to concrete thinking. This pattern of findings is consistent with the view that neurocognitive and, possibly, social cognitive deficits underlie these two aspects of formal thinking disturbance in schizophrenia.

Diminished emotionality and social functioning in schizophrenia.

There is indirect evidence to suggest that a subgroup of patients with schizophrenia exhibit a diminished capacity to experience both positive and negative emotions. To date however, no studies have focused specifically on this diminished emotionality (DE). The main objective of the present project was to determine whether patients with self-reported DE differed from other patients in level of social functioning, physical and social anhedonia, and negative/deficit symptoms. Seventy-three state hospital patients with DSM-IV diagnosed schizophrenia and 22 nonpsychiatric controls were examined. Results provided mixed support for the present hypotheses. Patients with self-reported DE (N = 10) versus those without (N = 63) had poorer social functioning, similar levels of physical and social anhedonia, and significantly less severe negative/deficit symptoms. Moreover, there was a substantial amount of discrepancy between patients' self-reported levels of emotionality and the ratings of their emotionality as made by trained observers. Implications of these results are discussed.

Internal source monitoring and communication disturbance in patients with schizophrenia.

BACKGROUND: This study examined the relationship between internal source monitoring and disordered speech in patients with schizophrenia or schizoaffective disorder. It was predicted that internal source monitoring would relate specifically to one type of communication disturbance, the missing information reference. METHOD: Immediate, working, and internal source memory were assessed in 47 out-patients diagnosed with schizophrenia or schizoaffective disorder. Speech samples were also collected from this sample and coded for six types of communication disturbance. RESULTS: Of the six types of communication disturbance coded in this study, internal source monitoring indices were uniquely related to the frequency of the missing information reference. Furthermore, internal source monitoring was the only type of short-term memory process assessed in this study that was related to the missing information reference. Neither immediate nor working-memory capacity was related significantly to the frequency of this type of communication disturbance. CONCLUSIONS: This study adds to our knowledge of the neurocognitive processes that underlie communication disturbance in the speech of patients with schizophrenia.

Internal source monitoring and thought disorder in schizophrenia.

A new task was developed to examine source monitoring in 52 patients with schizophrenia. Patients and nonpsychiatric controls were not found to differ on recognition memory, source discrimination, or attribution bias when the between group difference in IQ was controlled. However, among patients, source discrimination was significantly related to severity of thought disorder. After controlling for IQ and verbal working memory, thought-disordered patients were significantly poorer than nonthought-disordered patients at discriminating the source of previously presented information. Results suggest that internal source monitoring is specifically related to thought disorder in patients with schizophrenia.

Stress and arousability in schizophrenia.

This paper examines trait arousability (TA), a temperament characteristic, in 47 stable outpatients with schizophrenia and 50 non-psychiatric controls. Self-reported levels of stress were obtained during a negative and positive memory speech task. Levels of TA, and the association of TA scores with reported stress during the speech tasks, were examined both between and within groups. In addition, TA scores were examined in relation to symptom presentation in the patient group. Patients reported higher levels of trait arousability and higher levels of stress than controls. Trait arousability scores were significantly associated with reported stress in one of the speech condition in patients, and with the severity of positive and affective symptoms. These results suggest that temperament characteristics of an individual with schizophrenia may be related to stress responsiveness and symptom presentation.

Stability of formal thought disorder and referential communication disturbances in schizophrenia.

This study examined the degree to which different types of communication disturbances in the speech of 48 schizophrenia patients and 28 controls were variable and state related versus stable and traitlike. Clinically rated formal thought disorder and 5 types of referential disturbance showed substantial stability within participants over time. The sixth type of referential disturbance, the vague reference, was not stable over time. Formal thought disorder was associated with the severity of core psychotic symptoms in patients. whereas referential disturbances showed little or no association with positive or negative symptom severity. Furthermore, changes in psychotic symptoms over time were accompanied by corresponding changes in formal thought disorder but not referential disturbances. These results support the idea that some types of referential disturbances are traitlike and may be reflective of vulnerability as well as manifest illness.

Self-reported stress and the deficit syndrome of schizophrenia.

GENERALLY speaking, schizophrenia is not associated with diminished positive and negative emotions. Even patients with negative symptoms such as blunted affect have generally not differed in their levels of self-reported emotionality compared to patients without negative symptoms. However, there is evidence to suggest that a subgroup of patients with negative symptoms, those with the deficit syndrome, have a diminished capacity to experience positive and negative emotions. The present study examined whether ratings of the deficit and negative syndrome were associated with lower levels of self-reported stress during a laboratory-based, emotion-induction manipulation. Thirty-six participants with schizophrenia were asked to produce separate affectively positive and affectively negative narratives. Immediately following each narrative, participants were asked to report the level of stress they had experienced while recounting their memories. The deficit syndrome ratings, analyzed in a continuous and a categorical manner, were associated with lower levels of self-reported stress in the affectively negative condition. Moreover, the deficit and negative syndrome ratings significantly differed in their associations to levels of self-reported stress during both tasks, supporting the notion that there are appreciable differences between the two syndromes. Given that stress has been an essential component in conceptualizations of schizophrenia onset and relapse, the possibility of stress-resistant properties associated with the deficit syndrome should be tested in future research.