Exploring the "Insight Paradox" in Treatment-Resistant Schizophrenia: Correlations Between Dimensions of Insight and Depressive Symptoms in Patients Receiving Clozapine.

Objective: There remains a lack of clarity as to the possible cross talk of insight into illness and depressive symptoms in treatment-resistant schizophrenia. We therefore set our primary aim to evaluate relationship between insight dimensions and depressive symptoms in patients with treatment-resistant schizophrenia receiving clozapine. Methods: This was a cross-sectional, non-interventional study, conducted in daily clinical practice conditions. Patients in outpatient clinics between March 2020 and May 2020 with treatment-resistant schizophrenia (based on Treatment Response and Resistance in Psychosis), with no comorbid psychiatric disorder, and with no body mass index greater than 40.0 kg/m2 were included. We collected sociodemographic variables, scores of insight dimensions (treatment compliance, illness recognition, and symptom relabeling with the Schedule for Assessment of Insight), and depressive symptoms with Calgary Depression Score for Schizophrenia. Linear regression models were used to investigate variables associated with depressive symptoms as the outcome of interest. Results: The final analysis sample comprised 55 patients with treatment-resistant schizophrenia, with a mean age of 42.48 (SD = 9.18) years and a predominance of the male sex (n = 42, 76.9%). Model 1 [Calgary Depression Score for Schizophrenia ~ (Schedule for Assessment of Insight + Positive and Negative Syndrome Scale)] displayed that 48% of the variation in the Calgary Depression Score for Schizophrenia can be explained by Schedule for Assessment of Insight-composite and Positive and Negative Syndrome Scale-composite (P < .001). More effectively, model 2 [Calgary Depression Score for Schizophrenia ~ (Schedule for Assessment of Insight-illness recognition + Positive and Negative Syndrome Scale-general psychopathology)] revealed that 51% of the variation in the Calgary Depression Score for Schizophrenia can be explained by the sub-scales (P < .001). We further designed a new model in which Global Assessment of Functioning scores were the response variable to explore the link between awareness into illness and functionality (Global Assessment of Functioning ~ Schedule for Assessment of Insight-illness recognition). In this model, awareness of illness did not explain a significant proportion of variance in functionality scores (R 2 = 0.045, F(1,52) = 2.48, P = 0.121). Conclusion: The treatment compliance part of insight was not one of the significant explanatory variables of depressive symptoms, but it explained the variance in functioning, in contrast to the illness recognition dimension of insight. If our findings were replicated in treatment-resistant schizophrenia, they would suggest that promoting treatment compliance dimension of insight instead of recognition of illness could not increase depressive symptoms.

Socio-demographic characteristics and factors associated with hospitalization in psychiatry of old age patients: an international comparison between Ireland and Turkey.

BACKGROUND: Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis. AIMS: We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features. METHODS: The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression. RESULTS: There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey. DISCUSSION: Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population. CONCLUSIONS: It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.

Patient body image, self-esteem, and cosmetic results of minimally invasive robotic cardiac surgery.

BACKGROUND: Patient-reported outcome measures reveal the quality of surgical care from the patient's perspective. We aimed to compare body image, self-esteem, hospital anxiety and depression, and cosmetic outcomes by using validated tools between patients undergoing robot-assisted surgery and those undergoing conventional open surgery. MATERIALS AND METHODS: This single-center, multidisciplinary, randomized, prospective study of 62 patients who underwent cardiac surgery was conducted at Hospital from May 2013 to January 2015. The patients were divided into two groups: the robotic group (n = 33) and the open group (n = 29). The study employed five different tools to assess body image, self-esteem, and overall patient-rated scar satisfaction. RESULTS: There were statistically significant differences between the groups in terms of self-esteem scores (p = 0.038), body image scores (p = 0.026), overall Observer Scar Assessment Scale (p = 0.013), and overall Patient Scar Assessment Scale (p = 0.036) scores in favor of the robotic group during the postoperative period. Robot-assisted surgery protected the patient's body image and self-esteem, while conventional open surgery decreased these levels but without causing pathologies. Preoperative depression and anxiety level was reduced by both robot-assisted surgery and conventional open surgery. The groups did not significantly differ on Patient Satisfaction Scores and depression/anxiety scores. CONCLUSION: The results of this study clearly demonstrated that a minimally invasive approach using robotic-assisted surgery has advantages in terms of body image, self-esteem, and cosmetic outcomes over the conventional approach in patients undergoing cardiac surgery.

Relationship Between Metabolic Syndrome and Clinical Features, and Its Personal-Social Performance in Patients with Schizophrenia.

The aim of this study was to evaluate the metabolic syndrome (MS) criteria and also to investigate the effects of MS on medical treatment, clinical course and personal and social performance in patients with schizophrenia. One hundred-sixteen patients with schizophrenia were included in the study. Measurements of MS were calculated in all patients. Brief Psychiatric Rating Scale, Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Personal and Social Performance Scale (PSP) were applied. The frequency of MS according to IDF criteria was 42.2 % among the patients. There was no significant difference between patients with and without MS in terms of age. The ratios of MS were 62.5 % for the group taking typical and atypical antipsychotics together and 35.7 % for the group taking two or more atypical antipsychotics together. The duration of disorder in patients with MS was higher than those without MS. Furthermore there was no significant difference between the schizophrenic patients with and without MS, in terms of PSP scores. Our findings showed that the duration of illness, high scores of BMI, use of clozapine or concurrent use of typical and atypical antipsychotics, depressive and negative symptoms of schizophrenia were significant risk factors for the development of MS.

Attentional Bias and Training in Social Anxiety Disorder.

Cognitive behavioral therapy (CBT) is one of the most effective treatment modalities for social anxiety disorder (SAD), showing a high level of clinical evidence supporting its effectiveness. On the other hand, lack of the desired benefit from this treatment in some patients causes continuation of the search for new techniques. Recent research studies have focused on attentional bias and attention training in SAD. Attention processes in SAD have been a major target of interest and investigation since the introduction of the first cognitive models explaining SAD. In the first model, it was highlighted that attention was self-focused. The relationship between threatening stimuli and attention was considered in the subsequent models. Attentional bias towards threat may take place in several ways, such as facilitated processing of threat, difficulty in disengaging attention from the threat and avoidance of attention from the threat. After these descriptions regarding the phenomenology of the disorder, treatments to modify attention, processes were developed. In spite of conflicting results, investigations on attentional training are promising. Attention processes, attentional bias and attentional training in SAD are discussed in this review.

The relationship between adulthood traumatic experiences and psychotic symptoms in female patients with schizophrenia.

BACKGROUND: Previously, research aiming to investigate the effects of interpersonal traumatic experiences on psychotic symptoms mainly focused on adverse experiences in childhood. As mentioned above, patients with schizophrenia, particularly women, are at high risk for physical and sexual abuse in adulthood. In this study we aimed to investigate the effects of adulthood trauma in a sample of patients with schizophrenia who did not report childhood trauma. METHODS: Seventy female patients with schizophrenia participated in the study. Assessment included Traumatic Experiences Checklist, Positive and Negative Syndrome Scale and Calgary Depression Scale for Schizophrenia. RESULTS: The rates of traumatic events were as follows: physical abuse (81.4%), emotional abuse (78.6%), emotional neglect (55.7%), sexual harassment (28.6%), and sexual abuse (24.3%). Positive and Negative Syndrome Scale hallucinations, blunted affect, emotional withdrawal hostility, anxiety and affective lability item scores were significantly higher for patients who reported a history of sexual harassment. Patients who were exposed to sexual assault as adults had significantly higher scores in the Positive and Negative Syndrome Scale, anxiety, anger and difficulty in delaying gratification items. CONCLUSION: We concluded that traumatic life events and exposure to violence were common among female patients with schizophrenia and sexual trauma in adulthood was associated with particular clinical symptoms.

[ADHD in adult psychiatric outpatients: prevalence and comorbidity]. / Ayaktan psikiyatri hastalarinda dikkat eksikligi ve hiperaktivite bozuklugu: yayginlik ve estanilar.

AIM: This study aimed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) in adult psychiatric outpatients. Moreover, comorbid psychiatric diagnoses in adults with ADHD were determined. Patients with and without ADHD were compared regarding DSM Axis I-II comorbidity and sociodemographic characteristics. MATERIALS AND METHODS: The study included patients that presented for the first time to a psychiatric outpatient clinic during a 3-month period and were evaluated for adult ADHD. A sociodemographic form, Wender Utah Rating Scale, Turgay's Adult ADD/ADHD Evaluation Scale, Structured Clinical Interview I and II, Symptom Check List-90-R, and Beck Depression Inventory were administered. RESULTS: The study included 246 patients. Among the 39 patients diagnosed with ADHD, 25 were female (64.1%) and 14 were male (35.9%), and the mean age was 27.38 ± 8.3 years. The prevalence of ADHD in adult psychiatric patients was 15.9%. Adults with ADHD usually presented due to comorbid psychiatric problems; major depression (43%), generalized anxiety disorder (23%), and obsessive-compulsive disorder (17%) were the most common comorbid diagnoses. Substance abuse (58.9%) and attempted suicide (38.5%) were among the most prevalent psychiatric problems. CONCLUSION: The present findings show that ADHD is an important comorbidity in adult patients that present to psychiatric clinics, and may cause serious mental health problems or complicate mental illness.

[The impact of disease course and type of episodes in bipolar disorder on caregiver burden]. / Bipolar I bozuklugu olan hastalarda dönem ve seyirözelliklerinin bakici yüküne etkisi.

OBJECTIVE: The aim of this study was to determine how the disease course and type of episodes in patients with bipolar I disorder (BPD-I) affect caregiver burden. MATERIALS AND METHODS: The study was conducted between February and July 2010, and included 89 euthymic-state BPD-I patients (55 with a natural course and 34 with ≥1 mixed episode or a rapid cycling course) diagnosed according to DSM-IV-TR criteria and 89 of their caregivers. The patients were evaluated using a sociodemographic clinical form, the Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), and Global Assessment of Functionality Scale (GAFS). The caregivers were evaluated using a sociodemographic form and the Zarit Caregiver Burden Interview (ZCBI). RESULTS: In all, 44% of the BPD-I patients' caregivers had moderate to severe burden. More of the caregivers of patients with rapid cycling or mixed episodes had social relationships negatively affected by caregiver burden (P < 0.01). The mean YMRS score was higher in the caregivers with moderate to severe burden (P< 0.01). As patient age, YMRS score, number of manic episodes, duration of illness, and duration of caregiving during the euthymic period increased (P < 0.05) the level of caregiver-perceived dependency also increased; as caregiver age and the duration of caregiving increased, the perception of economic burden decreased (P< 0.05). CONCLUSION: BPD-I patient caregiving, even when patients are in a euthymic state, results in considerable caregiver burden. Mixed episodes or rapid cycling increases the severity of caregiver burden, as does the number of manic episodes and the presence of subsyndromal manic features.

Effects of childhood trauma and clinical features on determining quality of life in patients with bipolar I disorder.

BACKGROUND: We explored how childhood trauma (CHT) affects the clinical expression of disorder and quality of life in patients with bipolar I (BP-I) disorder. METHODS: Euthymic patients (n=116) who subsequently received a diagnosis of BP-I disorder were consecutively included and were interviewed using the following sociodemographic and clinical data forms; Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Childhood Abuse and Neglect Questionnaire (CANQ) and the 36-item Medical Outcome Study Short Form Health Survey (SF-36). The quality of life of BP-I patients with and without a history of CHT were examined. RESULTS: The percentage of trauma was 61.2%. Patients who had CHT had higher frequencies of depressive episodes (t=-2.38, p=0.019), total episodes (t=-2.25, p=0.026), attempted suicide more often (χ(2)=18.12, p=0.003) and had lower scores on the pain subscale of the SF-36 (z=-2.817, p=0.005). In patients with mixed or rapid-cycling episodes, SF-36 subscale scores except general health and pain were found to be lower. LIMITATIONS: Our sample may fail to reflect the general BD population; the patients were included consecutively and consisted of a majority of female patients. CONCLUSIONS: CHT plays an important role in the clinical expression of BP-I disorder and having mixed/rapid-cycling episodes negatively affects both physical and mental components, as measured by the SF-36. While both males and females reported experiencing sexual abuse, female BP-I patients complained about pain more often. It is suggested that treatment of BP-I patients with a history of CHT should differ from that provided for patients with no CHT history.

Thyroid status in lithium-treated bipolar disorder patients: An one-year follow-up study / Estudio de un año de seguimiento del estado de la tiroides en pacientes con trastorno bipolar tratados con litio

Objective In this follow-up study, the hormonal changes were determined in bipolar euthyroid patients who were treated with lithium for the duration of one year. Method For the study, 23 bipolar I disorder patients without any axis I co-morbidity were consecutively selected and followed up for one year. All patients were compared with 25 age- and sex-matched healthy controls in terms of thyroid hormone levels and thyroid volumes. The Sociodemographic and Clinical Characteristics Data Form, Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I and SCID-I/NP) were administered. Initial thyroid hormone levels and thyroid volumes were measured in the patients and controls. Patient and control groups were compared at baseline for thyroid volumes. Patients' lithium levels were measured at baseline, they were re-examined at six months for thyroid hormones, and at the first year for thyroid hormones and lithium levels. Results Thyroid hormone levels changed in no patients during the follow-up period. Thyroid hormone levels were measured within the normal range. No correlation was found between the final TSH levels and duration of illness, duration of lithium treatment, initial thyroid volumes, and the initial TSH levels. Conclusions Lithium can safely be used in bipolar patients who were already receiving this treatment before and not developed any thyroid problem for a substantial period.

En este estudio de seguimiento se determinarán los cambios hormonales que se producen en pacientes eutiroideos con trastorno bipolar en tratamiento con litio durante un periodo de un año. Método Para el estudio se seleccionaron de forma consecutiva 23 pacientes con trastorno bipolar tipo I sin prevalencia concomitante de otros trastornos del eje I, y fueron seguidos durante un año. En todos los pacientes se compararon los niveles de las hormonas tiroideas y el volumen de la glándula tiroides con las del grupo control sano pareado por sexo y compuesto de sujetos de 25 años de edad. La evaluación se hizo por medio de: una hoja de datos de las características sociodemográficas y clínicas, la Escala de Valoración de Hamilton para la Evaluación de la Depresión (HDRS), la Escala de Young para la Evaluación de la Manía (YMRS), Entrevistas clínicas estructuradas para los trastornos del eje I del DSM-IV (SCID-I y SCID-I/NP). A los pacientes y al grupo control se les midieron los niveles iniciales de las hormonas tiroideas y el volumen de la glándula tiroides, a la vez que se les comparó la línea base del volumen de la glándula tiroides. Al inicio del estudio se determinó la línea base de los niveles de litio en los pacientes. Al sexto mes, se reexaminaron las hormonas tiroideas y, al cabo del primer año, los niveles hormonales tiroideos y de litio. Resultados Los niveles de las hormonas tiroideas no sufrieron cambios en ningún paciente durante todo el seguimiento. Dichos niveles se midieron dentro de los intervalos normales. No se detectó ninguna correlación entre los niveles de TSH y la duración de la enfermedad, ni con la duración del tratamiento con litio, ni entre los volúmenes iniciales de las glándulas tiroideas con los niveles iniciales de TSH. Conclusión El litio puede administrarse con seguridad en pacientes bipolares que se hayan sometido antes a este tratamiento, y a los cuales no les produzca problemas tiroideos durante un periodo significativo de tiempo.

Differences in Affective Temperaments in Anxiety Disorders: Comparison of Panic Disorder and Obsessive Compulsive Disorder.

INTRODUCTION: In this study, probable differences in affective temperament among anxiety disorders were investigated via a comparison of panic disorder (PD) and obsessive-compulsive disorder (OCD). METHOD: 44 patients with OCD and 42 patients with PD, who were admitted to Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery outpatient clinics with complaints of OCD and PD and were diagnosed according to DSM IV criteria, were consecutively included in the study after informed consent was taken. A sociodemographic form, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I), Hamilton Depression Rating Scale (HAM-D), Beck Anxiety Inventory, Panic and Agoraphobia Scale, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the temperament evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) were given to the patients. PD and OCD patients were compared in terms of affective temperament characteristics. RESULTS: Mean age, educational status and gender distribution of OCD and PD patients were similar (p>0.05). Dominant depressive temperament was more prominent in OCD group than in PD group (p=0.021). Hyperthymic temperament scores were higher in PD group than in OCD group (p=0.002). Dominant hyperthymic temperament was not encountered in either group. CONCLUSION: Dominant depressive temperament was more prominent in OCD group whereas hyperthymic temperament scores were higher in PD group. These findings should be evaluated in studies with larger sample sizes.

The relationship between temperament and character in conversion disorder and comorbid depression.

AIMS: The aim of this study was to compare conversion disorder patients with healthy controls in terms of temperament and character, and to determine the effect of these characteristics on comorbid depression, based on the idea that conversion disorder patients may have distinctive temperament and character qualities. METHODS: The study involved 58 patients diagnosed with conversion disorder, based on the DSM-IV diagnostic criteria, under observation at the Bakirköy Psychiatric and Neurological Disorders Outpatient Center, Istanbul. The patients were interviewed with a Structured Clinical Interview (SCID-I) and 57 healthy volunteers, matched for age, sex and education level, were interviewed with a Structured Clinical Interview for people without a psychiatric disorder (SCID-I/NP). All the participants completed a sociodemographic form, the Hamilton Depression Rating Scale, the Hamilton Anxiety Scale and the Temperament and Character Inventory. RESULTS: The conversion disorder patients displayed more harm avoidance (P<.001), more impulsivity (P<.01) and more sentimentality (P<.01) than the healthy controls, but were less persistent (P<.05). In terms of character qualities, conversion disorder patients had high self-transcendence (P<.05), but were inadequate in terms of self-directedness (P<.001) and took on less responsibility (P<.05) than the healthy controls. CONCLUSION: Conversion disorder patients are significantly different from healthy controls on temperament and character measures of harm avoidance, persistence, self-transcendence and self-directedness.

[Assessment of executive functions in social phobia patients using the Wisconsin Card Sorting Test]. / Sosyal fobide yönetici islevlerin Wisconsin Kart Esleme Testi ile degerlendirilmesi.

OBJECTIVE: Problem solving and adjusting responses according to feedback are among the executive functions that may be impaired in social phobia patients. The objective of this study was to compare social phobia patients' Wisconsin Card Sorting Test scores with those of controls; thus, our aim was to examine executive functions in social phobia patients. METHOD: The study included 36 social phobia patients (16 female [44.4%] and 20 male [55.6%]) whose age, sex, and level of education were matched with those of a healthy control group. Participants were administered the Structured Clinical Interview for DSM-IV Axis I Disorders, Beck Depression Inventory, State-Trait Anxiety Inventory, Liebowitz Social Anxiety Scale along, and Wisconsin Card Sorting Test. RESULTS: Patients with social phobia scored lower than the control group in terms of the total number of correct responses, number of categories completed, and percentage of conceptual level responses on the Wisconsin Card Sorting Test. The total number of errors and total non-preservative errors were elevated in the patient group. No differences were observed in preservative errors and set-maintenance between the patient and control groups. The number of correct responses and the percentage of conceptual level responses were negatively correlated with trait anxiety and social avoidance scores, whereas the number of errors was positively correlated with trait anxiety and social avoidance scores. Non-preservative errors were positively correlated with state-anxiety, social fear, and social avoidance scores. CONCLUSION: Working memory in the social phobia patients was impaired, as compared to that of the healthy controls. High social anxiety scores had a negative impact on working memory.

Geriatric psychiatry consultations in a Turkish university hospital.

OBJECTIVE: The size of the elderly population is growing rapidly in Turkey. We aimed to characterize geriatric psychiatry consultations to obtain the characteristic pattern of these patients for further interventions. METHOD: A retrospective chart review was undertaken for each patient. RESULTS: One hundred and sixty-six patients with a mean age (+/- S.D.) of 75.5 +/- 6.6 years were included in this study. Most referrals came from the Department of Internal Medicine (42.2%), with sleep problems (42.1%), depression (29.5%) and anxiety (28.3%) being the most common reasons for referral. Hypertension was the most frequent medical diagnosis (53.6%). The mean number +/- S.D.) of medications used by each patient was 4.4 +/- 2.0. The leading psychiatric diagnosis at the end of the assessment was adjustment disorder (31.3%). CONCLUSION: Turkish geriatric psychiatry consultation patients display similar characteristics to elderly patients from other western countries. The main difference comes from diagnosis of adjustment disorder, which may be related to hospital conditions and strong family ties in developing countries.