Effects of Metacognitive Training on Cognitive Insight in a Sample of Patients with Schizophrenia.

Metacognitive training (MCT) is a group intervention that addresses cognitive biases and distortions that could help maintain delusions and hallucinations in people with schizophrenia. This program has proven its effectiveness in reducing the symptoms, but its impact on cognitive insight has scarcely been investigated. Therefore, the aim of the study was to assess the program's impact on cognitive insight in patients with long-term schizophrenia. A sample of 22 patients with schizophrenia was divided into two groups: one received 16 sessions of MCT (n = 11), while the other received the usual treatment (n = 11). They were assessed using the Beck Cognitive Insight Scale which measures two components, self-reflection and self-certainty, and the Positive and Negative Syndrome Scale (PANSS). The experimental group showed high levels of adherence, an increase in self-reflection, and a decrease in self-assurance levels as hypothesized. We found statistically significant differences between the control and experimental groups in excitation, hostility, positive symptomatology total score, hallucinatory behavior, and suspicion. In the usual treatment group, a non-significant decrease in positive symptoms was also observed. The findings showed that the implementation of the MCT program in real clinical settings can contribute to an improvement in the metacognitive ability and symptomatology of people with schizophrenia.

Prevalencia de primer episodio de delirio, factores relacionados y su impacto sobre mortalidad, en pacientes ingresados en convalecencia / Prevalence of the first episode of delirium, related factors and their impact on mortality, in patients admitted in a convalescence unit

Objetivos: Determinar la prevalencia de aparición de primer episodio de delirium en mayores de 65 años, su impacto sobre mortalidad y factores relacionados. Métodos: Estudio cross-sectional, prospectivo. Durante 4 meses se incluyeron pacientes ≥ 65 años ingresados en una unidad de convalecencia, excluyéndose sujetos con demencia avanzada, diagnóstico de encefalopatía orgánica o evidencia de delirium al momento del ingreso. Se estudiaron variables específicas de la valoración geriátrica y mediante un cuestionario se observaron probables factores predisponentes (deterioro visual/auditivo, uso de medicamentos psicoactivos) y factores precipitantes (uso de catéter urinario, fiebre, mal control del dolor o alteraciones en el sueño). El delirium se diagnosticó mediante la escala CAM. Se realizó análisis multivariable utilizando métodos de regresión logística para descripción de factores relacionados con delirium; y método proporcional de Cox para descripción de los predictores de mortalidad. Resultados: Se incluyeron 195 pacientes. El 39% (76/195) fueron hombres, con edad media de 81.9 años (8.5). El índice de Barthel al ingreso fue 45 (IQR 25-60) y el índice de Charlson 2 (IQR 1-4). El 21% (41/195) presentó delirium previo. La prevalencia de primer episodio de delirium fue de 23.1% (95% CI: 17.7-29.5). Los principales factores relacionados con el riesgo de desarrollo de delirium fueron: la edad OR:1.6 (95%CI 1.01-1.11), el número de errores según Test de Pfeiffer OR:1.4 (95%CI 1.2-1.64) y el Indice de Charlson al ingreso OR:1.25 (95%CI 1.02-1.53). La estancia media fue de 37.1 (21.2) días y e tiempo para desarollo de delirium fue de 15 días. Fueron éxitus 11 sujetos (5.7%). Los principales predictores de mortalidad global, ajustados por edad e índice de Charlson, fueron: Delirium HR:5.26 (95%CI 1.30-21.29) y derivación desde Urgencias (Subagudos) HR:5.34 (95%CI 1.6217.56). Conclusión: Las variables relacionadas con deterioro cognitivo fueron las más importantes relacionadas con el desarrollo de delirium en una unidad de convalescencia. El delirium es un factor independiente de mortalidad en estas unidades

Objectives: To determine the prevalence of the first episode of delirium in patients older than 65 years, its impact on mortality and related factors. Methods: Prospective and cross-sectional study. During 4 months of follow-up, patients older than 65 years admitted in a post-acute convalescence unit were included. Using a questionnaire, we studied probable predisposing factors (visual and hearing impairment, psychoactive drugs) and precipitating factors (bladder catheter, fever, poor control of pain and sleep disturbances). Additionally, demographic data, comorbidity, pre-existing cognitive impairment and physical function were recorded. Subjects with advanced dementia, diagnosis of any organic encephaloencephalopathy or evidence of delirium at the time of the admission were excluded. Delirium was defined according the Confusion Assessment Method. The factors associated with delirium were studied by a multivariate analysis performed by logistic regression. A multivariate Cox proportional hazards regression analysis was used to examine predictors of mortality with competing endpoints (death and discharge alive) and estimated both the daily hazard and cumulative risk of death. Results: A total of 195 patients received follow-up during the observation period. A 39% (76/195) were men (mean 82.1 years). Admission Barthel index score was 45 (IQR 25-60) and Charlson comorbidity score was 2 (IQR 1-4). A 21% (41/195) had presented history of delirium prior. Prevalence of first episode of delirium was 23.1% (95% CI: 17.7-29.5). Principal related factors to delirium were: Age OR:1.6 (95%CI 1.01-1.11), total errors according Pfeiffer's Test OR:1.4 (95%CI 1.2-1.64) and Charlson comorbidity score OR:1.25 (95%CI 1.02-1.53). Mean time for development of delirium was 15 days and average time for hospital discharge was 37.1 days. 11 subjects (5.7%) died during followup. Adjusted by age and Charlson score, main predictors for mortality were: Delirium HR:5.26 (95%CI 1.30-21.29) and derivation from emergency room HR:5.34 (95%CI 1.6217.56). Conclusions: Associated variables with cognitive impairment were the most important with development of first episode of delirium in a convalescence unit. Delirium is an independent factor of mortality in these units

Mindfulness and psychotic experiences in college students / Mindfulness y experiencias psicóticas en estudiantes universitarios

The study of the relation between psychotic experiences and mindfulness in the general population is linked to research into factors of risk and protection against the development of a psychotic disorder. This study looks into the presence of psychotic experiences in a sample of university students and whether there is any variation according to gender. It also analyzes the predictive and discriminant relation of mindfulness with these experiences. The sample consisted of 526 university students (72.8% women) with a mean age of 21.39 years (SD = 3.53). The results showed the presence of psychotic experiences with differing levels of intensity, with variations according to gender, and an inverse relationship between mindfulness and psychotic experiences. Results indicated that students with high scores in psychotic experiences had lower scores in mindfulness. Our findings imply that mindfulness may be a factor of protection against psychotic experiences and its training may have a role to play in the development and implementation of preventive and early intervention programs in risk groups in the general and clinical population

El estudio de la relación entre experiencias psicóticas y mindfulness en la población general se asocia con la investigación de factores de riesgo y protección frente al desarrollo de un trastorno psicótico. Con este estudio se pretende examinar la presencia de experiencias psicóticas en una muestra de estudiantes universitarios y sus diferencias según el sexo, así como analizar la relación predictiva y discriminante de mindfulness con estas experiencias. Los participantes fueron 526 estudiantes universitarios (72.8% mujeres) con una media de edad de 21.39 años (DT = 3.53). Los resultados mostraron la presencia de experiencias psicóticas con diferentes niveles de intensidad, diferencias según el sexo en las mismas, y una relación inversa entre mindfulness y las experiencias psicóticas, y se encontró que las personas con altas puntuaciones en experiencias psicóticas contaron con menores puntuaciones en mindfulness. Estos resultados suponen que mindfulness puede ser un factor de protección en la experimentación de experiencias psicóticas y su entrenamiento puede ser útil para implementación y desarrollo de programas preventivos y de intervención precoz en grupos de riesgo en población general y clínica

[Acute psychosis as a side effect of efavirenz therapy with metabolic anomalies: an important differential diagnosis of HIV-associated psychoses]. / Akute Psychose als Nebenwirkung der Therapie mit Efavirenz bei metabolischer Anomalie : Eine wichtige Differenzialdiagnose HIV-assoziierter Psychosen.

Among patients with human immunodeficiency virus (HIV) infections psychiatric disease poses a particular challenge for caregivers. Neuropsychiatric side effects of efavirenz have been described in up to 40% of patients showing dizziness, insomnia, unusual dreams, mood instability, personality alterations and thought disorders. In immigrants from Africa and South America these side effects may be related to elevated plasma concentrations of efavirenz due to polymorphisms of cytochrome P450 isozymes (especially G516T). Alleles for these polymorphisms are more frequent in African and South American patients. We report a case of a 52-year-old patient from Guinea who was referred to the department of neurology under the diagnosis of HIV-associated neurocognitive disorder (HAND). Since the start of combined antiretroviral therapy (cART) including efavirenz the patient had suffered severe personality alterations, acoustic and visual hallucinations and delusions which led to discrimination and reduced quality of life. Diagnostic procedures including magnetic resonance imaging (MRT) and spinal fluid analysis resulted in normal values and did not explain the disease. After switching to nevirapin instead of efavirenz the psychotic symptoms disappeared within 5 days.

Brief psychoeducation for schizophrenia primarily intended to change the cognition of auditory hallucinations: an exploratory study.

Auditory hallucinations and delusions are core symptoms of schizophrenia, which interact with each other. The attribution of auditory hallucinations to other people is considered to lead to secondary delusions. This study examined whether brief psychoeducation can change the cognition of auditory hallucinations, particularly, their attribution, and thus alleviate secondary delusions. Twenty-two schizophrenic patients with auditory hallucinations were recruited in this open study. The intervention consisted of five sessions during the course of 4 weeks. Outcome measures were used to assess delusions, beliefs about auditory hallucinations, and depression. At the end of the intervention, statistically significant reduction was observed in both delusions and depression. Beliefs about hallucinations showed statistically significant improvement in terms of malevolence, omnipotence, and resistance but not in terms of benevolence and engagement. In conclusion, the present study suggests that psychoeducation might be useful in reducing secondary delusions without exacerbating a depressive state.

[The sense of the senseless, psychoanalytic aspects of delusion in psychosis]. / Le sens de l'insensé, aspects psychanalytiques du délire dans la psychose.

The psychoanalytic approach to delusion in psychosis leads us to examine the function of a "furrow". It is necessary to remain in the furrow in order not to become delusional. References to Sigmund Freud, Jacques Lacan, Mélanie Klein and Jean-Claude Maleval enlighten us as to the origin and the function of delusion as an attempt to give meaning.

[Distress and delusion]. / Le souffre délire.

Delusional and pervasive speech, beyond the usual patient dialogue, is one of the fundamental aspects which the nursing team must deal with on a daily basis. The supportive care provided to Edouard, a delusional patient, is an example.

Psychological distress and delusional memories after critical care: a literature review.

BACKGROUND: A considerable number of intensive care unit (ICU) survivors report delusional memories, which refer to dreams, nightmares, paranoid delusions and hallucinations experienced in the ICU. These memories often have a strong vividness, long duration and high emotional impact. AIM: The aim of this review was to investigate and synthesize published literature about psychological distress associated with delusional memories of adult ICU survivors. METHODS: Using key terms, a search was conducted in major health care electronic databases [Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science and PsycInfo] focusing on articles published between 1990 and 2009 in English-language journals. FINDINGS: Ten articles met the inclusion criteria. Recall of delusional memories at various intervals after ICU discharge was associated with post-traumatic stress disorder (PTSD)-related symptoms in many studies, while associations with other aspects of psychological distress, mainly feelings of fear, anxiety and depression, were also reported. Recent studies did not seem to confirm the protective role of factual memories. CONCLUSIONS: The findings support the association between delusional memories and PTSD-related symptoms, but further research is needed to confirm their association with other psychological disorders. Development of a safety sense in the ICU can protect patients against the emotional impact of both delusional and stressful factual ICU memories. Appropriate follow-up of high-risk patients could improve their long-term psychological recovery.

Prevention of negative symptom psychopathologies in first-episode schizophrenia: two-year effects of reducing the duration of untreated psychosis.

BACKGROUND: The duration of untreated psychosis (DUP)-the time from onset of psychotic symptoms to the start of adequate treatment--is consistently correlated with better course and outcome, but the mechanisms are poorly understood. OBJECTIVE: To report the effects of reducing DUP on 2-year course and outcome. DESIGN: A total of 281 patients with a DSM-IV diagnosis of nonorganic, nonaffective psychosis coming to their first treatment during 4 consecutive years were recruited, of which 231 participated in the 2-year follow-up. A comprehensive early detection (ED) system, based on public information campaigns and low-threshold-psychosis-detecting teams, was introduced in 1 health care area (ED area), but not in a comparable area (no-ED area). Both areas ran equivalent 2-year treatment programs. RESULTS: First-episode patients from the ED area had a significantly lower DUP, better clinical status, and milder negative symptoms at the start of treatment. There were no differences in treatment received for the first 2 years between the groups. The difference in negative symptoms was maintained at the 1-year follow-up. There was a statistically significant difference in the Positive and Negative Syndrome Scale negative component, cognitive component, and depressive component in favor of the ED group at the 2-year follow-up. Multiple linear regression analyses gave no indication that these differences were due to confounders. CONCLUSION: Reducing the DUP has effects on the course of symptoms and functioning, including negative symptoms, suggesting secondary prevention of the negative psychopathologies in first-episode schizophrenia.

[Delusion in the critical patient]. / Delirio en el paciente crítico.

Delirium, the acute confusional syndrome, is a common although infradiagnosed problem in the critically ill patient, especially the hypoactive subtype. Risk factors for delirium are previous cognitive disturbances, some comorbidities, ambiental factors and the acute organic alterations of critical illness. Delirium is associated to an increase in short and long term mortality, prolongation of mechanical ventilation, increased Intensive Care Unit (ICU) and hospital length of stay, and cognitive impairment after hospital discharge. In the last years several tools have been developed to detect delirium in critically ill patients. The Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for ICU patients (CAM-ICU) have been validated and are useful even in patients receiving mechanical ventilation. Some interventions on specific risk factors can decrease the incidence of delirium in hospitalized patients. Treatment of delirium is based on the identification and correction of contributing factors, the introduction of support measures, and pharmacological therapy for symptomatic control. Halloperidol is the first line therapy of delirium in the critically ill patient, while experience with atypical neuroleptics and other drugs is limited, precluding to do recommendations about its use. Neuroleptic drugs can produce severe side effects and need careful dosage and monitoring. When agitation is important, can be necessary the simultaneous use of benzodiazepines or propofol, and some times, the temporal and protocolized application of physical restraints.

Gender, threat/control-override delusions and violence.

This study brings together the threat/control-override perspective and the literature on gender and stress coping to argue that gender moderates the association between threat delusions and violence. We suggest that men are more likely than women to respond to stressors such as threat delusions with violence. We test these ideas using data from the MacArthur Violence Risk Assessment Study, a multi-wave study of post-discharge psychiatric patients. Within-person results from two-level hierarchical models support the idea that men and women cope with threat delusions differently. Specifically, we find that men are significantly more likely to engage in violence during periods when they experience threat delusions, compared with periods when they do not experience threat delusions. In contrast, women are significantly less likely to engage in violence during times when they experience threat delusions, compared with periods when they do not. We discuss these findings in light of the literature on gender and stress coping.

Lithium combinations in acute and maintenance treatment of unipolar and bipolar depression.

Bipolar illness and unipolar depression are both affective disorders associated with high lifetime morbidity and premature mortality due to suicide. Numerous double-blind, placebo-controlled trials have shown that lithium augmentation therapy is effective in treating acute episodes of bipolar depression, refractory major depression, and delusional depression as well as in reducing recurrences of these illnesses. Lithium is the only agent approved by the U.S. Food and Drug Administration for maintenance treatment of bipolar disorder. Further research is needed to specifically address whether the antidepressant effect of adding lithium is greater in bipolar disorder or in unipolar depressions. This article will summarize available evidence and clinical considerations regarding the use of lithium augmentation in acute and maintenance treatment of unipolar and bipolar depressions.

The schizophrenia prodrome revisited: a neurodevelopmental perspective.

Despite the widespread acceptance of the neurodevelopmental model of schizophrenia, its application to research concerned with the prodromal phase of illness is limited. Little recognition has been given to the concept of an enduring biological vulnerability to illness that may be responsive to early intervention. Rather, the focus of most prodromal studies is on emerging positive symptoms. The Recognition and Prevention (RAP) program follows the strategy of being equally concerned with the nonspecific symptoms reflecting the core of schizophrenia and those directly related to psychosis. Data were collected from 62 adolescents (mean age = 16.4 years) during the initial 3-year pilot phase of the RAP program (1998-2001). Subjects were divided into three clinical high-risk groups, characterized by (1) negative and nonspecific symptoms (e.g., social isolation, school failures), the earliest prodrome stage; (2) emerging attenuated positive symptoms of moderate intensity; and (3) severe attenuated (but subpsychotic) positive symptoms, considered most proximal to psychosis. Four risk factors, derived from the neurodevelopmental literature, were selected to reflect the vulnerability core: cognitive deficits, affective disturbances, social isolation, and school failure. All four domains were equally impaired across the three risk groups, supporting the presence of the underlying vulnerability core regardless of the magnitude of emerging positive symptoms. An observational pilot study was also conducted to identify the medications typically used to treat emerging positive symptoms. Antidepressants were used as frequently as antipsychotics to treat adolescents presenting with moderate attenuated positive symptoms. Regardless of type of medication, moderately symptomatic youngsters did quite well over the approximately 1-year followup period. By contrast, adolescents presenting with more severe (but nonpsychotic) attenuated symptoms were treated with antipsychotics, often in combination with other agents. Outcome for the more symptomatic youngsters was, however, more guarded, with nearly half (i.e., 47%) of the group converting to a schizophrenia spectrum psychotic disorder. Nonadherence to medication appeared to be a major risk factor in this group. We conclude that a neurodevelopmental model of schizophrenia is supported by our data and that a range of novel treatment strategies may be neuroprotective by directly affecting the disorder's vulnerability core.

The effects of olanzapine in reducing the emergence of psychosis among nursing home patients with Alzheimer's disease.

BACKGROUND: Elderly patients with Alzheimer's disease (AD) commonly exhibit psychotic symptoms, prompting clinicians to administer antipsychotics. This article compares the effects of olanzapine and placebo in the emergence of hallucinations or delusions in AD patients with symptoms of agitation/aggression but little or no psychotic symptomatology at baseline. METHOD: A multicenter, double-blind, placebo-controlled study was conducted in nursing home patients with AD according to DSM-IV criteria and symptoms of agitation/aggression and/or psychosis. Patients (N = 206) were randomly assigned to receive either placebo or fixed-dose olanzapine (5, 10, or 15 mg/day) for up to 6 weeks. This article analyzes data from a subgroup of patients (N = 165) with no or minimal delusions and/or hallucinations at baseline as measured by the Neuropsychiatric Inventory-Nursing Home Version (NPI/NH). Three subsets of patients were identified on the basis of their symptoms at baseline: those with no clinically significant hallucinations, those with no clinically significant delusions, and those with no clinically significant delusions or hallucinations. RESULTS: Of the patients without hallucinations or delusions at baseline (N = 75), the placebo-treated patients showed significantly greater development of these symptoms compared with olanzapine-treated patients overall (NPI/NH hallucinations + delusions mean change score, +2.73 vs. +0.27, p = .006). Similarly, of the patients without baseline hallucinations (N = 153), the placebo-treated patients showed greater hallucinations score increases than did olanzapine-treated patients overall (+1.25 vs. +0.33, p = .026), whereas patients without baseline delusions (N = 87) showed no significant treatment effects. Olanzapine had a favorable safety profile in each patient subset. CONCLUSION: These results suggest that, overall, olanzapine effectively attenuated emergence of psychosis in a short-term trial of patients with Alzheimer's disease.

Cognitive therapy of schizophrenia: a new therapy for the new millennium.

Over the past decade, major advances have been made in extending the principles and therapeutic strategies of cognitive therapy to the treatment of schizophrenia. In a number of large-scale outcome studies with cognitive therapy for schizophrenia, cognitive therapy has been shown to offer significant gains for those patients who have not been wholly helped with medications. It may even serve to prevent the consolidation of the illness if delivered with those in the early stage of the illness. We first outline the "state-of-the-art" conceptualization and strategies employed by cognitive therapists to treat positive and negative symptoms and then review the clinical trials.

Hallucinations and delusions. 2: A dual diagnosis case study.

This article, the second of two parts, describes how evidence-based psychological interventions were used to help a client suffering from treatment-resistant delusions and substance misuse, allied to a chaotic lifestyle, that had previously presented a substantial challenge to services. The first part (Vol 8(15): 998-1002) Investigated how the neurobiological, social and environmental factors involved in the course and treatment of schizophrenia have helped to establish a pathway to recovery or remission that does not involve pharmacological therapy alone.

Outcome at discharge and six months in major depression. The significance of psychotic features.

Inpatients with nonbipolar psychotic major depression (N = 46) had significantly lower Hamilton Rating Scale scores at discharge and a significantly greater number of weeks back to their "normal selves" during a 6-month follow-up than did patients with nonpsychotic major depression (N = 159). While both baseline severity and the receipt of electroconvulsive therapy distinguished these groups, neither accounted for the outcome differences noted. Severity ratings at discharge were clearly more predictive of follow-up course in psychotic patients than they were in nonpsychotic patients. Moreover, patients with psychotic depression had clearer outcomes in that their average follow-up weeks were more likely to involve either full syndromes or a complete absence of depressive symptoms. This finding, if replicated, may account in part for the lack of consensus on the prognostic significance of psychotic depression.