Can “Model Projects of Need-Adapted Care” Reduce Involuntary Hospital Treatment and the Use of Coercive Measures?

Intensive outpatient models of need-adapted psychiatric care have been shown to reduce the length of hospital stays and to improve retention in care for people with severe mental illnesses. In contrast, evidence regarding the impact of such models on involuntary hospital treatment and other coercive measures in inpatient settings is still sparse, although these represent important indicators of the patients' wellbeing. In Germany, intensive models of care still have not been routinely implemented, and their effectiveness within the German psychiatric system is only studied in a few pioneering regions. An innovative model of flexible, assertive, need-adapted care established in Berlin, Germany, in 2014, treating unselected 14% of the catchment area's patients, was evaluated on the basis of routine clinical data. Records of n = 302 patients diagnosed with severe mental disorders, who had been hospitalized at least once during a 4-year-observational period, were analyzed in a retrospective individual mirror-image design, comparing the 2 years before and after inclusion in the model project regarding the time spent in hospital, the number and duration of involuntary hospital treatments and the use of direct coercive interventions like restraint or isolation. After inclusion to the project, patients spent significantly less time in hospital. Among patients treated on acute wards and patients with a diagnosis of psychosis, the number of patients subjected to provisional detention due to acute endangerment of self or others decreased significantly, as did the time spent under involuntary hospital treatment. The number of patients subjected to mechanical restraint, but not to isolation, on the ward decreased significantly, while the total number of coercive interventions remained unchanged. Findings suggest some potential of intensive models of need-adapted care to reduce coercive interventions in psychiatry. However, results must be substantiated by evidence from randomized-controlled trials and longer observation periods

Traumatic Events, Social Adversity and Discrimination as Risk Factors for Psychosis - An Umbrella Review

Exposure to childhood trauma is a well-known risk factor for severe mental disorders including schizophrenia and other non-affective psychoses. Beyond childhood trauma, there is increasing evidence that bullying, social exclusion, and discrimination during adolescence and adulthood may increase the risk of developing a psychotic disorder, and that such forms of traumatization may also underlie the elevated psychosis risk among migrants or persons with a visible minority status. In this umbrella review, we systematically assess meta-analyses regarding trauma and social adversity. A systematic literature review yielded 11 meta-analyses that met inclusion criteria and could be summarized quantitatively with a random effect model. Furthermore, six meta-analyses were evaluated qualitatively. Heterogeneity and publication bias were apparent in several meta-analyses. We observed that most significant social risk factors for psychosis were vulnerability for racist discrimination [OR = 3.90 (3.25-4.70)], migration [OR = 2.22 (1.75-2.80)], and childhood adversities [OR = 2.81 (2.03-3.83)]. Furthermore, social factors increasing the risk for psychosis were variation/impairment of parental communication, aversive adult life events, bullying, and factors associated with social isolation and discrimination. In spite of these environmental risk factors, there is a lack of evidence regarding treatment of trauma and psychosis, although some psychotherapeutic and art therapy approaches appear to be promising. Beyond individual interventions, stigmatization, racism, and other forms of discrimination need to be targeted to increase solidarity and communal support

Levels of Structural Integration Mediate the Impact of Metacognition on Functioning in Non-affective Psychosis: Adding a Psychodynamic Perspective to the Metacognitive Approach

Synthetic metacognition is defined by integrative and contextualizing processes of discrete reflexive moments. These processes are supposed to be needed to meet intrapsychic as well as interpersonal challenges and to meaningfully include psychotic experience in a personal life narrative. A substantial body of evidence has linked this phenomenon to psychosocial functioning and treatment options were developed. The concept of synthetic metacognition, measured with the Metacognition Assessment Scale-Abbreviated (MAS-A), rises hope to bridge gaps between therapeutic orientations and shares valuable parallels to modern psychodynamic constructs, especially the 'levels of structural integration' of the Operationalized Psychodynamic Diagnosis (OPD-2). As theoretical distinctions remain, aim of this study was to compare the predictive value of both constructs with regard to psychosocial functioning of patients with non-affective psychoses, measured with the International Classification of Functioning, Disability and Health (MINI-ICF-APP). It was further explored if levels of structural integration (OPD-LSIA) would mediate the impact of metacognition (MAS-A) on function (MINI-ICF-APP). Expert ratings of synthetic metacognition (MAS-A), the OPD-2 'levels of structural integration' axis (OPD-LSIA), psychosocial functioning (MINI-ICF-APP) and assessments of general cognition and symptoms were applied to 100 individuals with non-affective psychoses. Whereas both, MAS-A and OPD-LSIA, significantly predicted MINI-ICF-APP beyond cognition and symptoms, OPD-LSIA explained a higher share of variance and mediated the impact of MAS-A on MINI-ICF-APP. Levels of structural integration, including the quality of internalized object representations and unconscious interpersonal schemas, might therefore be considered as valuable predictors of social functioning and as one therapeutic focus in patients with non-affective psychoses. Structural integration might go beyond and form the base of a person's actual reflexive and metacognitive capabilities. Psychotherapeutic procedures specific for psychoses may promote and challenge a patient's metacognitive capacities, but should equally take the need for maturing structural skills into account. Modern psychodynamic approaches to psychosis are shortly presented, providing concepts and techniques for the implicit regulation of interpersonal experience and aiming at structural integration in this patient group

Peripheral oxytocin is inversely correlated with cognitive, but not emotional empathy in schizophrenia

Endogenous oxytocin has been associated with different aspects of social cognition in healthy subjects and patients with schizophrenia. In this pilot study, we investigated the relationship between plasma oxytocin and oxytocin level changes induced by empathy-eliciting, attachment-related movie scenes with correlates of cognitive and emotional empathy in patients and healthy controls. The Multifaceted Empathy Test (MET) and the Interpersonal Reactivity Index (IRI) were administered to patients with schizophrenia (N = 35, 12 females) and healthy controls (N = 35, 12 females) to estimate dimensions of cognitive and emotional empathy. Peripheral basal oxytocin concentrations and oxytocin responses to movie-based emotional stimuli were assessed using radioimmunoassay with sample extraction. In patients, induced oxytocin level changes were inversely correlated with MET cognitive empathy regarding negative emotional states. Controlling for non-social cognition and age revealed a significant negative association between basal oxytocin levels and MET cognitive empathy for positive emotions. In healthy subjects, oxytocin reactivity was inversely correlated with the IRI subscale "fantasy". Oxytocin was not related to any measure of emotional empathy. A hyper-reactive oxytocin system might be linked to impaired cognitive empathy as a part of a dysfunctional regulative circuit of attachment-related emotions and interpersonal stressors or threats by attribution of meaning. Healthy adults with a disposition to identify with fictional characters showed lower oxytocin reactivity, possibly indicating familiarity with movie-based stimuli. The oxytocinergic system may be involved in maladaptive coping mechanisms in the framework of impaired mentalizing and associated dysfunctional responses to interpersonal challenges in schizophrenia

Exploring Influences on Theory of Mind Impairment in Opioid Dependent Patients

Theory of mind (ToM) is an aspect of social cognition impaired in different addictive disorders, including opioid addiction. This study aimed at replicating ToM deficits in opioid dependent patients undergoing opioid maintenance treatment (OMT) and exploring the influence of substance use related variables, executive functions and childhood maltreatment on ToM in opioid dependent patients. 66 opioid dependent patients were tested using the Movie for Assessment of Social Cognition (MASC) and compared with the data of healthy controls. Furthermore, the opioid dependent patients underwent testing for executive functions and filled in the Childhood Trauma Questionnaire (CTQ). Performance on the MASC was significantly poorer in the opioid dependence group than in the control group, even when recent additional drug use and psychiatric comorbidities were controlled for. No correlations were found between ToM and substance use related factors. Aspects of ToM performance in opioid dependent patients correlated significantly with different EF domains. ToM correlated significantly with the CTQ scales for physical maltreatment. The results confirm impaired ToM in opioid dependent patients and highlight executive functions and childhood maltreatment as influential factors. The lack of associations between ToM and substance use related variables and the association with childhood maltreatment suggest that ToM impairments might be a risk factor predating substance abuse.Peer Reviewe

Structural impairment and conflict load as vulnerability factors for burnout – A cross-sectional study from the German working population

IntroductionIndividual vulnerability and resilience factors are increasingly studied in burnout research. This is especially true for clinical variables that translate directly into intervention programs from a psychodynamic perspective. For example, few studies have examined the relationship between structural impairment and the individual spectrum of motivational conflicts according to the Operationalized Psychodynamic Diagnosis system (OPD) in relation to burnout. To substantiate previous findings, we hypothesized that structural impairment as well as motivational conflicts are related to burnout, but that structural impairment explained additional variance and mediated a possible relationship between conflicts and burnout.MethodThe present cross-sectional study was carried out on a sample of the German working population (N = 545). Questionnaires were used to measure structural impairment (OPD-SQS), the conflict-modes along with the category K0 (OPD-CQ), as well as burnout (BOSS-I/-II).ResultsStructural impairment, a number of conflict modes, and burnout were significantly associated. Moreover, structural impairment explained additional variance in burnout. The requirements for the conflict-specific mediation models were given for 9 of the 12 OPD conflict modes. In these models the impact of the conflict modes on burnout was mediated by structural impairment.DiscussionThe current study broadens the comprehension of the relations between structural impairment, the conflict modes and burnout. In addition it higlights the role of structural impairment in predicting burnout risk and possible prevention approaches

Linguistic findings in persons with schizophrenia—a review of the current literature

IntroductionAlterations of verbalized thought occur frequently in psychotic disorders. We characterize linguistic findings in individuals with schizophrenia based on the current literature, including findings relevant for differential and early diagnosis.MethodsReview of literature published via PubMed search between January 2010 and May 2022.ResultsA total of 143 articles were included. In persons with schizophrenia, language-related alterations can occur at all linguistic levels. Differentiating from findings in persons with affective disorders, typical symptoms in those with schizophrenia mainly include so-called “poverty of speech,” reduced word and sentence production, impaired processing of complex syntax, pragmatic language deficits as well as reduced semantic verbal fluency. At the at-risk state, “poverty of content,” pragmatic difficulties and reduced verbal fluency could be of predictive value.DiscussionThe current results support multilevel alterations of the language system in persons with schizophrenia. Creative expressions of psychotic experiences are frequently found but are not in the focus of this review. Clinical examinations of linguistic alterations can support differential diagnostics and early detection. Computational methods (Natural Language Processing) may improve the precision of corresponding diagnostics. The relations between language-related and other symptoms can improve diagnostics

Modeling Incoherent Discourse in Non-Affective Psychosis

Background: Computational linguistic methodology allows quantification of speech abnormalities in non-affective psychosis. For this patient group, incoherent speech has long been described as a symptom of formal thought disorder. Our study is an interdisciplinary attempt at developing a model of incoherence in non-affective psychosis, informed by computational linguistic methodology as well as psychiatric research, which both conceptualize incoherence as associative loosening. The primary aim of this pilot study was methodological: to validate the model against clinical data and reduce bias in automated coherence analysis. Methods: Speech samples were obtained from patients with a diagnosis of schizophrenia or schizoaffective disorder, who were divided into two groups of n = 20 subjects each, based on different clinical ratings of positive formal thought disorder, and n = 20 healthy control subjects. Results: Coherence metrics that were automatically derived from interview transcripts significantly predicted clinical ratings of thought disorder. Significant results from multinomial regression analysis revealed that group membership (controls vs. patients with vs. without formal thought disorder) could be predicted based on automated coherence analysis when bias was considered. Further improvement of the regression model was reached by including variables that psychiatric research has shown to inform clinical diagnostics of positive formal thought disorder. Conclusions: Automated coherence analysis may capture different features of incoherent speech than clinical ratings of formal thought disorder. Models of incoherence in non-affective psychosis should include automatically derived coherence metrics as well as lexical and syntactic features that influence the comprehensibility of speech