Theory of the paranoid mind: Sozial-kognitive Verarbeitungsstile, emotionale Prozesse und Verfolgungswahn bei Patienten mit schizophrenen Störungen

Ziel der vorliegenden Dissertation ist die Prüfung von Annahmen psychologischer Modelle zur Erklärung der Entstehung und Aufrechterhaltung von Verfolgungswahn, die die Rolle spezifischer sozial-kognitiver Verarbeitungsstile und emotionaler Prozesse betonen. Zu den sozial-kognitiven Verarbeitungsstilen wird der Attributionsstil gezählt, d.h. die Tendenz, negative Ereignisse auf externe Faktoren (andere Personen/Zufall) zurückzuführen, Defizite in der Theory of Mind (ToM; Premack; Woodruff, 1978), der Fähigkeit, korrekte Schlussfolgerungen über Intentionen, Emotionen und Verhalten anderer Menschen zu ziehen, und drittens die Tendenz, voreilige Schlussfolgerungen zu ziehen. Neuere kognitiv-behaviorale Interventionsstrategien setzen an den sozial-kognitiven und emotionalen Verarbeitungsstilen an, um eine Reduktion von Verfolgungswahn sowie eine verbesserte Lebensqualität zu bewirken. Jedoch sind die genauen Prozesse, durch die die spezifischen sozial-kognitiven Verarbeitungsstile und emotionalen Faktoren die Entstehung und Aufrechterhaltung wahnhafter Überzeugungen beeinflussen, noch nicht hinreichend untersucht. Die wesentlichen Zielsetzung des Dissertationsprojekts besteht somit darin, zugrunde liegende Mechanismen der sozial-kognitiven Verarbeitungsstile und emotionalen Prozesse zu untersuchen und dadurch die Weiterentwicklung kognitiv-behavioraler Interventionen für diese Patientengruppe voranzutreiben. Die Untersuchung erfolgte als Querschnittsdesign, bei dem insgesamt 63 Patienten mit schizophrenen Störungen mit 63 gesunden Kontrollprobanden verglichen wurden. Das erste Ziel war zu prüfen, ob bei Patienten mit akuten paranoiden Wahnvorstellungen ein implizit selbstabwertender Attributionsstil sowie ein implizit niedriger Selbstwert vorliegt. Dabei wurde ein modifiziertes Messinstrument zur Untersuchung des impliziten Attributionsstils verwendet, welches zwischen drei Attributionsloci (internal, external-personal und external-situational) differenzierte, statt zwischen zwei Attributionsloci wie in bisherigen Studien. Die Ergebnisse der vorliegenden Studie belegen einen implizit selbstabwertenden Attributionsstil bei Patienten mit paranoidem Wahn: Im Vergleich zu Patienten mit remittiertem Wahn und Kontrollprobanden attribuierten Patienten mit akutem Verfolgungswahn negative Ereignisse eher auf ihre eigene Person, während sie positive Ereignisse auf situationale Faktoren zurückführten. Der explizite Attributionsstil von Patienten mit paranoiden Wahnüberzeugungen war vergleichbar mit der Kontrollgruppe. Patienten mit akutem Verfolgungswahn, die einen selbstabwertenden impliziten Kausalattributionsstil aufwiesen, zeigten mit erhöhter Wahrscheinlichkeit auch einen niedrigeren impliziten Selbstwert. Generell war bei Patienten mit Verfolgungswahn ein instabiles Selbstkonzept festzustellen (normaler impliziter Selbstwert und niedriger expliziter Selbstwert). Das zweite Ziel bestand in der Testung eines spezifischen Zusammenhangs zwischen einem Aspekt der ToM-Fähigkeit, nämlich der Fähigkeit, in sozialen Situationen korrekte Schlussfolgerungen über Intentionen anderer Menschen zu ziehen, und dem Vorliegen paranoider Überzeugungen. Die Überprüfung erfolgte mit einer im Rahmen der vorliegenden Dissertation neu entwickelten ToM-Aufgabe, in der den Probanden soziale Situationen in Form von Filmsequenzen gezeigt wurden. Aufgabe der Probanden war es, Fragen bezüglich der Intentionen und der Emotionen der Filmcharaktere zu beantworten. Die Ergebnisse belegen einen spezifischen Zusammenhang zwischen Problemen im Treffen korrekter Schlussfolgerungen über Intentionen und dem Ausprägungsgrad allgemeiner Wahnüberzeugungen, der auch nach Kontrolle von Defiziten in exekutiven Funktionen bestehen blieb. Das dritte Ziel bestand in der Untersuchung der Hypothese, dass Defizite in der ToM-Fähigkeit und im autobiographischen Gedächtnis in Zusammenhang mit Problemen in der sozialen Kompetenz schizophrener Patienten stehen. Die Ergebnisse bestätigen diese Hypothese und weisen sogar darauf hin, dass Defizite in der ToM-Fähigkeit, Schlussfolgerungen über Emotionen anderer Menschen in sozialen Situationen zu treffen und Defizite im Abruf autobiographischer Erinnerungen besser die soziale Kompetenz vorhersagen als die klinische Symptomatik der Patienten und neuropsychologische Defizite. Insgesamt konnte im vorliegenden Dissertationsprojekt ein Beitrag zum Verständnis der psychologischen Modelle zur Erklärung der Entwicklung und Aufrechterhaltung wahnhafter Überzeugungen geleistet werden. Die Ergebnisse belegen die Notwendigkeit der Weiterentwicklung kognitiv-behavioraler Interventionen im Bereich der Verbesserung von sozial-kognitiven Fähigkeiten und emotionalen Problemen von Patienten mit Verfolgungswahn

Synthesis and photochromic properties of a bis(diarylethene)-naphthopyran hybrid

The synthesis and photochromic properties of a triphotochromic molecule consisting of one naphthopyran flanked by two diarylethene units investigated by UV-Visible and NMR spectroscopies are reported. Six different states resulting from the open/closed naphthopyran associated with one or two open/cyclized diarylethenes have been characterized. Switching of the naphthopyran group is possible, independently of the state of the diarylethene groups, permitting the controlled generation of electronically connected diarylethene groups. However, the diarylethene groups cannot be closed if the naphthopyran group is open

Metacognitive and cognitive-behavioral interventions for psychosis: new developments

This review describes four cognitive approaches for the treatment of schizophrenia: cognitive-behavioral therapy for psychosis (CBTp), metacognitive therapy, metacognitive training, and metacognitive reflection insight therapy (MERIT). A central reference point of our review is a seminal paper by James Flavell, who introduced the term metacognition ("cognition about cognition"). In a way, every psychotherapeutic approach adopts a metacognitive perspective when therapists reflect with clients about their thoughts. Yet, the four approaches map onto different components of metacognition. CBTp conveys some "metacognitive knowledge" (eg, thoughts are not facts) but is mainly concerned with individual beliefs. Metacognitive therapy focuses on unhelpful metacognitive beliefs about thinking styles (eg, thought suppression). Metacognitive training brings distorted cognitive biases to the awareness of patients; a central goal is the reduction of overconfidence. MERIT focuses on larger senses of identity and highlights metacognitive knowledge about oneself and other persons. For CBTp and metacognitive training, meta-analytic evidence supports their efficacy; single studies speak for the effectiveness of MERIT and metacognitive therapy.

Feasibility and efficacy of an acceptance and mindfulness-based group intervention for young people with early psychosis (Feel-Good group)

Background: Over the last decade, researchers have sought for alternative interventions that have better treatment effects than Cognitive Behavioral Therapy (CBT) when treating psychotic symptoms. Mindfulness-based interventions have been a proposed alternative to CBT, yet research regarding its feasibility, acceptance and effectiveness is lacking when treating individuals with early psychosis in inpatient settings. Objective: Before conducting a large-scale randomized-controlled trial (RCT), this pilot study evaluated the feasibility and the potential efficacy of a mindfulness-based inpatient group intervention that targets emotion regulation in patients with early psychosis, and thus indirectly improving psychotic symptoms. Methods: A pre–post study was performed. Thirty-six patients with early psychosis treated at the specialized inpatient treatment “Frühinterventionsund Therapiezentrum; FRITZ” (early intervention and therapy center) received eight group therapy sessions. Assessments were performed at baseline, after 8 weeks post treatment and at follow-up after 16 weeks. Results: Rates of patients who participated in the study suggests that a mindfulness-based group therapy is highly accepted and feasible for patients with early psychosis being treated in an inpatient ward. Friedman analyses revealed significant changes in the primary outcomes of emotional goal attainment (Goal 1: W = 0.79; Goal 2: W = 0.71) and psychotic symptoms (PANSS-T: W = 0.74). Significant, albeit small, effect sizes were found in patients’ self-perception of emotion regulation skills (ERSQ: W = 0.23). Discussion: We found favorable findings regarding the feasibility and acceptance of the Feel-Good mindfulness-based intervention. Results of the study provide a basis for an estimation of an adequate sample size for a fully powered RCT that needs to be conducted to test whether Feel-Good is effective in the inpatient treatment of psychotic symptoms for individuals with early psychosis

Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis

This study investigates predictors of outcome in a secondary analysis of dropout and completer data from a randomized controlled effectiveness trial comparing CBTp to a wait-list group (Lincoln et al., 2012). Eighty patients with DSM-IV psychotic disorders seeking outpatient treatment were included. Predictors were assessed at baseline. Symptom outcome was assessed at post-treatment and at one-year follow-up. The predictor x group interactions indicate that a longer duration of disorder predicted less improvement in negative symptoms in the CBTp but not in the wait-list group whereas jumping-to-conclusions was associated with poorer outcome only in the wait-list group. There were no CBTp specific predictors of improvement in positive symptoms. However, in the combined sample (immediate CBTp+the delayed CBTp group) baseline variables predicted significant amounts of positive and negative symptom variance at post-therapy and one-year follow-up after controlling for pre-treatment symptoms. Lack of insight and low social functioning were the main predictors of drop-out, contributing to a prediction accuracy of 87%. The findings indicate that higher baseline symptom severity, poorer functioning, neurocognitive deficits, reasoning biases and comorbidity pose no barrier to improvement during CBTp. However, in line with previous predictor-research, the findings imply that patients need to receive treatment earlier

Implementation of Anaphylaxis Management Guidelines: A Register-Based Study

BACKGROUND: Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines. METHODS: Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data. RESULTS: 2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time. CONCLUSION: There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted

Assessing land use and flood management impacts on ecosystem services in a river landscape (Upper Danube, Germany)

Rivers and floodplains provide many regulating, provisioning and cultural ecosystem services (ES) such as flood risk regulation, crop production or recreation. Intensive use of resources such as hydropower production, construction of detention basins and intensive agriculture substantially change ecosystems and may affect their capacity to provide ES. Legal frameworks such as the European Water Framework Directive, Bird and Habitats Directive and Floods Directive already address various uses and interests. However, management is still sectoral and often potential synergies or trade‐offs between sectors are not considered. The ES concept could support a joint and holistic evaluation of impacts and proactively suggest advantageous options. The river ecosystem service index (RESI) method evaluates the capacity of floodplains to provide ES by using a standardized five‐point scale for 1 km‐floodplain segments based on available spatial data. This scaling allows consistent scoring of all ES and their integration into a single index. The aim of this article is to assess ES impacts of different flood prevention scenarios on a 75 km section of the Danube river corridor in Germany. The RESI method was applied to evaluate scenario effects on 13 ES with the standardized five‐point scale. Synergies and trade‐offs were identified as well as ES bundles and dependencies on land use and connectivity. The ratio of actual and former floodplain has the strongest influence on the total ES provision: the higher the percentage and area of an active floodplain, the higher the sum of ES. The RESI method proved useful to support decision‐making in regional planning.BMBF, 033W024A, ReWaM - Verbundprojekt RESI: River Ecosystem Service Index, Teilprojekt

The genetic architecture of membranous nephropathy and its potential to improve non-invasive diagnosis

Membranous Nephropathy (MN) is a rare autoimmune cause of kidney failure. Here we report a genome-wide association study (GWAS) for primary MN in 3,782 cases and 9,038 controls of East Asian and European ancestries. We discover two previously unreported loci, NFKB1 (rs230540, OR = 1.25, P = 3.4 × 10-12) and IRF4 (rs9405192, OR = 1.29, P = 1.4 × 10-14), fine-map the PLA2R1 locus (rs17831251, OR = 2.25, P = 4.7 × 10-103) and report ancestry-specific effects of three classical HLA alleles: DRB1*1501 in East Asians (OR = 3.81, P = 2.0 × 10-49), DQA1*0501 in Europeans (OR = 2.88, P = 5.7 × 10-93), and DRB1*0301 in both ethnicities (OR = 3.50, P = 9.2 × 10-23 and OR = 3.39, P = 5.2 × 10-82, respectively). GWAS loci explain 32% of disease risk in East Asians and 25% in Europeans, and correctly re-classify 20-37% of the cases in validation cohorts that are antibody-negative by the serum anti-PLA2R ELISA diagnostic test. Our findings highlight an unusual genetic architecture of MN, with four loci and their interactions accounting for nearly one-third of the disease risk

Does Cognitive Behavior Therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis

Cognitive Behavior Therapy for psychosis (CBTp) is an effective treatment resulting in small to medium effect sizes with regard to changes in positive symptoms and psychopathology. As a consequence, CBTp is recommended by national guidelines for all patients with schizophrenia. However, although CBTp was originally developed as a means to improve delusions, meta-analyses have generally integrated effects for positive symptoms rather than for delusions. Thus, it is still an open question whether CBTp is more effective with regard to change in delusions compared to treatment as usual (TAU) and to other interventions, and whether this effect remains stable over a follow-up period. Moreover, it would be interesting to explore whether newer studies that focus on specific factors involved in the formation and maintenance of delusions (causal-interventionist approach) are more effective than the first generation of CBTp studies. A systematic search of the trial literature identified 19 RCTs that compared CBTp with TAU and/or other interventions and reported delusions as an outcome measure. Meta-analytic integration resulted in a significant small to medium effect size for CBTp in comparison to TAU at end-of-therapy (k = 13; d¯ = 0.27). However, the comparison between CBTp and TAU after an average follow-up period of 47 weeks was not statistically significant (k = 12, d¯ = 0.16). When compared with other interventions, there was no significant effect of CBTp at end-of-therapy (k = 8; d¯ = 0.16) and after a follow-up period (k = 5; d¯ = −0.04). Comparison between newer studies taking a causal-interventionist approach (k = 4) and first-generation studies showed a difference of 0.33 in mean effect sizes in favor of newer studies at end-of-therapy. The findings suggest that CBTp is superior to TAU post-therapy in bringing about a change in delusions, but that this change may not be maintained over the follow-up period. Moreover, interventions that focus on causal factors of delusions seem to be a promising approach to improving interventions for delusions