Interpersonal problems and psychosocial functioning in the context of psychotic illnesses

Einschränkungen des psychosozialen Funktionsniveaus gehören zu den schwerwiegendsten Folgen für Menschen mit psychotischen Erkrankungen und tragen maßgeblich zur sozialen Marginalisierung der Betroffenen bei. Grundlegend für die psychosoziale Kompetenz einer Person ist unter anderem die Fähigkeit zu einer gelingenden Interpersonalität, der Einfluss spezifischer interpersoneller Probleme ist bei dieser Patient_innengruppe nach aktuellem Kenntnisstand jedoch noch nicht hinreichend untersucht. In der psychotherapeutischen Praxis zeigen Menschen mit psychotischen Erkrankungen oftmals spezifische innerpsychische Antagonismen hinsichtlich der Regulation von Nähe und Distanz (dem Widerstreit zwischen Individuation und Abhängigkeit), die Stavros Mentzos im Begriff des „psychotischen Dilemmas“ konzeptualisiert hat. Auch dieser psychodynamisch fundierte Erklärungsansatz bedarf noch einer empirischen Überprüfung. Um psychodynamische Konzepte für den aktuellen kognitiv-psychologischen und neurowissenschaftlichen Diskurs anschlussfähig zu machen, wurde 2015 eine der ersten randomisiert-kontrollierten Wirksamkeitsstudien zu einem manualbasierten psychodynamischen Therapieverfahren der Psychosenpsychotherapie initiiert (MPP-S-Studie). In der Baseline-Stichprobe wurden an 129 Proband_innen mit nicht-affektiven Psychosen mögliche prädiktive Effekte interpersoneller Probleme auf das psychosoziale Funktionsniveau untersucht, während für den Einfluss kognitiver Defizite und Psychopathologie kontrolliert wurde. Spezifische Arten interpersoneller Probleme wurden zudem zwischen Teilnehmenden mit oder ohne hypothetischem „psychotischen Dilemma“ verglichen. Die Ergebnisse zeigten, dass Proband_innen größere Einschränkungen ihres psychosozialen Funktionsniveaus aufwiesen, je mehr interpersonelle Probleme sie berichteten. Insbesondere Probleme, die mit „sozial vermeidendem“ Verhalten einhergingen zeigten einen prädiktiven Effekt für Defizite im psychosozialen Funktionsniveau, wohingegen ein „kalter“ Persönlichkeitsstil den gegenteiligen Effekt hatte. Proband_innen mit einem hypothetischen „psychotischen Dilemma“ berichteten hinsichtlich selbstbezogener interpersoneller Probleme eine signifikant höhere Problemlast als Teilnehmende ohne „psychotisches Dilemma“. Zusammenfassend weisen die hier besprochenen Ergebnisse auf die klinische Bedeutsamkeit hin, interpersonelle Dysfunktionen bei der Behandlung von Menschen mit psychotischen Erkrankungen gezielter zu diagnostizieren und therapeutisch zu fokussieren, da sie mit dem psychosozialen Funktionsniveau assoziiert sind.Limitations in psychosocial functioning are among the most serious consequences for people with psychotic illnesses, which contribute to a large extent to the social marginalization of those affected. Interpersonal skills are fundamental to the psychosocial competence of a person, the influence of interpersonal problems on psychosocial functioning, however, has not yet been adequately investigated in this patient group. In psychotherapeutic practice, people with psychotic illnesses often show pronounced internal antagonisms regarding the regulation of closeness and distance (the contradiction between individuation and dependency), which Stavros Mentzos conceptualized in the term “psychotic dilemma”. This psychodynamic concept, likewise, lacks empirical examination. In order to emphasize psychodynamic concepts within the current cognitive-psychological and neuroscientific discourse, one of the first randomized-controlled efficacy studies regarding a manual-based psychodynamic therapy method for patients with psychoses was initiated in 2015 (MPP-S study). In the baseline sample, possible predictive effects of interpersonal problems on the psychosocial functional level were examined in 129 subjects with non-affective psychoses, while controlling for the influence of cognitive deficits and psychopathology. Specific types of interpersonal problems were then compared between the groups with or without a hypothetical “psychotic dilemma”. Results showed that subjects present with greater limitations in their psychosocial functioning the more interpersonal problems they reported. Especially “socially avoidant” behavior showed a predictive effect for deficits in psychosocial functioning, whereas a “cold” personality style had the opposite effect. Subjects with a hypothetical “psychotic dilemma” reported significantly more problems regarding the self-related interpersonal problem dimensions than participants without a “psychotic dilemma”. In summary, the results discussed here indicate the clinical importance of diagnosing and therapeutically focusing interpersonal problems in the treatment of people with psychotic illnesses in a more targeted manner, as they are associated with the psychosocial functional level

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

Measuring Emotional Awareness in Patients With Schizophrenia and Schizoaffective Disorders

The ability to mentalize (i.e., to form representations of mental states and processes of oneself and others) is often impaired in people with schizophrenia spectrum disorders. Emotional awareness (EA) represents one aspect of affective mentalizing and can be assessed with the Levels of Emotional Awareness Scale (LEAS), but findings regarding individuals with schizophrenia spectrum disorders are inconsistent. The present study aimed at examining the usability and convergent validity of the LEAS in a sample of N = 130 stabilized outpatients with schizophrenia or schizoaffective disorders. An adequacy rating was added to the conventional LEAS rating to account for distortions of content due to, for example, delusional thinking. Scores of the patient group were compared with those of a matched healthy control sample. Correlation with symptom clusters, a self-report measure of EA, a measure of synthetic metacognition (MAS-A-G), and an expert rating capturing EA from the psychodynamic perspective of psychic structure (OPD-LSIA) were examined. Regarding self-related emotional awareness, patients did not score lower than controls neither in terms of conventional LEAS nor in terms of adequacy. Regarding other-related emotional awareness, however, patients showed a reduced level of adequacy compared to controls whereas no such difference was found for conventional LEAS scores. Higher conventional LEAS scores were associated with fewer negative symptoms, and higher structural integration of self-perceptions measured by the OPD-LSIA. Higher adequacy of responses correlated with fewer symptoms of disorganization as well as excitement, higher scores of self-reflection on the MAS-A-G as well as self- and object-perception and internal and external communication as measured by the subscales of the OPD-LSIA. Findings suggest that the LEAS might not be sensitive enough to detect differences between mildly symptomatic patients with schizophrenia or schizoaffective disorders and healthy controls. However, LEAS ratings are still suitable to track intraindividual changes in EA over time. Observing the adequacy of patients' responses when using the LEAS may be a promising way to increase diagnostical utility and to identify patterns of formal and content-related alterations of mentalizing in this patient group. Methodological indications for future studies are discussed