Childhood sexual and physical abuse : age at exposure modulates impact on functional outcome in early psychosis patients

Introduction : La litt��rature sugg��re un lien entre l'exposition �� des exp��riences traumatiques durant l'enfance et des d��ficits dans le niveau de fonctionnement chez des patients souffrant de psychose. Par contre, l'impact de l'��ge au moment de l'exposition �� ces exp��riences n'a pas ��t�� investigu�� chez des patients dans leur phase pr��coce de la psychose. M��thodes : Deux cents vingt-cinq patients ��g��s entre 18 et 35 ans ont ��t�� ��valu��s au moment de leur entr��e dans un programme th��rapeutique sp��cialis�� pour la psychose d��butante (TIPP), et apr��s 2, 6, 12, 18, 24, 30 et 36 mois de traitement. Les patients expos��s �� des abus sexuel et/ou physiques (SPA) ont ��t�� classifi��s selon l'��ge au moment de la premi��re exposition (Early-SPA : avant 11 ans d'��ge; Late-SPA : entre 12 et 15 ans d'��ge) et ils ont ��t�� compar��s �� des patients qui n'ont jamais ��t�� expos��s �� une telle exp��rience (Non-SPA). Le niveau de fonctionnement dans la phase premorbide a ��t�� mesur�� avec la Premorbid Adjustment Scale (PAS) et avec les ��chelles Global Assessment of Functioning (GAF) et Social and Occupational Functionning Assessment Scale (SOFAS) durant le suivi th��rapeutique. R��sultats : 24.8 % des patients ont ��t�� expos��s �� SPA. Les patients dans le groupe Late-SPA ��taient plus souvent des femmes (p=0.010). Les comparaisons avec les patients dans le groupe Non-SPA ont r��v��l�� que : (1) Les patients dans le groupe Early et Late-SPA ont montr�� un moins bon niveau de fonctionnement social premorbide durant l'adolescence pr��coce, et (2) alors que les patients dans le groupe Early-SPA ont pr��sent�� un moins bon niveau de fonctionnement durant tout le suivi selon les scores de GAF (p=0.025) et SOFAS (p=0.048), les patients dans le groupe Late-SPA n'ont pas montr�� telles diff��rences avec le groupe non expos��. Conclusion : Nos r��sultats sugg��rent un lien entre l'exposition �� SPA et une alt��ration ult��rieure de niveau de fonctionnement social, avant l'apparition de la maladie. Les patients dans leur phase pr��coce de la psychose expos��s �� SPA avant l'��ge de 12 ans ont des alt��rations fonctionnelles durables, alors que les patients expos��s �� SPA plus tardivement semblent s'am��liorer �� ce niveau et montrent une meilleure capacit�� de r��cup��ration.

Directional and fluctuating asymmetry in finger and a-b ridge counts in psychosis: a case-control study

Background: Several studies have reported alterations in finger and a-b ridge counts, and theirderived measures of asymmetry, in schizophrenia compared to controls. Because ridges are fully formed by the end of the second trimester, they may provide clues to disturbed early development. The aim of this study was to assess these measures in a sample of patients with psychosis and normal controls.Methods: Individuals with psychosis (n = 240), and normal controls (n = 228) were drawn from a catchment-area case-control study. Differences in finger and a-b ridge count and Fluctuating Asymmetry were assessed in three group comparisons (non-affective psychosis versus controls; affective psychosis versus controls; non-affective psychosis versus affective psychosis). The analyses were performed separately for males and females. Results: There were no significant group differences for finger nor a-b ridge counts. While there were no group difference for Directional Asymmetry, for Fluctuating Asymmetry measures men with non-affective psychosis had significantly higher fluctuating asymmetry of the index finger ridge count (a) when compared to controls (FA-correlation score, p = 0.02), and (b) when compared to affective psychosis (adjusted FA-difference score, p = 0.04). Conclusion: Overall, measures of finger and a-b ridge counts, and their derived measures of directional and fluctuating asymmetry were not prominent features of psychosis in this sample. While directional asymmetry in cerebral morphology is reduced in schizophrenia, this is not reflected in dermatoglyphic variables.

Attachment and coping in psychosis in relation to spiritual figures

Background: Studies have found higher levels of insecure attachment in individuals with schizophrenia. Attachment theory provides a framework necessary for conceptualizing the development of interpersonal functioning. Some aspects of the attachment of the believer to his/her spiritual figure are similar to those between the child and his/her parents. The correspondence hypothesis suggests that early child-parent interactions correspond to a person's relation to a spiritual figure. The compensation hypothesis suggests that an insecure attachment history would lead to a strong religiousness/spirituality as a compensation for the lack of felt security. The aim of this study is to explore attachment models in psychosis vs. healthy controls, the relationships between attachment and psychopathology and the attachment processes related to spiritual figures. Methods: Attachment models were measured in 30 patients with psychosis and 18 controls with the AAI (Adult Attachment interview) in relationship with psychopathology. Beliefs and practices related to a spiritual figure were investigated by qualitative and quantitative analyses. Results: Patients with psychosis showed a high prevalence of insecure avoidant attachment. Spiritual entities functioned like attachment figures in two thirds of cases. Interviews revealed the transformation of internal working models within relation to a spiritual figure: a compensation process was found in 7 of the 32 subjects who showed a significant attachment to a spiritual figure. Conclusions: Attachment theory allows us to highlight one of the underlying dimensions of spiritual coping in patients with psychosis.

Duration of untreated psychosis: Impact of the definition of treatment onset on its predictive value over three years of treatment.

BACKGROUND: While reduction of DUP (Duration of Untreated Psychosis) is a key goal in early intervention strategies, the predictive value of DUP on outcome has been questioned. We planned this study in order to explore the impact of three different definition of "treatment initiation" on the predictive value of DUP on outcome in an early psychosis sample. METHODS: 221 early psychosis patients aged 18-35 were followed-up prospectively over 36 months. DUP was measured using three definitions for treatment onset: Initiation of antipsychotic medication (DUP1); engagement in a specialized programme (DUP2) and combination of engagement in a specialized programme and adherence to medication (DUP3). RESULTS: 10% of patients never reached criteria for DUP3 and therefore were never adequately treated over the 36-month period of care. While DUP1 and DUP2 had a limited predictive value on outcome, DUP3, based on a more restrictive definition for treatment onset, was a better predictor of positive and negative symptoms, as well as functional outcome at 12, 24 and 36 months. Globally, DUP3 explained 2 to 5 times more of the variance than DUP1 and DUP2, with effect sizes falling in the medium range according to Cohen. CONCLUSIONS: The limited predictive value of DUP on outcome in previous studies may be linked to problems of definitions that do not take adherence to treatment into account. While they need replication, our results suggest effort to reduce DUP should continue and aim both at early detection and development of engagement strategies.

The grammar of psychosis

This thesis is concerned with the philosophical grammar of certain psychiatric concepts, which play a central role in delineating the field of psychiatric work. The concepts studied are ���psychosis���, ���delusion���, ���person���, ���understanding��� and ���incomprehensibility���. The purpose of this conceptual analysis is to provide a more perspicuous view of the logic of these concepts, how psychiatric work is constituted in relation to them, and what this tells us about the relationships between the conceptual and the empirical in psychiatric concepts. The method used in the thesis is indebted primarily to Ludwig Wittgenstein���s conception of philosophy, where we are urged to look at language uses in relation to practices in order to obtain a clearer overview of practices of interest; this will enable us to resolve the conceptual problems related to these practices. This questioning takes as its starting point the concept of psychosis, a central psychiatric concept during the twentieth century. The conceptual analysis of ���psychosis��� shows that the concept is logically dependent on the concepts of ���understanding��� and ���person���. Following the lead found in this analysis, the logic of person-concepts in psychiatric discourse is analysed by a detailed textual analysis of a psychiatric journal article. The main finding is the ambiguous uses of ���person���, enabling a specifically psychiatric form of concern in human affairs. The grammar of ���understanding��� is then tackled from the opposite end, by exploring the logic of the concept of ���incomprehensibility���. First, by studying the DSM-IV definition of delusion it is shown that its ambiguities boil down to the question of whether psychiatric practice is better accounted for in terms of the grammar of ���incorrectness��� or ���incomprehensibility���. Second, the grammar of ���incomprehensibility��� is further focused on by introducing the distinction between positive and negative conceptions of ���incomprehensibility���. The main finding is that this distinction has wide-ranging implications for our understanding of psychiatric concepts. Finally, some of the findings gained in these studies are ���put into practice��� in studying the more practical question of the conceptual and ethical problems associated with the concept of ���prodromal symptom of schizophrenia��� and the agenda of early detection and intervention in schizophrenia more generally.

Attention in schizophrenia and in epileptic psychosis

The adaptive behavior of human beings is usually supported by rapid monitoring of outstanding events in the environment. Some investigators have suggested that a primary attention deficit might trigger symptoms of schizophrenia. In addition, researchers have long discussed the relationship between schizophrenia and the schizophrenia-like psychosis of epilepsy (SLPE). On the basis of these considerations, the objective of the present study was to investigate attention performance of patients with both disorders. Patient age was 18 to 60 years, and all patients had received formal schooling for at least four years. Patients were excluded if they had any systemic disease with neurologic or psychiatric comorbidity, or a history of brain surgery. The computer-assisted TAVIS-2R test was applied to all patients and to a control group to evaluate and discriminate between selective, alternating and sustained attention. The TAVIS-2R test is divided into three parts: one for selective attention (5 min), the second for alternating attention (5 min), and the third for the evaluation of vigilance or sustained attention (10 min). The same computer software was used for statistical analysis of reaction time, omission errors, and commission errors. The sample consisted of 36 patients with schizophrenia, 28 with interictal SLPE, and 47 healthy controls. The results of the selective attention tests for both patient groups were significantly lower than that for controls. The patients with schizophrenia and SLPE performed differently in the alternating and sustained attention tests: patients with SLPE had alternating attention deficits, whereas patients with schizophrenia showed deficits in sustained attention. These quantitative results confirmed the qualitative clinical observations for both patient groups, that is, that patients with schizophrenia had difficulties in focusing attention, whereas those with epilepsy showed perseveration in attention focus.

A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service

Objective: To evaluate CBTp delivered by non-expert therapists, using CBT relevant measures. Methods: Participants (N=74) were randomised into immediate therapy or waiting list control groups. The therapy group was offered six months of therapy and followed up three months later. The waiting list group received therapy after waiting nine months (becoming the delayed therapy group). Results: Depression improved in the combined therapy group at both the end of therapy and follow-up. Other significant effects were found in only one of the two therapy groups (positive symptoms; cognitive flexibility; uncontrollability of thoughts) or one of the two timepoints (end of therapy: PANSS general symptoms, anxiety, suicidal ideation, social functioning, resistance to voices; follow-up: power beliefs about voices, negative symptoms). There was no difference in costs between the groups. Conclusions: The only robust improvement was in depression. Nevertheless, there were further encouraging but modest improvements in both emotional and cognitive variables, in addition to psychotic symptoms.

The multidimensional measurement of the positive symptoms of psychosis

The measures most frequently used to assess psychotic symptoms fail to reflect important dimensions. The Psychotic Symptom Rating Scale (PSYRATS) aims to capture the multidimensional nature of auditory hallucinations and delusions. Individuals (N = 276) who had recently relapsed with positive symptoms completed the auditory hallucinations and delusions PSYRATS scales. These scores were compared with the relevant items from the SAPS and PANSS, and with measures of current mood. Total scores and distribution of items of the PSYRATS scales are presented and correlated with other measures. Positive symptom items from the SAPS and PANSS reflected the more objective aspects of PSYRATS ratings of auditory hallucinations and delusions (frequency and conviction) but were relatively poor at measuring distress. A major strength of the PSYRATS scales is the specific measurement of the distress dimension of symptoms, which is a key target of psychological intervention. It is advised that the PSYRATS should not be used as a total score alone, whilst further research is needed to clarify the best use of potential subscales. Copyright (c) 2007 John Wiley & Sons, Ltd.

Cognitive behaviour therapy for psychosis: current evidence and future directions

The past decade has seen considerable growth in the evidence base of cognitive behavioural therapy for psychosis. Consistent reports of moderate effect sizes have led to such interventions being recommended as part of routine clinical practice. Most of this evidence is based on a generic form of CBT for psychosis applied to a heterogeneous group. An increase in the effectiveness of cognitive behavioural interventions may require new protocols. Such therapeutic developments should be based on the theoretical understanding of the psychological processes associated with specific forms of psychotic presentation. The current evidence base of CBT for psychosis is reviewed, and barriers that have held back the development of this research are discussed.

Family interventions in psychosis: a scale to measure therapist adherence

The efficacy of family interventions in psychosis is well documented. UK and USA schizophrenia treatment guidelines advocate the practice of family interventions within routine clinical services. However, less attention has been paid to the study of treatment fidelity and the tools used in its assessment. This study reports the inter-rater reliability of a new scale: Family Intervention in Psychosis-Adherence Scale (FIPAS). This measure is designed to assess therapist adherence to the Kuipers et al. (2002) family intervention in psychosis treatment manual. Reliability ratings were based on a sample of thirteen audiotapes drawn from a randomized controlled trial of family intervention. The results indicated that the majority of items of the FIPAS had acceptable levels of inter-rater reliability. The findings are discussed in terms of their implications for the training and monitoring of the effectiveness of practitioners for family interventions in psychosis.

Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial

Objectives To evaluate the effectiveness of integrated motivational interviewing and cognitive behaviour therapy in addition to standard care for patients with psychosis and a co-morbid substance use problem. Design Two-centre, open, rater-blind randomised controlled trial Setting UK Secondary Care Participants 327 patients with clinical diagnoses of schizophrenia, schizophreniform or schizoaffective disorder and DSM-IV diagnoses of drug and/or alcohol dependence or abuse Interventions Participants were randomly allocated to integrated motivational interviewing and cognitive behaviour therapy or standard care. Therapy has two phases. Phase one ��� ���motivation building��� ��� concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two ������Action��� ��� supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year. Main outcomes The primary outcome was death from any cause or admission to hospital in the 12 months after therapy. Secondary outcomes were frequency and amount of substance use (Timeline Followback), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, global assessment of functioning and deliberate self harm, at 12 and 24 months, with additional Timeline Followback assessments at 6 and 18 months. Analysis was by intention-to-treat with robust treatment effect estimates. Results 327 participants were randomised. 326 (99.7%) were assessed on the primary outcome, 246 (75.2%) on main secondary outcomes at 24 months. Regarding the primary outcome, there was no beneficial treatment effect on hospital admissions/ death during follow-up, with 20.2% (33/163) of controls and 23.3% (38/163) of the therapy group deceased or admitted (adjusted odds-ratio 1.16; P= 0.579; 95% confidence interval 0.68 to 1.99). For secondary outcomes there was no treatment effect on frequency of substance use or perceived negative consequences, but a statistically significant effect of therapy on amount used per substance-using day (adjusted odds-ratios: (a) for main substance 1.50; P=0.016; 1.08 to 2.09, (b) all substances 1.48; P=0.017; 1.07 to 2.05). There was a statistically significant treatment effect on readiness to change use at 12 months (adjusted odds-ratio 2.05; P=0.004; 1.26 to 3.31), not maintained at 24 months. There were no treatment effects on assessed clinical outcomes. Conclusions Integrated motivational interviewing and cognitive behaviour therapy for people with psychosis and substance misuse does not improve outcome in terms of hospitalisation, symptom outcomes or functioning. It does result in a reduction in amount of substance use which is maintained over the year���s follow up. Trial registration Current Controlled Trials: ISRCTN14404480