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Kendler KS, Ohlsson H, Sundquist J, Sundquist K. The genetic epidemiology of schizotypal personality disorder. Psychol Med 2024; 54:2144-2151. [PMID: 38362845 DOI: 10.1017/s0033291724000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The concept of schizotypal personality disorder (SPD) emerged from observations of personality characteristics common in relatives of schizophrenic patients. While often studied in family designs, few studies and none with genetic measures, have examined SPD in epidemiological samples. METHODS We studied individuals born in Sweden 1940-2000 with an ICD-10 diagnosis of SPD with no prior schizophrenia (SZ) diagnosis (n = 2292). Demographic features, patterns of comorbidity, and Family Genetic Risk Scores (FGRS) were assessed from multiple Swedish registries. Prediction of progression to SZ was assessed by Cox models. RESULTS SPD was rare, with a prevalence of 0.044%, and had high levels of comorbidity with autism spectrum disorder (ASD), OCD, ADHD, and major depression (MD), and increased rates of being single, unemployed and in receipt of welfare. Affected individuals had elevated levels of FGRS for SZ (+0.42), ASD (+0.30), MD (+0.29), and ADHD (+0.20). Compared to cases of schizophrenia, they had significantly lower rates of FGRSSZ, but significantly elevated rates of genetic risk for ASD, MD, and ADHD. Over a mean follow-up of 8.7 years, 14.6% of SPD cases received a first diagnosis of SZ, the risk for which was significantly increased by levels of FGRSSZ, male sex, young age at SPD diagnosis and an in-patient SPD diagnosis and significantly decreased by comorbidity with MD, ASD, and ADHD. CONCLUSIONS Our results not only support the designation of SPD as a schizophrenia spectrum disorder but also suggest potentially important etiologic links between SPD and ASD and, to a lesser extent, ADHD, OCD, and MD.
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Affiliation(s)
- Kenneth S Kendler
- Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Henrik Ohlsson
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- University Clinic Primary Care Skane, Sweden
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- University Clinic Primary Care Skane, Sweden
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
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Dong F, Liu J, Hodgson NA, Medoff-Cooper B. Early life factors of schizotypal personality disorder in adolescents: A systematic review. J Psychiatr Ment Health Nurs 2021; 28:1092-1112. [PMID: 33502097 DOI: 10.1111/jpm.12733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 12/25/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: The complexity and high prevalence of schizotypal personality disorders (SPD) pose serious challenges for mental health practice in its management, and also bring severe consequences for the patients. The identification of the specific early life factors (ELFs) that confer risk to SPD has become a major focus of clinical research on schizophrenia-spectrum disorders which aligns well with the mental health nursing's responsibility in health promotion, prevention and treatment. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Adolescents may experience certain ELFs, which contribute to the occurrence of SPD, but no systematic review has been conducted to identify ELF among them. And nursing literature addressing modifiable ELF is very limited. Two clusters of ELF and SPD in adolescents were identified: prenatal and early postnatal factors; childhood trauma and parental factors. The findings also show that more research is needed to determine the specificity and cumulative effects of ELF on the development of SPD by using rigorous and comprehensive measurements and a longitudinal design. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses, especially nurses in the primary care, should be aware of potentially modifiable ELFs and incorporate more comprehensive and valid instrument for assessing cumulative ELF and SPD. These findings may serve to inform possible future interventions for SPD, such as parent education and support to mitigate these risk factors. ABSTRACT INTRODUCTION: Schizotypal personality disorder (SPD) affects 4% of the general population in the United States. The identification of early life factors (ELFs) that confer risk to SPD in adolescents (ages 10-24 years old) has become a major focus of clinical research on schizophrenia-spectrum disorders. AIM This systematic review aims to determine what ELFs contribute to the onset of SPD in the adolescent population. METHODS A systematic search of PubMed, PsycINFO, Psychiatry online, Scopus, Web of Science, EMBASE and CINAHL databases was conducted using relevant keywords. Data were extracted using a standardized form following PRISMA guidelines. RESULTS Twenty-four studies met the criteria for inclusion. ELFs in the development of SPD were grouped into two important clusters: (a) prenatal and early postnatal factors; (b) childhood trauma and parental factors. CONCLUSION Mental health nurses, especially nurses in primary care, should be aware of potentially modifiable ELF. Longitudinal research is needed to determine the causative roles of these ELF play in the occurrence of SPD by using rigorous measurements. IMPLICATIONS FOR PRACTICE These findings call for awareness of the modifiable ELF for SPD and also inform possible future interventions to reduce these risks, such as parent-training or environmental enrichment programmes.
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Affiliation(s)
- Fanghong Dong
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Jianghong Liu
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy A Hodgson
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Clay KB, Raugh IM, Bartolomeo LA, Strauss GP. Defeatist performance beliefs in individuals at clinical high-risk for psychosis and outpatients with chronic schizophrenia. Early Interv Psychiatry 2021; 15:865-873. [PMID: 32743974 DOI: 10.1111/eip.13024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 12/29/2022]
Abstract
AIM Prior studies indicate that defeatist performance beliefs (DPBs) are elevated in those in the chronic phase of schizophrenia (SZ) and associated with negative symptoms, functional outcome and neurocognitive impairment. However, it is unclear whether these same patterns of results hold in participants at clinical high-risk (CHR) for psychosis. METHODS Two studies were conducted to determine whether prior results in SZ could be replicated and extended to CHR. Participants included 184 healthy controls (CN) and 186 outpatients with chronic SZ for Study 1, and 30 CN and 35 CHR in Study 2. In both studies, participants completed the DPB scale and measures of negative symptoms, psychosocial functioning and neurocognition. RESULTS Both chronic SZ and CHR participants had elevated DPBs compared to CN (p's < .01). In SZ, higher DPBs were associated with greater negative symptoms (r's = .31-.37, p's < .01), poorer social functioning and impaired social cognition (r = -.40, P < .001). In CHR, greater DPBs were associated with poorer social functioning (r = -.52, P < .05) and impairments in the neurocognitive domains of reasoning (r = -.48, P < .05) and processing speed (r = -.41, P < .05). Models testing whether DPBs mediated links between negative symptoms and functioning, negative symptoms and cognition and cognition and functioning were nonsignificant in SZ and CHR samples. CONCLUSIONS Findings generally provide support for the cognitive model of negative symptoms and functioning and suggest that DPBs are an important clinical target across phases of psychotic illness.
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Affiliation(s)
- Kendall B Clay
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Ian M Raugh
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Lisa A Bartolomeo
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Gregory P Strauss
- Department of Psychology, University of Georgia, Athens, Georgia, USA
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4
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Hur JW, Kim T, Cho KIK, Kwon JS. Attenuated Resting-State Functional Anticorrelation between Attention and Executive Control Networks in Schizotypal Personality Disorder. J Clin Med 2021; 10:jcm10020312. [PMID: 33467694 PMCID: PMC7829946 DOI: 10.3390/jcm10020312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 11/18/2022] Open
Abstract
Exploring the disruptions to intrinsic resting-state networks (RSNs) in schizophrenia-spectrum disorders yields a better understanding of the disease-specific pathophysiology. However, our knowledge of the neurobiological underpinnings of schizotypal personality disorders mostly relies on research on schizotypy or schizophrenia. This study aimed to investigate the RSN abnormalities of schizotypal personality disorder (SPD) and their clinical implications. Using resting-state data, the intra- and inter-network of the higher-order functional networks (default mode network, DMN; frontoparietal network, FPN; dorsal attention network, DAN; salience network, SN) were explored in 22 medication-free, community-dwelling, non-help seeking individuals diagnosed with SPD and 30 control individuals. Consequently, while there were no group differences in intra-network functional connectivity across DMN, FPN, DAN, and SN, the SPD participants exhibited attenuated anticorrelation between the right frontal eye field region of the DAN and the right posterior parietal cortex region of the FPN. The decreases in anticorrelation were correlated with increased cognitive–perceptual deficits and disorganization factors of the schizotypal personality questionnaire, as well as reduced independence–performance of the social functioning scale for all participants together. This study, which links SPD pathology and social functioning deficits, is the first evidence of impaired large-scale intrinsic brain networks in SPD.
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Affiliation(s)
- Ji-Won Hur
- Department of Psychology, Korea University, Seoul 02841, Korea;
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul 08826, Korea;
| | - Taekwan Kim
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul 08826, Korea;
| | - Kang Ik K. Cho
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA;
| | - Jun Soo Kwon
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul 08826, Korea;
- Department of Psychiatry, Seoul National University College of Medicine, Seoul 03080, Korea
- Institute of Human Behavioral Medicine, SNU-MRC, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-2072-2972; Fax: +82-2-747-9063
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Salazar de Pablo G, Catalan A, Fusar-Poli P. Clinical Validity of DSM-5 Attenuated Psychosis Syndrome: Advances in Diagnosis, Prognosis, and Treatment. JAMA Psychiatry 2020; 77:311-320. [PMID: 31746950 DOI: 10.1001/jamapsychiatry.2019.3561] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Since the release of the DSM-5 diagnosis of attenuated psychosis syndrome (DSM-5-APS) in 2013, several research studies have investigated its clinical validity. Although critical and narrative reviews have reviewed these progresses, no systematic review has comprehensively summarized the available evidence regarding the clinical validity of DSM-5-APS. OBJECTIVE To provide current evidence on the clinical validity of DSM-5-APS, focusing on recent advances in diagnosis, prognosis, and treatment. EVIDENCE REVIEW A multistep literature search using the Web of Science database, Cochrane Central Register of Reviews, Ovid/PsychINFO, conference proceedings, and trial registries from database inception to June 16, 2019, was conducted following PRISMA and MOOSE guidelines and PROSPERO protocol. Studies with original data investigating individuals diagnosed using DSM-5-APS or meeting comparable criteria were included. The results of the systematic review were summarized in tables and narratively synthesized against established evidence-based antecedent, concurrent, and prognostic validators. A quantitative meta-analysis was conducted to explore the cumulative risk of psychosis onset at 6, 12, 24, and 36 months in individuals diagnosed using DSM-5-APS criteria. FINDINGS The systematic review included 56 articles, which reported on 124 validators, including 15 antecedent, 55 concurrent, and 54 prognostic validators. The epidemiological prevalence of the general non-help-seeking young population meeting DSM-5-APS criteria was 0.3%; the prevalence of individuals meeting DSM-5-APS criteria was variable in clinical samples. The interrater reliability for DSM-5-APS criteria was comparable with that of other DSM-5 mental disorders and can be optimized by the use of specific psychometric instruments. DSM-5-APS criteria were associated with frequent depressive comorbid disorders, distress, suicidality, and functional impairment. The meta-analysis included 23 prospective cohort studies, including 2376 individuals. The meta-analytical risk of psychosis onset was 11% at 6 months, 15% at 12 months, 20% at 24 months, and 23% at 36 months. Research into predisposing and precipitating epidemiological factors, neurobiological correlates, and effective treatments for DSM-5-APS criteria has been limited. CONCLUSIONS AND RELEVANCE Over recent years, DSM-5-APS criteria have received substantial concurrent and prognostic validation, mostly driven by research into the clinical high-risk state for psychosis. Precipitating and predisposing factors, neurobiological correlates, and effective treatments are undetermined to date.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Institute of Psychiatry and Mental Health, Department of Psychiatry, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Centro de Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Ana Catalan
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Department of Psychiatry, Basurto University Hospital, Bilbao, Spain.,Mental Health Group, BioCruces Health Research Institute, Bizkaia, Spain.,Neuroscience Department, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,OASIS Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Maudsley Biomedical Research Centre, National Institute for Health Research, South London and Maudsley NHS Foundation Trust, London, United Kingdom
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6
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Salazar de Pablo G, Guinart D, Cornblatt BA, Auther AM, Carrión RE, Carbon M, Jiménez-Fernández S, Vernal DL, Walitza S, Gerstenberg M, Saba R, Lo Cascio N, Brandizzi M, Arango C, Moreno C, Van Meter A, Fusar-Poli P, Correll CU. DSM-5 Attenuated Psychosis Syndrome in Adolescents Hospitalized With Non-psychotic Psychiatric Disorders. Front Psychiatry 2020; 11:568982. [PMID: 33192693 PMCID: PMC7609900 DOI: 10.3389/fpsyt.2020.568982] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/14/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction: Although attenuated psychotic symptoms often occur for the first time during adolescence, studies focusing on adolescents are scarce. Attenuated psychotic symptoms form the criteria to identify individuals at increased clinical risk of developing psychosis. The study of individuals with these symptoms has led to the release of the DSM-5 diagnosis of Attenuated Psychosis Syndrome (APS) as a condition for further research. We aimed to characterize and compare hospitalized adolescents with DSM-5-APS diagnosis vs. hospitalized adolescents without a DSM-5-APS diagnosis. Methods: Interviewing help-seeking, hospitalized adolescents (aged 12-18 years) and their caregivers independently with established research instruments, we (1) evaluated the presence of APS among non-psychotic adolescents, (2) characterized and compared APS and non-APS individuals regarding sociodemographic, illness and intervention characteristics, (3) correlated psychopathology with levels of functioning and severity of illness and (4) investigated the influence of individual clinical, functional and comorbidity variables on the likelihood of participants to be diagnosed with APS. Results: Among 248 consecutively recruited adolescents (age=15.4 ± 1.5 years, females = 69.6%) with non-psychotic psychiatric disorders, 65 (26.2%) fulfilled APS criteria and 183 (73.8%) did not fulfill them. Adolescents with APS had higher number of psychiatric disorders than non-APS adolescents (3.5 vs. 2.4, p < 0.001; Cohen's d = 0.77), particularly, disruptive behavior disorders (Cramer's V = 0.16), personality disorder traits (Cramer's V = 0.26), anxiety disorders (Cramer's V = 0.15), and eating disorders (Cramer's V = 0.16). Adolescents with APS scored higher on positive (Cohen's d = 1.5), negative (Cohen's d = 0.55), disorganized (Cohen's d = 0.51), and general symptoms (Cohen's d = 0.84), and were more severely ill (Cohen's d = 1.0) and functionally impaired (Cohen's d = 0.31). Negative symptoms were associated with lower functional levels (Pearson ρ = -0.17 to -0.20; p = 0.014 to 0.031). Global illness severity was associated with higher positive, negative, and general symptoms (Pearson ρ = 0.22 to 0.46; p = 0.04 to p < 0.001). APS status was independently associated with perceptual abnormalities (OR = 2.0; 95% CI = 1.6-2.5, p < 0.001), number of psychiatric diagnoses (OR = 1.5; 95% CI = 1.2-2.0, p = 0.002), and impaired stress tolerance (OR = 1.4; 95% CI = 1.1-1.7, p = 0.002) (r 2 = 0.315, p < 0.001). Conclusions: A considerable number of adolescents hospitalized with non-psychotic psychiatric disorders meet DSM-5-APS criteria. These help-seeking adolescents have more comorbid disorders and more severe symptoms, functional impairment, and severity of illness than non-APS adolescents. Thus, they warrant high intensity clinical care.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Department of Child and Adolescent Psychiatry, Centro de Investigación Biomédica en Red de Salud Mental, General Universitario Gregorio Marañón School of Medicine, Institute of Psychiatry and Mental Health, Hospital Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, Madrid, Spain
| | - Daniel Guinart
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Barbara A Cornblatt
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.,Institute for Behavioral Science, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Andrea M Auther
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Ricardo E Carrión
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.,Institute for Behavioral Science, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Maren Carbon
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States
| | - Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Jaén Medical Center, Jaén, Spain.,Department of Psychiatry, University of Granada, Granada, Spain
| | - Ditte L Vernal
- Research Unit for Child- and Adolescent Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Walitza
- Psychiatric University Hospital Zurich, Department of Child and Adolescent Psychiatry and Psychotherapy, Zurich, Switzerland
| | - Miriam Gerstenberg
- Psychiatric University Hospital Zurich, Department of Child and Adolescent Psychiatry and Psychotherapy, Zurich, Switzerland
| | | | - Nella Lo Cascio
- Prevention and Early Intervention Service, Department of Mental Health, Rome, Italy
| | - Martina Brandizzi
- Local Health Agency Rome 1, Santo Spirito in Sassia Hospital, Department of Mental Health, Inpatient Psychiatric Unit, Rome, Italy
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Centro de Investigación Biomédica en Red de Salud Mental, General Universitario Gregorio Marañón School of Medicine, Institute of Psychiatry and Mental Health, Hospital Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, Madrid, Spain
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Centro de Investigación Biomédica en Red de Salud Mental, General Universitario Gregorio Marañón School of Medicine, Institute of Psychiatry and Mental Health, Hospital Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, Madrid, Spain
| | - Anna Van Meter
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.,Institute for Behavioral Science, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Outreach and Support in South London Service, South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.,Institute for Behavioral Science, The Feinstein Institutes for Medical Research, Manhasset, NY, United States.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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