The impact of thought disorder on therapeutic alliance and personal recovery in schizophrenia and schizoaffective disorder: An exploratory study

Motivational Interviewing in Patients with Acute Psychosis: A Feasibility Study

Background and Hypothesis

Psychotic disorders are among the top causes of disability worldwide. Guidelines emphasize the need for psychotherapeutic approaches in the acute phase of this illness. Motivational interviewing (MI) is highly suitable for establishing a therapeutic alliance wherein the patient's intrinsic motivation can be strengthened to adhere to therapy. This pilot study investigated the feasibility and impact of MI for patients with acute psychosis.

Study Design

A feasibility study was conducted, comparing MI and supportive counseling. The sample included 20 inpatients, who all received 4 therapy sessions. In line with CONSORT guidelines for pilot and feasibility studies, we measured various feasibility outcomes. Clinical outcomes were assessed using linear regression models, with baseline values used as covariates.

Study Results

The recruitment target (N = 24) was achieved at 83% in a reasonable timeframe (8 months), with a retention rate of 83% and a completion rate of 71%. The eligibility rate (82 %) was high, the consent rate (48%) was moderate, and both the dropout rate 17% and the missing data rate (0.3%) were low. Regarding the clinical outcomes, a group difference was found for the severity of psychotic symptoms, with an advantage for MI (b = -12.0, 95% CI: [-18.7, -5.2], P < 0.01), although the small sample size must be kept in mind.

Conclusions

The study demonstrated the feasibility and acceptability of a clinical trial with MI for patients with psychosis in an inpatient setting. MI could offer benefits, particularly in terms of reducing psychotic symptoms.

Latent mechanisms of language disorganization relate to specific dimensions of psychopathology

Comprehensible communication is critical for social functioning and well-being. In psychopathology, incoherent discourse is assumed to reflect disorganized thinking, which is classically linked to psychotic disorders. However, people do not express everything that comes to mind, rendering inferences from discourse to the underlying structure of thought challenging. Indeed, a range of psychopathologies are linked to self-reported disorganized thinking in the absence of language output incoherence. Here we combine natural language processing and computational modeling of free association to detail the relationship between disorganized thinking and language (in)coherence in a large sample of participants varying across different dimensions of psychopathology. Our approach allowed us to differentiate between disorganized thinking, disinhibited thought expression and deliberate creativity. We find evidence for both under-regulated and over-regulated disorganized thinking, which relate to two specific dimensions of psychopathology: self-reported eccentricity and suspiciousness. Broadly, these results underscore the theoretical progress afforded by analyzing latent dimensions underlying behavior and psychopathology.

Relapse prevention through health technology program reduces hospitalization in schizophrenia

BACKGROUND

Psychiatric hospitalization is a major driver of cost in the treatment of schizophrenia. Here, we asked whether a technology-enhanced approach to relapse prevention could reduce days spent in a hospital after discharge.

METHODS

The Improving Care and Reducing Cost (ICRC) study was a quasi-experimental clinical trial in outpatients with schizophrenia conducted between 26 February 2013 and 17 April 2015 at 10 different sites in the USA in an outpatient setting. Patients were between 18 and 60 years old with a diagnosis of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Patients received usual care or a technology-enhanced relapse prevention program during a 6-month period after discharge. The health technology program included in-person, individualized relapse prevention planning with treatments delivered via smartphones and computers, as well as a web-based prescriber decision support program. The main outcome measure was days spent in a psychiatric hospital during 6 months after discharge.

RESULTS

The study included 462 patients, of which 438 had complete baseline data and were thus used for propensity matching and analysis. Control participants (N = 89; 37 females) were enrolled first and received usual care for relapse prevention followed by 349 participants (128 females) who received technology-enhanced relapse prevention. During 6-month follow-up, 43% of control and 24% of intervention participants were hospitalized (χ2 = 11.76, p<0.001). Days of hospitalization were reduced by 5 days (mean days: b = -4.58, 95% CI -9.03 to -0.13, p = 0.044) in the intervention condition compared to control.

CONCLUSIONS

These results suggest that technology-enhanced relapse prevention is an effective and feasible way to reduce rehospitalization days among patients with schizophrenia.

Recovery-oriented nursing service for people with schizophrenia in the community: An integrative review

Background

The recovery-oriented service concept has been recognized for its impact on mental health practices and services. As the largest group of mental healthcare providers, mental health nurses are well-positioned to deliver recovery-oriented services but face challenges due to role ambiguity and identity issues. Therefore, clarifying the role and principles of mental health nursing is essential.

Objective

This study aimed to identify essential nursing practices for individuals with schizophrenia in recovery-oriented mental health services.

Design

The study utilized a five-step integrative review approach, including problem identification, literature search definition, critical analysis of methodological quality, data analysis, and data presentation.

Data Sources

Multiple databases, such as ScienceDirect and Scopus, as well as online libraries and journals/publishers, including Sage journals, APA PsyNet, SpringerLink, PsychiatryOnline, Taylor & Francis Online, and Wiley Online Library, were searched. The search spanned from the inception of the recovery-oriented services concept in 1993 to 2022.

Review Methods

Content and thematic analysis were employed to analyze and synthesize the findings from the included studies.

Results

Twenty-four articles met the inclusion criteria. Two themes were identified: 1) Direct nursing care, consisting of six sub-themes: therapeutic nurse-patient relationship (TNPR), psychoeducation (PE), coping skill training (CST), cognitive behavioral techniques (CBT), interventions to improve medication adherence (IMA), and social functioning (SF); and 2) Indirect nursing care.

Conclusion

This study highlights the crucial role of nursing and nursing practices in recovery-oriented services. Mental health nurses prioritize person-centered care, therapeutic relationships, and collaboration with peer support workers to enhance treatment effectiveness. In addition, they focus on improving medication adherence, providing coping support, and promoting social capabilities, ultimately improving individuals' quality of life. Aligning actions with recovery-oriented principles, mental health nurses emphasize empowerment and holistic care. Further research in this area will enhance the healthcare system and better support individuals on their recovery journey.

Defining recovery in schizophrenia: A review of outcome studies

Schizophrenia is a chronic disorder with a heterogenous course and different ways in which recovery is measured or perceived. Recovery in schizophrenia is a complex process that it can be defined either from a clinical perspective focused on sustained symptom and functional remission, or from a patient-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. Therefore, this meta-analysis aimed to examine the relationship of global measures of subjective recovery with each of the components of clinical recovery such as symptom severity and functioning, in patients with schizophrenia spectrum disorders. The results showed that the association between different indicators of personal recovery and remission are weak and inverse (^dIG⁺ = -0.18, z = -2.71, p < 0.01), however, this finding is not substantial according to the sensitivity indicators. With respect to functionality and personal recovery, there was a moderate relationship (^dIG⁺ = 0.26, z = 7.894, p < 0.01) with adequate sensitivity indices. In addition, a low consensus exists between subjective measures that are more related to the patient's perspective and clinical measures based on experts and clinician's viewpoint.

Relationships between neuropsychological performance, insight, medication adherence, and social metacognition in schizophrenia

BACKGROUND

Social metacognition is still poorly understood in schizophrenia, particularly its neuropsychological basis and its impact on insight and medication adherence. We therefore quantified social metacognition as the agreement between objective and subjective mentalization and assessed its correlates in a sample of individuals with schizophrenia spectrum disorders.

METHODS

Participants consisted of 143 patients with schizophrenia or schizoaffective disorders who underwent a metacognitive version of a mentalization task, an extensive neuropsychological battery, and a clinical evaluation to assess their insight into illness and medication adherence. We studied potential interactions between confidence judgments and several neuropsychological and clinical variables on mentalization accuracy with mixed-effects multiple logistic regressions.

RESULTS

Confidence judgments were closely associated with mentalization accuracy, indicative of good social metacognition in this task. Working memory, visual memory, and reasoning and problem-solving were the three neuropsychological dimensions positively associated with metacognition. By contrast, the two measures of medication adherence were associated with poorer metacognition, whereas no association was found between metacognition and clinical insight. The multiple regression model showed a significant positive impact of better working memory, older age at onset, longer duration of hospitalization, and worse medication adherence on social metacognition.

CONCLUSIONS

We discuss possible mechanisms underlying the apparent association between social metacognition and working memory. Adherence should be monitored when remediating social metacognition, and psychoeducation should be given to patients with a high level of awareness of their capacity to mentalize.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness

BACKGROUND

Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery.

AIMS

To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates.

METHODS

Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test.

RESULTS

Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point.

CONCLUSIONS

Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.

Association between formal thought disorders, neurocognition and functioning in the early stages of psychosis: a systematic review of the last half-century studies

Recent review articles provided an extensive collection of studies covering many aspects of format thought disorders (FTD) among their epidemiology and phenomenology, their neurobiological underpinnings, genetics as well as their transdiagnostic prevalence. However, less attention has been paid to the association of FTD with neurocognitive and functioning deficits in the early stages of evolving psychosis. Therefore, this systematic review aims to investigate the state of the art regarding the association between FTD, neurocognition and functioning in the early stages of evolving psychotic disorders in adolescents and young adults, by following the PRISMA flowchart. A total of 106 studies were screened. We included 8 studies due to their reports of associations between FTD measures and functioning outcomes measured with different scales and 7 studies due to their reports of associations between FTD measures and neurocognition. In summary, the main findings of the included studies for functioning outcomes showed that FTD severity predicted poor social functioning, unemployment, relapses, re-hospitalisations, whereas the main findings of the included studies for neurocognition showed correlations between attentional deficits, executive functions and FTD, and highlighted the predictive potential of executive dysfunctions for sustained FTD. Further studies in upcoming years taking advantage of the acceleration in computational psychiatry would allow researchers to re-investigate the clinical importance of FTD and their role in the transition from at-risk to full-blown psychosis conditions. Employing automated computer-assisted diagnostic tools in the early stages of psychosis might open new avenues to develop targeted neuropsychotherapeutics specific to FTD.

Improving Medication Adherence in Community-Dwelling Patients with Schizophrenia Through Therapeutic Alliance and Medication Attitude: A Serial Multiple Mediation Model

BACKGROUND

Increased medication adherence improves patient outcomes and lowers the overall cost of care by preventing disease relapse and hospital readmission. Several systematic reviews have identified that insight, therapeutic alliance, and attitude towards medication affect medication adherence in patients with schizophrenia; however, no study has examined all the aforementioned variables together nor has discussed the chains of these mediators.

PURPOSE

To examine the insight-medication adherence relationship among community-dwelling schizophrenia patients through a serial multiple mediation model of therapeutic alliance and medication attitude.

PATIENTS AND METHODS

This study with a cross-sectional correlational design included a convenience sample of community-dwelling schizophrenia patients from Taiwan (n = 229). From January 2017 to January 2018, data were collected by trained nurses using questionnaires. The PROCESS tool was used to analyse fine-grained chains.

RESULTS

In serial multiple mediation, the indirect effect of insight on medication adherence through therapeutic alliance and, subsequently, alteration of medication attitude was significant. However, the direct effect changed from significant to non-significant, indicating a complete mediating effect.

CONCLUSION

In community-dwelling schizophrenia patients, the effects of therapeutic alliance and medication attitude on medication adherence are greater than that of insight. We recommend revising the strategy of community home visits by different psychiatrists or nurses in alternating shifts. Therapeutic alliance is the first step required to promote medication adherence. Based on this alliance, altering the patients' medication attitude may be more effective in improving medication adherence than merely enhancing insight.

Examining Side Effect Variability of Antipsychotic Treatment in Schizophrenia Spectrum Disorders: A Meta-analysis of Variance

Side effects of antipsychotic drugs play a key role in nonadherence of treatment in schizophrenia spectrum disorders (SSD). While clinical observations suggest that side effect variability between patients may be considerable, statistical evidence is required to confirm this. Here, we hypothesized to find larger side effect variability under treatment compared with control. We included double-blind, placebo-controlled, randomized controlled trials (RCTs) of adults with a diagnosis of SSD treated with 1 out of 14 antipsychotics. Standard deviations of the pre-post treatment differences of weight gain, prolactin levels, and corrected QT (QTc) times were extracted. The outcome measure was the variability ratio of treatment to control for individual antipsychotic drugs and the overall variability ratio of treatment to control across RCTs. Individual variability ratios were weighted by the inverse-variance method and entered into a random-effects model. We included N = 16 578 patients for weight gain, N = 16 633 patients for prolactin levels, and N = 10 384 patients for QTc time. Variability ratios (VR) were significantly increased for weight gain (VR = 1.08; 95% CI: 1.02-1.14; P = .004) and prolactin levels (VR = 1.38; 95% CI: 1.17-1.62; P < .001) but did not reach significance for QTc time (VR = 1.05; 95% CI: 0.98-1.12; P = 0.135). We found marked differences between individual antipsychotics and increased variability in side effects in patients under treatment with antipsychotics suggesting that subgroups of patients or individual patients may benefit from treatment allocation through stratified or personalized medicine.

Cortical thickness and formal thought disorder in schizophrenia: An ultra high-field network-based morphometry study

BACKGROUND

Persistent formal thought disorder (FTD) is a core feature of schizophrenia. Recent cognitive and neuroimaging studies indicate a distinct mechanistic pathway underlying the persistent positive FTD (pFTD or disorganized thinking), though its structural determinants are still elusive. Using network-based cortical thickness estimates from ultra-high field 7-Tesla Magnetic Resonance Imaging (7T MRI), we investigated the structural correlates of pFTD.

METHODS

We obtained speech samples and 7T MRI anatomical scans from medicated clinically stable patients with schizophrenia (n = 19) and healthy controls (n = 20). Network-based morphometry was used to estimate the mean cortical thickness of 17 functional networks covering the entire cortical surface from each subject. We also quantified the vertexwise variability of thickness within each network to quantify the spatial coherence of the 17 networks, estimated patients vs. controls differences, and related the thickness of the affected networks to the severity of pFTD.

RESULTS

Patients had reduced thickness of the frontoparietal and default mode networks, and reduced spatial coherence affecting the salience and the frontoparietal control network. A higher burden of positive FTD related to reduced frontoparietal thickness and reduced spatial coherence of the salience network. The presence of positive FTD, but not its severity, related to the reduced thickness of the language network comprising of the superior temporal cortex.

CONCLUSIONS

These results suggest that cortical thickness of both cognitive control and language networks underlie the positive FTD in schizophrenia. The structural integrity of cognitive control networks is a critical determinant of the expressed severity of persistent FTD in schizophrenia.

A meta-analysis of client-therapist perspectives on the therapeutic alliance: Examining the moderating role of type of measurement and diagnosis

Background:

Clients and therapists often have different perspectives on their therapeutic alliance (TA), affecting the process and outcome of therapy. The aim of the present meta-analysis was to assess the mean differences between clients’ and therapists’ estimations of TA among clients with severe disturbances, while focusing on two potential moderators: client diagnosis and alliance instrument.

Method:

We conducted a systematic literature search of studies examining both client perspective and therapist perspective on TA in psychotherapy among people with schizophrenia spectrum disorders, personality disorders, and substance misuse disorders. We then analyzed the data using a random-effects meta-analytic model with Cohen’s d standardized mean effect size.

Results:

Heterogeneity analyses (k = 22, Cohen’s d = −.46, 95% confidence interval = .31–1.1) produced a significant Q-statistic (Q = 94.96) and indicated high heterogeneity, suggesting that moderator analyses were appropriate.

Conclusions:

Our findings show that the type of TA instrument moderates the agreement on TA between client and therapist, but there was no indication of the client’s diagnosis moderating the effect. The agreement between client and therapist estimations seems to be dependent on the instrument that is used to assess TA. Specific setting-related instruments seem to result in higher agreement between clients’ and therapists’ estimations than do more general instruments that are applied to assess TA.

Determinants of Therapeutic Alliance With People With Psychotic Disorders: A Systematic Literature Review

Therapeutic alliance determines medical treatment adherence, the success of psychotherapy, and the effectiveness of care. This systematic review aims at better understanding its determinants. The electronic databases Pubmed, Cochrane Library, and Web of Science were searched, using combinations of terms relating to psychosis and therapeutic alliance. Studies were selected and data were extracted using a PRISMA statement. Forty-one studies were selected, including 20 cross-sectional studies, 10 cohort studies, five randomized controlled trials, four literature reviews, and two retrospective studies. The quality of therapeutic alliance correlates with clinical symptoms, insight, social and family support, the therapist's qualities, the availability of shared therapeutic decision making, and the types of hospitalization. Although current evidence needs to be completed with further studies, it is already clear that group and family psychoeducation, cognitive remediation, community-based psychiatric services, and shared therapeutic decision making are essential approaches in the management of patients with psychosis.

Is cognitive behavioural therapy effective for individuals experiencing thought disorder?

Various clinical guidelines recommend cognitive behavioural therapy (CBT) to treat psychosis without reference to patients' thought disorder. However, there is a risk that disorganized thinking hampers CBT. We tested the prediction that thought disorder would interfere with the effectiveness of CBT for hallucinations and delusions, compared to treatment as usual and supportive counselling, in secondary data from two large, single blind randomised controlled trials. We fitted latent growth curve models separately for the development of frequency and distress of symptoms. CBT was significantly more successful than counselling in reducing delusional frequency in the short term and hallucinatory distress at any point, even in those with relatively high thought disorder. We found little evidence that clinicians should restrict CBT in this subgroup of patients. Nevertheless, the findings highlight the importance of effective initial treatment of thought disorder in maximising the benefit of CBT for psychosis, particularly for reducing distress from hallucinations.

The Complex Relationship Among Formal Thought Disorders, Neurocognition, and Functioning in Nonacutely Ill Schizophrenia Patients

The aims of the present study were to 1) evaluate clinical differences between patients suffering from schizophrenia (SZ) with mild versus moderate/severe formal thought disorder (FTD); 2) explore relationships between dimensions of FTD, neuropsychological domains, and global functioning; and 3) compare clinical dimensions of FTD in early and late SZ. One hundred thirty-six individuals with schizophrenia were recruited and evaluated during a nonacute phase of illness. FTD was assessed with the Thought, Language, and Communication Scale. Partial correlations, t-tests, and stepwise regression were undertaken to address the study aims. Patients with moderate/severe FTD performed worse than those with mild FTD for processing speed, reasoning and problem solving, and social cognition, and demonstrated poorer global functioning. Early SZ did not differ from late SZ in terms of negative FTD and difficulty in abstract thinking (DAT). Negative FTD was correlated with reasoning and problem solving; DAT was correlated with social cognition. All clinical dimensions of FTD, regardless of neurocognitive impairment, accounted for a significant amount of variance in global functioning. FTD predicted global functioning, regardless of neurocognitive factors. Due to their stability in different phases of the course of the disease and their strong relationship with other core variables, Neg-FTD and DAT should be investigated as an intermediate phenotype of the illness.

Barriers to recovery-focused care within therapeutic relationships in nursing: Attitudes and perceptions

There are numerous barriers to the therapeutic relationship between nurses and persons with schizophrenia, such as time constraints, communication issues and the requirements of practice policies. The main point of this paper is that the nature of these barriers is such that the nurse may not conceptualize these as barriers or be aware of how his or her responses to these can further entrench existing barriers to relationship or create new ones. If the nurse is not aware of how he or she responds to time pressure, frustration or lack of clarity of practice policy and address this, there is a risk that the patient may perceive the nurse's actions as lacking in care, presence or involvement. As consumers increasingly embrace recovery approaches to mental health that prioritize therapeutic activities within the context of collaborative relationship, psychiatric nurses, with a long tradition of therapeutic relationship, can rise to meet them. It is suggested here that this can only occur if nurses are fully aware of barriers to relationship, their responses to these and the impact of these on relationship with patients. Suggestions for educational and empirical work to further raise awareness and promote understanding of this process are provided.

Resilience and recovery style: a retrospective study on associations among personal resources, symptoms, neurocognition, quality of life and psychosocial functioning in psychotic patients

Background: Personal resources have been identified as important factors in predicting patient healing or symptoms control in schizophrenia. This observational retrospective study aims to explore the influence of resilience and recovery style on the modalities of clinical presentation of the disease, as well as individual functioning and quality of life. Methods: Participants were patients affected by schizophrenia spectrum disorders assessed at different mental health facilities. The rating scales considered are the following: Resilience Scale 10-items (RS); Recovery Style Questionnaire (RSQ); Montreal Cognitive Assessment (MoCA); Schizophrenia Quality of Life Scale (SQLS); Life Skills Profile (LSP); Positive and Negative Syndrome Scale (PANSS). Results: Forty-four patients fulfilled the inclusion criteria. The mean age was 46 years; the average length of the history of the disease at recruitment was 23 years with an average age at first episode of psychosis (FEP) of 23 years. General psychopathology, neurocognition, and integration recovery style can predict psychosocial functioning and explain ~54% of the LSP variance; RS total score and PANSS general psychopathology score can predict and explain ~29% of the LSP variance. A negative association between PANSS general psychopathology and LSP total score supports the need to reduce first the symptomatology, and then successfully apply other types of interventions. A strong positive association between neurocognition and life functioning was detected, showing that deficits in neurocognition have proved to be important predictors of the functional outcome. Integration was also proven to be significantly associated with a good functional outcome. Psychotic symptoms turn out to be a negative predictive factor, whereas resilience can be hypothesized as a protective factor. Conclusions: Resilience and recovery style "integration" can be considered as two complementary predictive resources for a good outcome; this result supports the need to set up personalized treatments, based on the characteristics of the patients.

The relationship between the therapeutic alliance and client variables in individual treatment for schizophrenia spectrum disorders and early psychosis: Narrative review

Given the high rates of treatment disengagement and medication nonadherence in individuals with schizophrenia spectrum disorders and early psychosis, fostering a strong alliance in treatment is critical. Moreover, the role of the therapeutic alliance extends beyond that in traditional psychotherapy because of the multifaceted nature of treatment. Thus, this review provides a comprehensive discussion of the relationship between the alliance and client variables across various provider types and individual treatments. This review summarizes existing research on (a) client correlates/predictors of the therapeutic alliance and on (b) the relationship between the alliance and client treatment outcomes in individual treatment for schizophrenia spectrum disorders and early psychosis. Parallel literature searches were conducted using PubMed and PsycINFO databases, which yielded 1202 potential studies with 84 studies meeting inclusion criteria. With regard to correlates/predictors, the existing evidence suggests that better insight, medication adherence, social support, and recovery variables were related to better client-rated alliance. Better medication adherence and recovery variables as well as less severe symptoms were related to better provider-rated alliance. In terms of alliance-outcome relationships, evidence suggests that a strong provider-rated alliance was predictive of improved functioning and medication and treatment adherence. There was some limited evidence that better client-rated alliance was related to improved recovery outcomes. Despite mixed results and heterogeneity among studies, this review suggests that a strong alliance can be beneficial in individual schizophrenia treatment. Thus, training and supervision of providers should emphasize developing a positive alliance, particularly with clients for whom developing an alliance may be difficult.

Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

Therapeutic alliance, relationship building, and communication strategies-for the schizophrenia population: An integrative review

BACKGROUND

Schizophrenia is a chronic mental illness that affects the client, family, and community. Nurses are educated to use the nurse-patient relationship to provide health education and collaborative health decision-making. However, challenges abound for nurses and clients with schizophrenia to effectively utilize the relationship to reach these goals.

PROBLEM

There is a lack of evidence-based information to assist nurses to meet the challenges of building effective therapeutic relationships with clients for whom schizophrenia hinders health education and decision-making.

PURPOSE

To examine current research findings on factors that influence therapeutic relationships in psychiatric treatment settings as an initial effort to provide empirically based guidance for psychiatric nurses who seek to better use the relationship to work with the client toward health-related goals.

METHOD

This integrative review of the literature follows Whittemore and Knafl's (2015) method, analyzes 15 studies from multiple databases between the years 2006-2017, and assesses the rigor of each.

FINDINGS

Numerous methods are used to assess therapeutic relationships. Few studies included nurses. Provider perception of client symptoms can negatively affect provider assessment of quality of relationship; no such association was found on the part of clients. Providers and clients prioritize client needs differently, with providers influenced by treatment setting demands, but provider-training programs can have a beneficial effect on their relationships.

CONCLUSION

Nurses and nurse educators can use the findings to guide assessment of how perceptions and priorities influence relationships. Findings also provide the foundation for further study of nurses' perceptions of therapeutic relationship, in progress, to yield more detailed information on what nurses and educators need to strengthen therapeutic relationships.

Disorganisation, thought disorder and socio-cognitive functioning in schizophrenia spectrum disorders

BACKGROUND

Poor social cognition is prevalent in schizophrenia spectrum disorders. Some authors argue that these effects are symptom-specific and that socio-cognitive difficulties (e.g. theory of mind) are strongly associated with thought disorder and symptoms of disorganisation.AimsThe current review tests the strength of this association.

METHOD

We meta-analysed studies published between 1980 and 2016 that tested the association between social cognition and these symptoms in schizophrenia spectrum disorders.

RESULTS

Our search (PsycINFO, MEDLINE and Web of Science) identified 123 studies (N = 9107). Overall effect size as r = -0.313, indicating a moderate association between symptoms and social cognition. Subanalyses yielded a moderate association between symptoms and theory of mind (r = -0.349) and emotion recognition (r = -0.334), but smaller effect sizes for social perception (r = -0.188), emotion regulation (r = -0.169) and attributional biases (r = -0.143).

CONCLUSIONS

The association is interpreted within models of communication that highlight the importance of mentalisation and processing of partner-specific cues in conversational alignment and grounding.Declaration of interestsNone.

Speech structure links the neural and socio-behavioural correlates of psychotic disorders

BACKGROUND

A longstanding notion in the concept of psychosis is the prominence of loosened associative links in thought processes. Assessment of such subtle aspects of thought disorders has proved to be a challenging task in clinical practice and to date no surrogate markers exist that can reliably track the physiological effects of treatments that could reduce thought disorders. Recently, automated speech graph analysis has emerged as a promising means to reliably quantify structural speech disorganization.

METHODS

Using structural and functional imaging, we investigated the neural basis and the functional relevance of the structural connectedness of speech samples obtained from 56 patients with psychosis (22 with bipolar disorder, 34 with schizophrenia). Speech structure was assessed by non-semantic graph analysis.

RESULTS

We found a canonical correlation linking speech connectedness and i) functional as well as developmentally relevant structural brain markers (degree centrality from resting state functional imaging and cortical gyrification index) ii) psychometric evaluation of thought disorder iii) aspects of cognitive performance (processing speed deficits) and iv) functional outcome in patients. Of various clinical metrics, only speech connectedness was correlated with biological markers. Speech connectedness filled the dynamic range of responses better than psychometric measurements of thought disorder.

CONCLUSIONS

The results provide novel evidence that speech dysconnectivity could emerge from neurodevelopmental deficits and associated dysconnectivity in psychosis.

The role of social isolation and social cognition in thought disorder

A better understanding of how social factors relate to the psychological processes in thought disorder (TD) is necessary for the development of effective psychological interventions. Sixty-eight participants diagnosed with psychosis (18-65; 47.1% female) were recruited and evaluated on social cognition (Hinting Task, HT; and reading the mind in the eyes test, RMET), social isolation (size of social network, frequency and quality of contact), psychotic symptoms (Positive and Negative Syndrome Scale, PANSS) and TD (Thought, Language and Communication Disorders Scale, TLC). A mediation model was tested with isolation as the predictor, TD as the outcome, and performance on HT and RMET as the mediators. The final model, with adjustment for comorbid symptoms (i.e. delusions, suspiciousness, hallucinations, and negative symptoms), supported full mediation and explained a significant amount of the observed variance (60%). Performance on the HT was a significant mediator of the relationship between social isolation and TD. From the covariates, delusions contributed independently and significantly to TD. The implications of the findings for psychological practice, and TD-specific interventions, are discussed as well as the limitations of the study. Further avenues for symptom-specific research are discussed, in particular with reference to more complex psychosocial models.

Formal thought disorder is related to aberrations in language-related white matter tracts in patients with schizophrenia

This study examined the hypothesis that a fronto-temporal disconnection in the language network underpins formal thought disorder (FTD) in schizophrenia. Forty-nine patients with a schizophrenia spectrum disorder (27 with mild FTD, 22 with severe FTD) and 26 healthy controls (HC) were included. Overall psychopathology and FTD were assessed by the Positive and Negative Syndrome Scale and the Thought, Language, and Communication scale, respectively. White matter (WM) microstructure was analysed using Tract-Based Spatial Statistics. In patients, severity of overall FTD (TLC Sum Score) was predicted by decreased fractional anisotropy (FA) in the right superior longitudinal fasciculus (SLF), and severity of negative FTD (TLC Emptiness subscale) was predicted by increased FA in the left SLF and arcuate fasciculus (AF). Notably, these results were no longer significant after correction for multiple comparisons. Compared with HC, patients showed lower FA in all the investigated language-related WM tracts as well as across the whole WM skeleton. No difference in FA was found between patients with severe and patients with mild FTD. Our results are compatible with earlier studies reporting impairments in widely spread WM tracts including those related to language processing in patients with schizophrenia.

Recover recovery style from psychosis: a psychometric evaluation of the German version of the Recovery Style Questionnaire (RSQ)

AIMS

The way an individual handles the experience of psychosis, the so-called 'recovery style', has been shown to substantially affect long-term outcomes. The Recovery Style Questionnaire (RSQ) measures this psychological dimension. The aim of this study was to provide a validation of the German version of the RSQ and to raise awareness for recovery-oriented approaches.

METHODS

The RSQ was translated into German according to the guidelines of the WHO and patients were administered this questionnaire and measures of internalised stigma, psychotic symptoms, illness concept, empowerment, self-esteem and quality of life. Descriptive statistics were demonstrated to characterise the sample. Reliability was assessed in different forms: internal consistency, test-retest reliability and split-half reliability. Items were evaluated with descriptive data and item-total correlations. Convergent and discriminant validity were shown, and a confirmatory factor analysis was performed. In order to ameliorate the model, a post hoc model modification was done.

RESULTS

The sample consisted of 138 patients diagnosed with schizophrenia spectrum disorders (mean age: 35.7 years; 53.6% men; mean duration of illness: 20.6 years) with a mean RSQ overall percentage of 66.12 (s.d. ± 17.43%), mainly representing the categories 'mixed picture' and 'tends towards integration'. The reliability of the RSQ was acceptable with a Cronbach's α of 0.741 and a test-retest coefficient of 0.502. Item-total correlations were not acceptable for 27 of 39 items. Moderate evidence for convergent validity of the RSQ was found. Confirmatory factor analysis revealed that the 13-factor model with 39 items originally proposed was partially poorly replicated in the present sample (χ2 ratio to degrees of freedom (χ2/df) of 1.732, Comparative Fit Index (CFI) of 0.585, Normed Fit Index (NFI) of 0.414, Tucker-Lewis Index (TLI) of 0.508, root mean square error of approximation (RMSEA) of 0.095). The RSQ was modified based on item-total correlations and path coefficients of the single items. The confirmatory factor analysis of the resulting one-factor model with 11 items showed adequate fit to the data (χ2/df of 1.562, CFI of 0.936, NFI of 0.847, TLI of 0.910, RMSEA of 0.083) and demonstrated good model fit.

CONCLUSIONS

Despite partially insufficient psychometric data of the original RSQ, the concept of recovery style is beneficial to psychiatric research and clinical practice. The underlying idea is valuable, and the questionnaire needs further development. Therefore, a short version of the RSQ is proposed.

Is formal thought disorder in schizophrenia related to structural and functional aberrations in the language network? A systematic review of neuroimaging findings

Formal thought disorder (FTD) is a core feature of schizophrenia, a marker of illness severity and a predictor of outcome. The underlying neural mechanisms are still a matter of debate. This study aimed at 1) reviewing the literature on the neural correlates of FTD in schizophrenia, and 2) testing the hypothesis that FTD correlates with structural and functional aberrations in the language network. Medline, PsychInfo, and Embase were searched for neuroimaging studies, which applied a clinical measure to assess FTD in adults with schizophrenia and were published in English or German in peer-reviewed journals until December 2016. Of 412 articles identified, 61 studies were included in the review. Volumetric studies reported bilateral grey matter deficits (L > R) to be associated with FTD in the inferior frontal gyrus, the superior temporal gyrus and the inferior parietal lobe. The same regions showed hyperactivity in resting state functional magnetic resonance imaging (fMRI) studies and both hyper- and hypoactivity in fMRI studies that employed semantic processing or free speech production tasks. Diffusion tensor imaging studies demonstrated white matter aberrations in fibre tracts that connect the frontal and temporo-parietal regions. FTD in schizophrenia was found to be associated with structural and functional aberrations in the language network. However, there are studies that did not find an association between FTD and neural aberrations of the language network and regions not included in the language network have been associated with FTD. Thus, future research is needed to clarify the specificity of the language network for FTD in schizophrenia.

Formal thought disorders: from phenomenology to neurobiology

Formal thought disorder (FTD) is present in most psychiatric disorders and in some healthy individuals. In this Review, we present a comprehensive, integrative, and multilevel account of what is known about FTD, covering genetic, cellular, and neurotransmitter effects, environmental influences, experimental psychology and neuropsychology, brain imaging, phenomenology, linguistics, and treatment. FTD is a dimensional, phenomenologically defined construct, which can be clinically subdivided into positive versus negative and objective versus subjective symptom clusters. Because FTDs have been traditionally linked to schizophrenia, studies in other diagnoses are scarce. Aetiologically, FTD is the only symptom under genetic influence in schizophrenia as shown in linkage studies, but familial communication patterns (allusive thinking) have also been associated with the condition. Positive FTDs are related to synaptic rarefication in the glutamate system of the superior and middle lateral temporal cortices. Cortical volume of the left superior temporal gyrus is decreased in patients with schizophrenia who have positive FTD in structural MRI studies and shows reversed hemispheric (right more than left) activation in functional MRI experiments during speech production. Semantic network dysfunction in positive FTD has been demonstrated in experiments of indirect semantic hyperpriming (reaction time). In acute positive FTD, antipsychotics are effective, but a subgroup of patients have treatment-resistant, chronic, positive or negative FTD. Specific psychotherapy as treatment for FTD has not yet been developed. With this solid data on the pathogenesis of FTD, we can now implement clinical studies to treat this condition.

The Relationship Between Clinical and Personal Recovery in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis

Patients describe experiencing personal recovery despite ongoing symptoms of psychosis. The aim of the current research was to perform a meta-analysis investigating the relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders. A comprehensive OvidSP database search was performed to identify relevant studies. Correlation coefficients of the relationship between clinical and personal recovery were retrieved from primary studies. Meta-analyses were performed, calculating mean weighted effect sizes for the association between clinical and personal recovery, hope, and empowerment. Additionally, associations between positive, negative, affective symptoms, general functioning, and personal recovery were investigated. The results show that heterogeneity across studies was substantial. Random effect meta-analysis of the relationship between symptom severity and personal recovery revealed a mean weighted correlation coefficient of r = -.21 (95% CI = -0.27 to -0.14, P < .001). We found the following mean weighted effect size for positive symptoms r = -.20 (95% CI = -0.27 to -0.12, P < .001), negative symptoms r = -.24 (95% CI = -0.33 to -0.15, P < .001), affective symptoms r = -.34 (95% CI = -0.44 to -0.24, P < .001) and functioning r = .21 (95% CI = -0.09 to 0.32, P < .001). The results indicate a significant small to medium association between clinical and personal recovery. Psychotic symptoms show a smaller correlation than affective symptoms with personal recovery. These findings suggest that clinical and personal recovery should both be considered in treatment and outcome monitoring of patients with schizophrenia spectrum disorders.

Meeting in difference: Revisiting the therapeutic relationship based on patients' and therapists' experiences in several clinical contexts

Despite decades of research on the therapeutic relationship and the therapeutic alliance and their connection with therapeutic outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011), only a handful of studies have examined how they are experienced by the therapy participants. The aim of the present study is to describe the therapeutic relationship from the subjective perspective of the patients and therapists involved in 3 clinical cases: (a) a 7-year-old child diagnosed with attention deficit hyperactivity disorder, (b) a 29-year old woman diagnosed with a personality disorder, and (c) a 22-year-old man diagnosed with schizophrenia. We conducted semistructured interviews with patients and therapists that were later analyzed following grounded theory coding procedures (Corbin & Strauss, 2008). The results obtained reveal that the constitutive elements of the therapeutic relationship are linked to 2 dimensions of the patient-therapist meeting experience: the technical and role-related dimension, characterized by relational asymmetry, and the affective exchange dimension, characterized by relational symmetry. The article discusses the possible association between the asymmetrical technical dimension, whose roles are defined by the organization of the helping relationship, and the notion of therapeutic alliance as commonly conceptualized and assessed; on the other hand, the experience of the bidirectional and symmetrical patient-therapist affective exchange is linked with concepts such as real relationship and intersubjectivity.

Can RDoC Help Find Order in Thought Disorder?

Thought disorder is a pernicious and nonspecific aspect of numerous serious mental illnesses (SMIs) and related conditions. Despite decades of empirical research on thought disorder, our present understanding of it is poor, our clinical assessments focus on a limited set of extreme behaviors, and treatments are palliative at best. Applying a Research Domain Criteria (RDoC) framework to thought disorder research offers advantages to explicate its phenotype; isolate its mechanisms; and develop more effective assessments, treatments, and potential cures. In this commentary, we discuss ways in which thought disorder can be understood within the RDoC framework. We propose operationalizing thought disorder within the RDoC construct of language using psycholinguistic sciences, to help objectify and quantify language within individuals; technologically sophisticated paradigms, to allow naturalistic behavioral sampling techniques with unprecedented ecological validity; and computational modeling, to account for a network of interconnected and dynamic linguistic, cognitive, affective, and social functions. We also highlight challenges for understanding thought disorder within an RDoC framework. Thought disorder likely does not occur as an isomorphic dysfunction in a single RDoC construct, but rather, as multiple potential dysfunctions in a network of RDoC constructs. Moreover, thought disorder is dynamic over time and context within individuals. In sum, RDoC is a useful framework to integrate multidisciplinary research efforts aimed at operationalizing, understanding, and ameliorating thought disorder.

The prognostic value of formal thought disorder following first episode psychosis

BACKGROUND

Formal thought disorder (FTD) is associated with poor outcome in established psychotic illnesses and it can be assessed as a categorical or dimensional variable. However, its influence on functional outcome and hospitalisation patterns in early psychosis has not been investigated. We evaluated the relationship between FTD and these outcomes in a first episode psychosis (FEP) sample.

MATERIALS AND METHODS

A mixed diagnostic FEP cohort was recruited through an Early Intervention in Psychosis Service in Ireland. Participants were assessed at initial presentation and one year later with the MIRECC GAF to evaluate social and occupational functioning domains. Disorganisation (disFTD), verbosity (verFTD) and poverty (povFTD) dimensions of FTD were examined at both time points, as well as a unitary FTD construct. Analyses were controlled for demographic, clinical and treatment variables.

RESULTS

DisFTD was the only FTD dimension associated with functional outcome, specifically social functioning, on multivariate analysis (beta=0.13, P<0.05). The unitary FTD construct was not associated with functional outcome. DisFTD at FEP presentation predicted a greater number of hospitalisations (adjusted beta=0.24, P<0.001) and prolonged inpatient admission (adjusted OR=1.08, 95% CI 1.02-1.15, P<0.05) following FEP.

CONCLUSIONS

Longitudinal and dimensional evaluation of FTD has a clinical utility that is distinct from a cross-sectional or unitary assessment. Dimensions of FTD may map onto different domains of functioning. These findings are supportive of some of the changes in DSM-V with an emphasis on longitudinal and dimensional appraisal of psychopathology. Communication disorders may be considered a potential target for intervention in psychotic disorders.