S85
The social self in schizophrenia: A neural network perspective on integrative external and internal information processing
- S. Ebisch
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- 23 March 2020, p. S45
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Social impairment is recognized as a basic aspects of schizophrenia. Although the nature of aberrant self-other relationship in schizophrenia is still poorly understood, it has been suggested that some social impairments could have their roots in self-disturbances typical of schizophrenia. For instance, experiencing otherness could become problematic with anomalous self-recognition. Furthermore, deficits in the processing of self-relatedness of social stimuli disconnect the self from its social environment. On the one hand, this could lead to problems in self-other distinction caused by misattributions of ownership of experience and agency in social interaction. On the other hand, this could result in feelings of isolation and reduced intersubjectivity due to interrupted self-referential processing of social stimuli, likely also mediated by memory and emotion. Brain networks involved in self-referential processing, sense of ownership, and agency also have been implied in social cognition. Whereas cortical midline structures are associated with self-referential processing of external stimuli including social information, sensorimotor and affective networks involved in bodily and interoceptive self-processing are also involved in the ability to share others’ experiences. Schizophrenia has been linked with a reduced integrity of these networks underlying various aspects of self and social impairments, though rather separately. Recent neuroimaging findings will be highlighted explaining how self-disturbances can pervade the social domain in schizophrenia. In particular, disruptions of the social self in schizophrenia will be addressed from a neuronal network and connectiomics perspective providing a unifying framework.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S86
Psychopathology of the self and the altered cortical midline structures in psychiatric disorders – a marriage?
- G. Northoff
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- 23 March 2020, p. S45
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The self is central in our mental life and disturbances of the self-figure most prominently in psychopathological symptoms. The cortical midline structures (CMS) have been associated with self-related processing and its changes in schizophrenia, depression and other psychiatric disorders. However, the exact neuronal mechanisms underlying self-related processing in CMS and its changes in psychiatric disorders remain unclear. Especially the neural overlap between high resting state activity levels and self-related processing in CMS is rather puzzling. I present recent data on the rest-self overlap in healthy subjects showing that resting state activity in CMS can predict self-relatedness. The implications for psychological symptoms as in depression and schizophrenia are pointed out.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S87
Brain networks sub-serving self-referential processing in depression
- G. Wagner, C. Schachtzabel, G. Peikert, K.J. Bär
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- 23 March 2020, p. S45
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Introduction
Persistent pondering over negative self-related thoughts is a central feature of depressive psychopathology.
ObjectivesIn the present study, we sought to investigate the neural correlates of abnormal negative self-referential processing (SRP) in patients with major depressive disorder (MDD) and its impact on subsequent cognitive control-related neuronal activation.
AimsWe hypothesized aberrant activation dynamics during the period of negative and neutral SRP in the rostral anterior cingulate cortex (rACC) and in the amygdala in patients with MDD. We assumed abnormal activation in the fronto-cingulate network during Stroop task execution.
MethodsNineteen depressed patients and 20 healthy controls participated in the study. Using an event-related fMRI design, negative, positive and neutral self-referential statements were displayed for 6.5s and followed by incongruent or congruent Stroop conditions.
ResultsIn contrast to controls, patients did not exhibit valence-dependent rACC activation differences during SRP. A novel finding was the significant activation of the amygdala and the reward-processing network during presentation of neutral self-referential stimuli relative to baseline and to affective stimuli in patients. The fMRI analysis of the Stroop task revealed a reduced BOLD activation in the right frontoparietal network of patients in the incongruent condition after negative SRP only.
ConclusionsThus, the inflexible activation in the rACC may correspond to the inability of depressed patients to shift their attention away from negative self-related stimuli. The accompanying negative affect and task-irrelevant emotional processing may compete for neuronal resources with cognitive control processes and lead thereby to deficient cognitive performance associated with decreased frontoparietal activation.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S88
Sex differences in emotional reactivity to daily life stress in psychosis
- I. Myin-Germeys, G. Merge
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- 23 March 2020, p. S46
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Background
A recent study did not find clear-cut sex differences in psychotic symptoms. Studies investigating altered stress reactivity more consistently report differences between the sexes, although the results are contradicting in suggesting either men or women to be more stress-sensitive. We assessed self-reported experiences in the context of real-life to more fully understand the nature of sex differences in psychosis.
MethodsWe employed the Experience Sampling Method, a structured diary technique, to investigate in real-life:
– symptoms;
– behavior in context;
– underlying mechanisms in 283 healthy controls, 268 subjects at risk for psychosis and 232 patients with psychotic disorder.
ResultsMultilevel regression analyses revealed no differences in symptom expression between the sexes. Similarly, men and women did not differ in their level of social interaction and overall activity. However, men at increased risk of psychosis were more often alone and were less involved in goal-directed activities compared to women. Finally, women reported more emotional reactivity to daily life stress then men but women also reported more positive affect when pleasant events had happened.
DiscussionThe data thus suggest only minor differences between men and women in psychotic symptoms and actual behavior. However, whenever differences were apparent, they consistently pointed towards more severe symptoms and more deficiencies in men compared to women. In contrast, increased environmental reactivity in women (to both negative and positive environments) in addition to more social contacts may constitute a protective factor for the development of more severe psychopathology.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S89
Sex and gender differences in schizophrenic psychoses
- A. Riecher-Rössler
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- 23 March 2020, p. S46
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Introduction
Sex and gender differences in schizophrenic psychoses have often been described but treatment approaches so far have hardly taken them into account.
ObjectivesTo describe the most important sex and gender differences in schizophrenic psychoses with clinical implications.
MethodsReview.
ResultsSchizophrenic disorders show a later age of onset in women and a slightly better course, especially in young women. As to pathogenesis, there is some evidence that the age difference might be at least partly due to the female sex hormone estradiol being a protective factor. Differences in course might also have to do with this biological factor, but at the same time with the psychosocial advantages of a higher age of onset and other psychosocial factors.
These gender differences have important implications for assessment and therapy. Thus, we have to consider gender differences in coping behaviour as well as psychosocial burdens and needs deriving from differing roles in partnership, family, household and profession, from dependent relationships, potential abuse and violence. Furthermore, there are specific biological risks such as gonadal dysfunction we have to deal with in both sexes differently. Thus, e.g. women with psychosis can also have very special needs regarding fertility, pregnancy and motherhood. Also, around menopause we have to consider special measures such as replacement of physiological 17-b-estradiol.
ConclusionsWomen, but also men, with schizophrenic psychoses should get a gender-sensitive assessment and treatment.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S90
Menopause and psychosis
- J. Usall, E. Huerta-Ramos
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- 23 March 2020, p. S46
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There has been little research into the effects of menopause on symptoms, social and cognitive functioning in women with schizophrenia, and the results are controversial. The most replicated finding is that late-onset schizophrenia is more prevalent in women than in men and that this fact appears to be related to the diminution of estrogen levels during menopause.
Estrogens have a known protective effect on CNS. Animal research has shown that estrogen has a modulating effect on the dopaminergic, glutamatergic and serotonergic systems.
There are concerns about long-term use of sexual hormone therapy in postmenopausal women with regard to breast cancer risk, and the use of the selective estrogen receptor modulators (SERMS's) can be a better option.
Raloxifene is a SERM that is used in the preventive treatment of postmenopausal osteoporosis and has no effect in the breast and uterus. A number of studies seem to indicate that raloxifene acts on brain dopamine and serotonin systems in a similar way to conjugated estrogens.
In this presentation, I will show the results of some clinical trials that have studied the efficacy of raloxifene as a coadjuvant treatment of patients with schizophrenia. Our team has done two clinical trials that studied the efficacy of 60 mg of raloxifene for the treatment of negative symptoms in postmenopausal women with schizophrenia. Our results showed that raloxifene improved the negative symptoms better than placebo. We concluded that raloxifene seems to be a promising option to treat some patients with schizophrenia.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S91
Recent guidelines for evidence-based pharmacological treatment of social anxiety disorder
- D. Baldwin
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- 23 March 2020, pp. S46-S47
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Pharmacological and psychological treatments
The findings of meta-analyses and randomized placebo-controlled treatment studies indicate that a range of approaches are efficacious in acute treatment. Pharmacological and psychological treatments, when delivered singly, have broadly similar efficacy in acute treatment. However, acute treatment with cognitive therapy (group or individual) may be associated with a reduced risk of symptomatic relapse at follow-up. Cognitive behaviour therapy is efficacious in adults and children: cognitive therapy appears superior to exposure therapy, but the evidence for the efficacy of social skills training is less strong. It is unlikely that the combination of pharmacological with psychological treatments is associated with greater overall efficacy than with either treatment, when given alone, as only 1 of 4 studies of the relative efficacy of combination treatment found evidence for superior efficacy.
Efficacy and length of acute pharmacological treatmentAntidepressant drugs with proven efficacy include most SSRIs, the SNRI venlafaxine, the MAOI phenelzine and the RIMA moclobemide: the potential efficacy of tricyclic antidepressants is unknown. Some benzodiazepines and anticonvulsants and the antipsychotic olanzapine also appear efficacious in acute treatment. A number of small single-dose placebo-controlled crossover studies together suggest that beta-blockers can be beneficial in reducing anxiety symptoms in individuals with ‘performance anxiety’ (for example, when speaking in public), which overlaps with mild non-generalized social anxiety disorder. Acute treatment studies indicate that the proportion of responding patients increases steadily over time. A post-hoc analysis of the clinical trial database with paroxetine indicates that many non-responders to treatment at 8 weeks become responders with a further 4 weeks of double-blind treatment: however a post-hoc analysis of the clinical trial database for escitalopram indicates that response is unlikely if there is no onset of clinical effect within the first 4 weeks of treatment.
Longer-term treatment and further treatment after non-responseThe findings of randomized placebo-controlled relapse prevention studies in patients who have responded to previous acute treatment reveal a significant advantage for staying on active medication (clonazepam, escitalopram, paroxetine, pregabalin, sertraline) for up to six months. Fixed-dose randomized controlled trials do not provide consistent evidence of a dose-response relationship with antidepressant drugs: but a fixed-dose study of pregabalin found that only the higher daily dosage was efficacious. A double-blind randomized controlled dosage escalation trial found no advantage for increasing to a higher daily dosage (of duloxetine), when compared to continuing treatment with a lower dosage. Switching between treatments with proven efficacy may be helpful. An uncontrolled study of augmentation of SSRI treatment with buspirone found some evidence of beneficial effects; but a placebo-controlled crossover-study of the augmentation of paroxetine with pindolol found no evidence of efficacy. A small placebo-controlled study of the augmentation of paroxetine with clonazepam found the combination was marginally short of superiority, when compared to paroxetine alone.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S92
Oxytocin in social anxiety: An overview
- I. Iancu
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- 23 March 2020, p. S47
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Oxytocin is a neuropeptide that is synthesized in the hypothalamus. It acts as a central neurotransmitter, as well as a peripheral hormone. It is called also trust hormone or love hormone. Because of its anxiolytic, pro-social and social cognitive enhancing effects, oxytocin has been suggested as a promising novel treatment for patients with social anxiety disorder. However, controlled research is small and the studies’ results are inconclusive. I will present the results of several studies with several recommendations about the role of oxytocin in social anxiety disorder. Whereas oxytocin shows some promising effects in resistant cases, of course the preferred agents are SSRIs, SNRIs and CBT.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S93
The relationship between social anxiety, shyness and blushing
- A. Pelissolo, A. Moukheiber
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- 23 March 2020, p. S47
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The diagnosis of social anxiety disorder (SAD) has seen substantial changes in the last 35 years from its first appearance in the DSM-III in 1980 up to the most recent ones in the DSM-5. Throughout all these changes, this disorder, previously called social phobia, is still considered one homogenous entity with only one specifier (“performance only”) introduced in the DSM-5 revision with specific fears or associated personality profiles not being considered relevant clinical markers to define SAD subtypes. However, our therapeutic experience suggested substantial particularities associated with the fear of blushing in patients with SAD. Some patients presenting this profile, historically called “erythrophobia”, seem to have a very specific type of social anxiety that does not include shyness and other characteristics of classical SAD. In a study conducted in a sample of 450 new consecutive outpatients seeking treatment for SAD, we compared 142 subjects with fear of blushing without other social fears, 97 subjects with fear of blushing with other associated social fears and 190 SAD subjects without fear of blushing. The group with pure fear of blushing presented a different profile when compared with the two other groups: later age of onset, less comorbidity, lower behavioral and temperamental inhibition, i.e. less shyness, and higher self-esteem. Furthermore, from a therapeutic point of view, some specific strategies such as the Task Concentration Training have shown to be particularly effective in fear of blushing. We will further argue the validity of a possible “fear of blushing” subtype of SAD.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S94
Exploring full-blown psychotic experiences in ‘non-need for care’ populations: Findings from the UNIQUE Study
- E. Peters, T. Ward, M. Jackson, C. Morgan, P. Mc Guire, P. Woodruff, P. Garety
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- 23 March 2020, p. S48
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Background
People displaying persistent, full-blown psychotic experiences without a need-for-care in the general population are an ideal group to investigate to differentiate those factors that are linked to distress and dysfunction from those that are merely associated with benign anomalous experiences. The UNIQUE study investigated the cognitive and social processes predicted by cognitive models of psychosis to differentiate between benign and pathological outcomes of psychotic experiences (PEs).
MethodTwo hundred and fifty-nine individuals were recruited (84 clinical participants with PEs; 92 non-clinical participants with PEs; 83 controls without PEs) from urban (South-East London) and rural (North Wales) UK sites. The three groups were compared on clinical and psychological measures, on reasoning tasks, and on their appraisals of experimental tasks inducing anomalous experiences (of thought interference symptoms and auditory hallucinations).
ResultsThe clinical picture demonstrated a distinctive pattern of similarities and differences on PEs between the clinical and non-clinical groups, while their demographic and psychological profiles were markedly different. As predicted, the clinical group showed a ‘jump-to-conclusions’ reasoning style, and endorsed more threatening appraisals ratings of the experimentally-induced anomalous experiences than the non-clinical group, who did not differ from the controls.
ConclusionsThe results of this study identified a number of specific factors that may be protective against transition to psychosis in individuals with persistent PEs. They also provide robust experimental evidence for the key role of appraisals in determining outcome, as postulated by cognitive models of psychosis.
FundingMedical research Council, UK.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S95
Prevention of psychotic disorders in the general population
- W. Rössler
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- 23 March 2020, p. S48
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Subthreshold psychotic experiences are widely reported within otherwise healthy populations. Their phenomenology is broad and very heterogeneous ranging from meaningful coincidences and precognitive dreams over haunting to out-of-body experiences and visual as well as auditory hallucinations.
Although creative aspects of these experiences are implied too, a similarity in form and content to positive symptoms in schizophrenia (e.g., delusion, disordered thought, and hallucinations) or schizotypy (e.g. magical thinking, unusual perceptual experiences, ideas of reference or paranoid ideation) seems to be obvious. However, the borderline between normal and pathological experiences and behaviour is unclear.
The so called “continuum approach” assumes that schizophrenia or schizotypy are not discrete or categorical illness entities. It implies a gradient in the severity of the symptoms, ranging from healthy population to full-blown schizophrenia. As such, psychotic signs are no longer restricted to formal diagnoses according to DSM or ICD, but would, instead, complete the spectrum of psychological and biological features that characterize individual variations among human beings.
Can subthreshold psychotic experiences be integrated in this continuum? Do individuals indicating such experiences lack some social cognitive abilities and are particularly vulnerable to false inferences in their social world. How are these experiences related to increased neural activity or an abnormal dopaminergic neurotransmission?
These and similar questions will be discussed in the presentation.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S96
Psychotic experiences as precursors in schizophrenia? Findings from a population-based sample in Germany (DEGS1-MH)
- C. Schmidt-Kraepelin
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- 23 March 2020, p. S48
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There are only a few studies that have studied the prevalence of psychotic experiences (PEs) in a representative population-based sample and a broad range of age. The association and predictive role of PEs in the context of psychotic and other mental disorders remains a subject of discussion. The Mental Health Module of the German Health Interview and Examination Survey for Adults is the first wave of a German health monitoring survey describing:
– the distribution and frequency, the severity and the impairments of a wide range of mental disorders;
– risk factors as well as patterns of help-seeking and health care utilization;
– associations between mental and somatic disorders.
A total of 4483 participants participated in the mental health section of the survey. The Composite International Diagnostic Interview, the Launay-Slade Hallucination Scale and the Peter's Delusion Inventory were used to assess PEs by clinically experienced interviewers. We can confirm and extend previous findings for younger age groups that PEs are very frequent psychopathological expressions in the general population across genders and all age groups. PEs rates were elevated among those with other mental disorders, particularly among possible psychotic disorders, PTSD and affective disorders. This points to the relevant role of PEs as a marker for psychopathology and mental disorders. Future prospective studies will have to focus on specific properties of psychotic experiences such as their appraisal or underlying social influences to determine their significance for the prediction of psychotic and other mental disorders.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S97
Clinic risk associated with comorbidity of (subclinical) psychosis, anxiety and depressive symptoms: A case for stratified medicine in psychiatry
- M. van Nierop, I. Myin-Germeys, R. van Winkel
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- Published online by Cambridge University Press:
- 23 March 2020, p. S49
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Background
Meta-analyses link childhood trauma to depression, mania, anxiety, and psychosis. It is unclear, however, whether these outcomes truly represent distinct disorders following childhood trauma, or that childhood trauma is associated with admixtures of affective, psychotic, anxiety and manic psychopathology throughout life.
AimTo investigate the impact of trauma on psychopathological phenotype, functional outcome, and daily life stress reactivity.
MethodsWe used data from a representative general population sample (NEMESIS-2; n = 6646), of whom respectively 1577 and 1120 had a lifetime diagnosis of mood or anxiety disorder, as well as from a sample of patients with a diagnosis of schizophrenia (GROUP; n = 825). Multinomial logistic regression was used to assess whether childhood trauma was more strongly associated with isolated affective/psychotic/anxiety/manic symptoms than with their admixture. Additionally, we examined these groups in terms of social functioning, clinical severity, and quality of life. In a separate sample (n = 621), daily life (emotional and cortisol) stress reactivity was assessed, using ambulatory assessment.
ResultsIn all samples, childhood trauma was considerably more strongly associated with an admixture of symptoms of depression, anxiety, psychosis, and mania, rather than with these symptoms in isolation. Individuals exposed to childhood trauma, who also had an admixture of symptoms, had a lower quality of life, more help-seeking behaviour, higher prevalence of substance use disorders, and lower social functioning, compared with individuals not exposed to trauma, without an admixture of symptoms, or neither. Furthermore, trauma-exposed individuals with an admixed psychopathological phenotype show a higher daily emotional stress reactivity.
ConclusionChildhood trauma increases the likelihood of a specific admixture of affective, anxiety and psychotic symptoms cutting across traditional diagnostic boundaries. Stratifying according to childhood trauma exposure thus identifies an admixed phenotype, possibly induced by continuous daily life stress reactivity, that has important clinical relevance. Identification of functionally meaningful aetiological subgroups may aid clinical practice.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S98
Information and communication technologies for the follow-up of patients
- E. Baca-Garcia
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- 23 March 2020, p. S49
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Clinical assessment in psychiatry is mostly based on brief, regularly scheduled face-to-face appointments. Although crucial, this approach reduces assessment to cross-sectional observations that often miss critical information about course of disease and risk assessment. Clinicians in-turn make all medical decisions based on this inevitably limited information. We discuss recent technological developments in terms of assessment and information triangulation, analysis of longitudinal data, approaches to enhance medical decision-making and improve communication between patients, caregivers and clinicians.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S99
A neurosciences based – semiology of suicidal behavior
- P. Courtet
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- 23 March 2020, p. S49
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The epidemiology, risk factors and biological basis of suicidal behaviors have been the object of an ever-increasing research in the last three decades. During this period, researchers all over the world have identified potential biomarkers of risk and developed several theories about the mechanisms leading to suicidal behavior. However, the lack of common terminology, instruments and cooperation has been a major deterrent. Today, the community has established the bases for this collaboration and evidence coming from neuroscientific studies can already be applied to the field of suicidology. We present here a potential semiology based on current evidence coming from biological, clinical and neuroimaging studies. Besides suicidal ideation and warning signs, the clinical features related to suicide risk and revealed by neuroscientific studies include notably: impulsive-aggression and hopelessness as well as high web consumption, sedentary behaviors and reduced sleep time, an enhanced sensibility to social exclusion and loneliness, a decreased sensitivity to detect social support, interpersonal problems related to decision-making impairments, difficulties to regulate negative emotional states, a propensity to perceive psychic and also physical pain and to receive opiates treatments. Improving the assessment will also open new targets for suicide prevention. In the short-term, some of these targets await us: standard protocols for evaluation of risk, healthcare continuity, implication of the family/caregivers, mitigation of social or psychological pain.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S100
Follow-up and chain of care in the prevention of suicide recurrence
- P.A. Sáiz Martinez
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- 23 March 2020, pp. S49-S50
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Suicide constitutes one of the most important problems in global public health. However, assessment as well as corresponding verification of suicide risk, either in case histories or clinical reports, is handled poorly in several clinical settings. Aspects as important as the existence of a personal history of suicidal tendencies are frequently omitted, despite this being one of the risk factors that most clearly predict the possibility of a complete suicide in the future. During this presentation, I would like to refer specific interventions in at-risk populations, with special emphasis on individuals who have made previous suicide attempts. Suicidal behaviour is a very complex phenomenon, making a specific treatment for it difficult to produce. Consequently, when the most appropriate therapeutic approach for an at-risk population is raised, the following fact is mentioned: in approximately 90% of suicide cases, there is an underlying psychiatric disorder. This makes psychopharmacological treatment of the base pathology the most adequate. Still totally in agreement with that affirmation, we want to point out that we often forget there is proven evidence of the preventative utility of non-pharmacological interventions designed to increase clinical follow-up and adherence to post-attempt outpatient treatment. It is important to indicate that these interventions are not aimed at specific disorders or population groups, but rather they are of a more universal character and are thus more easily generalised. During this presentation, some of these approaches will be addressed and discussed.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S101
GROUP 6 year outcome data in relation to antipsychotic medication
- W. Cahn, for GROUP Investigators
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- 23 March 2020, p. S50
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Objective
Genetic risk and outcome of psychoses (GROUP) is a 6 year longitudinal cohort study that focus on gene–environment vulnerability and resilience in patients with psychotic disorders, their unaffected family members and non-related controls. Its main aim is to elucidate etiological and pathogenetic factors that influence the onset and course of psychotic disorders. In this substudy, we will examine medication use over time, its relation with (the change in) metabolic syndrome status and effects on the brain.
MethodsA consortium of four university psychiatric centers and their affiliated mental health care institutions, conducted the GROUP study. At baseline, 1120 patients, 1057 siblings, 919 parents and 590 healthy controls were included. After inclusion, participants, except parents, were evaluated again after three and six years of follow-up. Extensive assessment of genetic factors, environmental factors, medication use, metabolic parameters and outcome were performed. Moreover, brain imaging was performed in a subset of participants, using a 1.5 Tesla MRI scanner.
ResultsAt baseline 65% of patients used atypical antipsychotics, 16% used conventional antipsychotics and 19% used clozapine. Siblings and controls used no antipsychotics. Forty-three percent of patients, 21.3% of siblings and 9.1% of controls used antidepressants; 43.9% of patients, 2.1% of siblings and none of the controls used a mood stabilizer. We are currently analyzing the medication data over time in relation to (change in) metabolic syndrome status and the effects on the brain.
ConclusionGROUP is a longitudinal cohort study in patients with psychotic disorders, their healthy siblings and controls without psychosis. This naturalistic substudy examines medication use, its association with (change of) metabolic status and effects on the brain in subjects with (high risk of) psychosis.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S102
Discontinuation vs. continuation treatment with neuroleptics for a better long-term outcome
- L. Wunderink, R. Nieboer, F. Nienhuis, S. Sytema, D. Wiersma
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- 23 March 2020, p. S50
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Background
Long-term functional outcome of dose-reduction/discontinuation strategies in first-episode psychosis (FEP) has not been studied before. The present study compared 7-year outcome of an early antipsychotic dose-reduction/discontinuation (DR) strategy with maintenance treatment (MT). Primary outcome was (symptomatic and functional) recovery; relapse rates, functional and symptomatic remission were secondary outcomes.
MethodsFEP patients (n = 128) symptomatically remitted for 6 m during their first treatment year who completed an 18 months trial comparing MT and DR were followed-up at 7 years. Symptomatic remission criteria were adopted from Andreasen et al., functional remission criteria were based on a functioning scale. Recovery was defined as meeting both criteria sets. MT or DR strategy, and baseline parameters were entered in a logistic regression analysis with symptom and functional remission and recovery at 7-years follow-up as dependent variables.
ResultsOne hundred and three patients consented to participate. DR-patients showed twice the recovery-rate of MT-patients (40% against 18%), odds ratio 3.5 (P = .014). Symptomatic remission-rates were equal (69% and 67%). Better DR recovery-rates were attributable to higher functional remission-rates (46% vs. 20%) in DR. Predictors of recovery were DR, baseline living together and less severe negative symptoms. During the last 2 years of follow-up the mean daily dose in haloperidol equivalents was 2.20 mg in DR vs. 3.60 mg in MT (P = .031).
Relapse rates were initially higher in DR but leveled at 3 years; 61.5% relapsed in DR and 68.6% in MT in 7 years.
ConclusionDR of antipsychotics during early stages of remitted FEP significantly improved 7-years outcome in terms of recovery and functional remission compared to maintenance treatment. Though initially relapse rates in GD were higher, these equalled those in MT from 3 years to the end of the study. While the necessity of immediate antipsychotic treatment in FEP and positive symptoms relapse is robustly demonstrated in a great number of studies, this study suggests that we are faced with a dilemma concerning the drawbacks of long-term maintenance antipsychotic treatment on functional capacity. Though antipsychotic discontinuation appears only feasible without relapse in a substantial minority of patients, guided dose-reduction as far as positive symptoms remain subsided and allow it, appears a feasible strategy in view of functional recovery, doing justice to both sides of the dilemma.
Disclosure of interestThe authors have not supplied their declaration of competing interest.
S103
Emotional instability and adult attention-deficit hyperactivity disorder (ADHD)
- P. Asherson
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- 23 March 2020, p. S51
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Background
ADHD is defined in DSM-5 by developmentally inappropriate and impairing levels of inattentive and hyperactive-impulsive symptoms. However, emotional dysregulation is considered to be an associated feature of the disorder that supports the diagnosis of ADHD. The common co-occurrence of emotional liability (EL) in ADHD raises the question of whether EL should be viewed as a component of ADHD or reflecting a comorbid condition.
AimsTo address the question of whether EL should be viewed as a third dimension of ADHD.
MethodWe investigated the association of EL with ADHD and impairment scores, in a sample of adults with ADHD that had been carefully selected for absence of comorbid conditions that could give rise to EL using both rating scale and experience sampling methods to measure emotional instability. We reviewed the effects of stimulants and atomoxetine on EL and the covariation of EL with ADHD inattention and hyperactivity-impulsivity. We further considered the phenotypic and genetic association of EL with ADHD using population twin data.
ResultsFrom these studies, we found that EL is strongly associated with ADHD even in non-comorbid cases and gives rise to additional impairments after ADHD symptoms are controlled for in the analysis. Stimulants and atomoxetine both improve EL and these improvements are correlated with changes in ADHD symptoms, indicating a shared treatment response. Genetic model fitting suggests a common pathway model, consistent with a single genetic liability for inattention, hyperactivity-impulsivity and EL.
ConclusionsTaken together these findings suggest that EL can be viewed as a third dimension of ADHD. Patients presenting with chronic emotional instability should always be screened for ADHD.
Disclosure of interestThe author has not supplied his declaration of competing interest.
S104
Emotional instability and borderline personality disorder
- U. Ebner-Priemer, P. Santangelo, M. Bohus
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- 23 March 2020, p. S51
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Affective instability is widely regarded as being the core problem in patients with borderline personality disorder (BPD) and the driving force behind the severe clinical manifestations of BPD symptoms. In ICD-10, BPD is even labelled as emotionally unstable personality disorder. In the last years, the advent of electronic diaries, in combination with sophisticated statistical analyses, enabled studying affective instability in everyday life. Surprisingly, most recent studies using state-of-the-art methodology to assess and model affective instability in BPD failed to show any specificity, supporting the idea of a transdiagnostic construct. In addition, dysfunctional emotion regulation strategies revealed results contradictory to current clinical beliefs. Using multiple data sets and multilevel modelling, we will demonstrate that to understand affective instability it is important:
– to statically model basic subcomponents of affective dynamics simultaneously;
– in combination with dysfunctional regulation strategies;
– cognitive processes in everyday life.
Altogether, current research suggests that the dynamics of affective states and their intentional regulation are even more important to psychological health and maladjustment, than the affective states itself. Current initiatives to fundamentally improve psychopathological research are looking at basic physiological processes spanning across disorders. However, these approaches do fall short in understanding human behaviours as dynamical processes that unfold in the broadest setting imaginable – everyday life. Only the combination of basic physiological processes and methods assessing dynamical affective mechanisms in everyday life will enhance our understanding how dysregulations and dysfunctions of fundamental aspects of behaviour cut across traditional disorders.
Disclosure of interestThe authors have not supplied their declaration of competing interest.