Alberto Siracusano

The influence of illness-related variables, personal resources and context-related factors on real-life functioning of people with schizophrenia.

In people suffering from schizophrenia, major areas of everyday life are impaired, including independent living, productive activities and social relationships. Enhanced understanding of factors that hinder real‐life functioning is vital for treatments to translate into more positive outcomes. The goal of the present study was to identify predictors of real‐life functioning in people with schizophrenia, and to assess their relative contribution. Based on previous literature and clinical experience, several factors were selected and grouped into three categories: illness‐related variables, personal resources and context‐related factors. Some of these variables were never investigated before in relationship with real‐life functioning. In 921 patients with schizophrenia living in the community, we found that variables relevant to the disease, personal resources and social context explain 53.8% of real‐life functioning variance in a structural equation model. Neurocognition exhibited the strongest, though indirect, association with real‐life functioning. Positive symptoms and disorganization, as well as avolition, proved to have significant direct and indirect effects, while depression had no significant association and poor emotional expression was only indirectly and weakly related to real‐life functioning. Availability of a disability pension and access to social and family incentives also showed a significant direct association with functioning. Social cognition, functional capacity, resilience, internalized stigma and engagement with mental health services served as mediators. The observed complex associations among investigated predictors, mediators and real‐life functioning strongly suggest that integrated and personalized programs should be provided as standard treatment to people with schizophrenia.

Pathways to functional outcome in subjects with schizophrenia living in the community and their unaffected first-degree relatives

RATIONALE Variables influencing real-life functioning have repeatedly been modeled in schizophrenia subjects but not systematically investigated in their unaffected first-degree relatives (SRs), in whom milder forms of deficits reported in schizophrenia have been observed, but confounders of clinical cohorts are not in play. Demonstrating that pathways to functional outcome are similar between patients and SRs would validate structural models developed in schizophrenia subjects. The present multicenter study aimed to explore whether variables associated with real-life functioning are similar in schizophrenia patients and their unaffected relatives. METHODS The study sample included 921 schizophrenia patients, 379 SRs and 780 healthy controls. Structural Equation Models (SEMs) were used in patients and SRs to test associations of psychopathological dimensions, neurocognition, social cognition, resilience, perceived stigma and functional capacity with real-life functioning domains, impaired in both patients and SRs. RESULTS Interpersonal Relationships and Work Skills were the only functional domains impaired in both patients and SRs. For both domains, functional impairment in patients was found to predict impairment in unaffected relatives, suggesting the involvement of similar illness-related vulnerability factors. In both groups variables significantly associated with Interpersonal Relationships included Social Cognition, Neurocognition, Avolition, Resilience, Disorganization, Perceived Stigma and Gender, and those significantly associated with Work Skills included Social Cognition, Neurocognition and Disorganization. CONCLUSIONS Pathways to functional outcome for Interpersonal relationships and Work skills are similar between schizophrenia patients and their unaffected first-degree relatives. These findings validate, in the absence of confounders of clinical cohorts, structural models of determinants of functional outcome in people with schizophrenia.

Psychoticism, Immature Defense Mechanisms and a Fearful Attachment Style are Associated with a Higher Homophobic Attitude

INTRODUCTION Homophobic behavior and a negative attitude toward homosexuals are prevalent among the population. Despite this, few researches have investigated the psychologic aspects associated with homophobia, as psychopathologic symptoms, the defensive system, and attachment styles. AIM The aim of this study was to investigate the psychologic factors mentioned earlier and their correlation with homophobia. METHODS Five hundred fifty-one university students recruited, aged 18-30, were asked to complete several psychometric evaluation. MAIN OUTCOME MEASURES In particular, Homophobia Scale (HS) was used to assess homophobia levels, the Symptoms Check List Revised (SCL-90-R) for the identification of psychopathologic symptoms, the Defence Style Questionnaire (DSQ-40) for the evaluation of defense mechanisms and the Relationship Questionnaire (RQ) for attachment styles. RESULTS After a regression analysis, we found a significant predictive value of psychoticism (β = 0.142; P = 0.04) and of immature defense mechanisms (β = 0.257; P < 0.0001) for homophobia, while neurotic defense mechanisms (β = -0.123; P = 0.02) and depressive symptoms (β = -0.152; P = 0.04) have an opposite role. Moreover, categorical constructs of the RQ revealed a significant difference between secure and fearful attachments styles in levels of homophobia (secure = 22.09 ± 17.22 vs. fearful = 31.07 ± 25.09; P < 0.05). Finally, a gender difference to HS scores and a significant influence of male sex was found (β = 0.213; P < 0.0001). CONCLUSIONS We demonstrated the involvement of psychoticism and immature defense mechanisms in homophobic attitudes, while a contrasting role is played by neurotic defense mechanisms and depressive symptoms. Moreover, secure attachment is an indicator of low levels of homophobia compared with the subjects demonstrating a fearful style of attachment. Hence, in the assessment of homophobia and in the relevant programs of prevention, it is necessary to consider the psychologic aspects described earlier.

The relationships of personal resources with symptom severity and psychosocial functioning in persons with schizophrenia: results from the Italian Network for Research on Psychoses study

The relationships of personal resources with symptom severity and psychosocial functioning have never been tested systematically in a large sample of people with schizophrenia. We applied structural equation models to a sample of 921 patients with schizophrenia collected in a nationwide Italian study, with the aim to identify, among a large set of personal resources, those that may have an association with symptom severity or psychosocial functioning. Several relevant demographic and clinical variables were considered concurrently. Poor service engagement and poor recovery style, as well as older age and younger age at onset, were related to greater symptom severity and poorer social functioning. Higher resilience and higher education were related to better social functioning only. Poor problem-focused coping and internalized stigma, as well as male gender and depression, were related to symptom severity only. The explored variables showed distinctive and partially independent associations with symptom severity and psychosocial functioning. A deeper understanding of these relationships may inform treatment decisions.

Interplay among psychopathologic variables, personal resources, context-related factors, and real-life functioning in individuals with schizophrenia a network analysis

Importance Enhanced understanding of factors associated with symptomatic and functional recovery is instrumental to designing personalized treatment plans for people with schizophrenia. To date, this is the first study using network analysis to investigate the associations among cognitive, psychopathologic, and psychosocial variables in a large sample of community-dwelling individuals with schizophrenia. Objective To assess the interplay among psychopathologic variables, cognitive dysfunctions, functional capacity, personal resources, perceived stigma, and real-life functioning in individuals with schizophrenia, using a data-driven approach. Design, Setting, and Participants This multicenter, cross-sectional study involved 26 university psychiatric clinics and/or mental health departments. A total of 921 community-dwelling individuals with a DSM-IV diagnosis of schizophrenia who were stabilized on antipsychotic treatment were recruited from those consecutively presenting to the outpatient units of the sites between March 1, 2012, and September 30, 2013. Statistical analysis was conducted between July 1 and September 30, 2017. Main Outcomes and Measures Measures covered psychopathologic variables, neurocognition, social cognition, functional capacity, real-life functioning, resilience, perceived stigma, incentives, and service engagement. Results Of 740 patients (221 women and 519 men; mean [SD] age, 40.0 [10.9] years) with complete data on the 27 study measures, 163 (22.0%) were remitted (with a score of mild or better on 8 core symptoms). The network analysis showed that functional capacity and everyday life skills were the most central and highly interconnected nodes in the network. Psychopathologic variables split in 2 domains, with positive symptoms being one of the most peripheral and least connected nodes. Functional capacity bridged cognition with everyday life skills; the everyday life skills node was connected to disorganization and expressive deficits. Interpersonal relationships and work skills were connected to avolition; the interpersonal relationships node was also linked to social competence, and the work skills node was linked to social incentives and engagement with mental health services. A case-dropping bootstrap procedure showed centrality indices correlations of 0.75 or greater between the original and randomly defined samples up to 481 of 740 case-dropping (65.0%). No difference in the network structure was found between men and women. Conclusions and Relevance The high centrality of functional capacity and everyday life skills in the network suggests that improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia. The pattern of network node connections supports the implementation of personalized interventions.

Adherence to antipsychotics in schizophrenia

1 Poor adherence to antipsychotic medication in people with schizophrenia: diffusion, consequences, and contributing factors.- Premise.- Role of antipsychotics in the treatment of schizophrenia.- Compliance versus adherence.- Assessment of medication adherence.- Frequency of poor adherence to antipsychotics.- Consequences of poor adherence to antipsychotics.- Determinants and moderators of adherence to antipsychotics.- Present and medium-term perspectives.- Closing Remarks.- 2 Pharmacological strategies to enhance adherence in schizophrenia.- Introduction.- Pharmacological factors contributing to non-adherence: efficacy, side effects, regimen, co-therapies.- First vs Second generation antipsychotics: efficacy, tolerability and the adherence issue.- Long-acting injectable antipsychotics.- Conclusion. 3 Non-pharmacological strategies to enhance adherence and continuity of care in schizophrenia.- Introduction.- Factors Influencing (non-)adherence in Schizophrenia.- Interventions to Enhance Adherence. Research and Clinical Evidence.- Comprehensive Review of Psychosocial and Programmatic Interventions to Enhance Adherence to Antipsychotic Medication in Schizophrenia.- Summary of Main Results and Evidences.- Conclusions and Future Directions.- 4 Psychological issues in improving adherence and alliance.- The patient-doctor relationship as a determinant of adherence to treatment.- Alliance and psychodynamic issues.- Towards the concept of concordance of the therapeutic project.

A critical review and meta-analysis of the perceptual pseudoneglect across psychiatric disorders: Is there a continuum?

The phenomenon known as “perceptual pseudoneglect” refers to the leftward bias in visuospatial attention in non-clinical samples, possibly as a consequence of right hemisphere dominance for visuospatial attention. The degree of such a lateralized visuospatial attention bias is often assessed using the line bisection task. Interestingly, various psychiatric disorders may influence the expression of this phenomenon. The aim of this paper was to perform a critical appraisal of the literature on the expression of the perceptual pseudoneglect across all psychiatric disorders accompanied by meta-analytical evaluation of the data. Moreover, we will discuss whether this phenomenon may be considered as a trait marker across different psychiatric disorders.

Personal resources and depression in schizophrenia: The role of self-esteem, resilience and internalized stigma

Depression in schizophrenia represents a challenge from a diagnostic, psychopathological and therapeutic perspective. The objective of this study is to test the hypothesis that resilience and self-stigma affect depression severity and to evaluate the strength of their relations in 921 patients with schizophrenia. A structural equation model was tested where depression is hypothesized as affected by resilience, internalized stigma, gender and negative symptoms, with the latter two variables used as exogenous covariates and the former two as mediators. The analysis reveals that low resilience, high negative symptoms, female gender were directly associated with depression severity, and internalized stigma acted only as a mediator between avolition and resilience, with similar magnitude. The cross-sectional study design and the variable selection limit the generalizability of the study results. The model supports a complex interaction between personal resources and negative symptoms in predicting depression in schizophrenia. The clinical implication of these findings is that personal resources could be a significant target of psychosocial treatments.

Disorganization and real-world functioning in schizophrenia: Results from the multicenter study of the Italian Network for Research on Psychoses

BACKGROUND A general consensus has not yet been reached regarding the role of disorganization symptoms in real-world functioning in schizophrenia. METHODS We used structural equations modeling (SEM) to analyze the direct and indirect associations between disorganization and real-world functioning assessed through the Specific Levels of Functioning Scale (SLOF) in 880 subjects with schizophrenia. RESULTS We found that: 1) conceptual disorganization was directly and strongly connected with SLOF daily activities; difficulty in abstract thinking was associated with moderate strength to all SLOF domains, and poor attention was connected with SLOF work skills; 2) grandiosity was only related with poor work skills, and delusions were associated with poor functioning in all SLOF domains; interpersonal relationships were weakly indirectly influenced by hallucinatory behavior, delusions and unusual thought contents through the mediation of social cognition (SC); 3) among the negative symptoms, avolition had only direct links with SLOF work skills and SLOF activities; anhedonia had direct links with SLOF work skills and SLOF interpersonal and indirect link with SLOF work skills through functional capacity (FC); asociality with SLOF interpersonal; blunted affect had direct links with SLOF activities and indirect links with SLOF interpersonal relationships mediated by SC. Lastly, alogia had only indirect links mediated by SC, FC, and neurocognition (NC). CONCLUSIONS Overall conceptual disorganization is the symptom that contributed more (both directly and indirectly) to the activities of community living in real-world. Thus, it should be considered as a treatment target in intervention programs for patients with schizophrenia.

Sexual Dysfunctions and Mood and Anxiety Disorders

Sexual dysfunctions are frequently associated with depression and anxiety: they are reported to be two to three times more likely in depressed population then in non-depressed population, and according to literature, the existence of a bidirectional relationship between depressive symptoms, anxiety, and sexual dysfunctions should always be taken into account. The same etiological mechanisms that are responsible for mood disorders can also be at the base of sexual dysfunctions: patients with sexual dysfunctions can, in fact, more commonly develop lower sexual satisfaction and control, higher distress, and higher social anxiety. What is more, in patients with a diagnosis of bipolar disorder, a disruption in sexual functioning can often be associated with both depressive and manic episodes, and severe fluctuations in sexual life may be difficult to manage for both the patients and their partners. To make the picture even more complex, pharmacological treatments used routinely may cause alterations in desire, excitement, and orgasm. In order to define the best possible treatment for the patient, every careful clinician should routinely evaluate symptoms of mood and anxiety disorders in individuals presenting with sexual complaints.