Moritz E. Wigand

Psychopathological Course Typology in Schizophrenia Spectrum Disorders: A Heuristic Approach in a Sample of 100 Patients

Background: Despite several previous attempts at subtyping schizophrenia, a typology that reflects neurobiological knowledge and reliably predicts course and outcome is lacking. We applied the system-specific concept of the Bern Psychopathology Scale (BPS) to generate a course typology based on three domains: language, affectivity, and motor behaviour. Sampling and Methods: A cohort of 100 patients with schizophrenia or schizoaffective disorders according to DSM-IV criteria underwent psychopathological assessment, and all their available medical records were retrospectively analysed on the basis of the BPS. Results: Overall, 39% of the patients showed dominant abnormalities in only one domain, 37% in two domains, and 24% in all three domains. The motor domain was affected in the majority of patients (76%), followed by affectivity (63%) and language (46%). Eighty-six percent of patients showed a bipolar course pattern in at least one domain. Conclusions: In a retrospective analysis of 100 patient records we described system-specific course patterns of schizophrenia by using a neurobiologically informed psychopathological assessment. The results showed a surprisingly high proportion of bipolar courses and a pattern of pure and mixed subtypes, which speaks for an overlap of domains with regards to psychopathological symptoms. A limitation of this heuristic and retrospective approach is that it was largely based on clinical judgement. Prospective studies with more rigorous threshold definitions are needed to clarify the neurobiological and clinical implications of the proposed reorganization of psychotic disorders.

Severe clinical events in 100 patients with schizophrenia: a retrospective clinical description using a system-specific psychopathological approach

Abstract Catatonic states and numerous other severe clinical events can complicate the course of schizophrenia. Whether these severe courses are associated with particular system-specific symptom dimensions remain unclear. Aim is to assess the frequency of severe clinical events in a clinical population and to investigate the association of these events with sociodemographic data and system-specific psychopathology, combining qualitative and quantitative data. We performed a comprehensive retrospective description of a well-described and geographically stable sample of 100 patients with schizophrenia or schizoaffective disorder and linked severe clinical events with sociodemographic data at inclusion into the study (as indicators of social functioning) and symptoms at first admission, classified with the Bern Psychopathology Scale (BPS). We found 12 mentions of catatonic stupor or excitement, 45 of suicide attempts, 26 of suicidality, 18 of deliberate self-harm, 18 of self-threatening behaviour other than deliberate self-harm, 34 of violence against other persons, 18 of violence against objects and six of sexual harassment. Disinhibited language on first admission seemed to be a protective factor against suicidality and disinhibited motor behaviour seemed to predict self-threatening and violent behaviour. Catatonia and violence in particular seemed to be socially disabling. This exploratory study showed that the BPS is a promising instrument and might represent a system-specific approach in identifying patients at risk for severe sequelae of schizophrenia. This will have to be tested in future prospective studies.

Computerbasierte Therapien: Eine Alternative in der modernen Psychotherapie? – Kontra

puter Deep Blue den damals amtierenden Weltmeister Kasparow im Schach und im März 2016 besiegte das artificial intelligence-Programm AlphaGo den amtierenden Go-Weltmeister Sedol in diesem wohl komplexesten aller Brettspiele überhaupt [1]. Da scheint es nur folgerichtig, dass Computer inzwischen auch psychotherapeutische Aufgaben übernehmen, und es ist ein ehrenwertes Vorhaben, Menschen mit psychischen Störungen, die aus verschiedenen Gründen keinen ausreichenden Zugang zum psychiatrisch/psychotherapeutischen Hilfesystem haben, einen Zugang zu entsprechenden Programmen zu verschaffen. Der Grundstein einer jeden Therapie ist es allerdings, den Patienten mit seiner individuellen Geschichte und seinem eigenen Erklärungsmodell wahrzunehmen und im besten Falle den therapeutischen Weg mit einem gemeinsamen Verständnis der Krankheitsmechanismen zu beginnen [2]. Dies wird nicht nur von Patienten gewünscht [3], sondern auch aus den Reihen der Psychiatrie angemahnt, so in Nancy C. Andreasens Kritik am mechanischen Abhaken von Diagnosekriterien, das einen „entmenschlichenden Einfluss“ auf die psychiatrische Praxis habe [4]. Mit der Einführung von Computerprogrammen in die Psychotherapie wird dieser Einfluss schmerzlich sichtbar. Beispielhaft sei das in Deutschland verfügbare Programm MoodGYM skizziert. Der Nutzer beantwortet Ratingskalen, wird durch psychoedukative Elemente geführt, lernt etwas über die „richtige und angemessene Denkweise“ und bekommt ein Feedback zu seinen Testantworten und seinem Erfolg. Begleitet wird er von holzschnittartigen Idealtypen mit sprechenden Namen; so werden „Miesepeter“ und „Anti“ einem infantil witzelnden „Nullproblemo“ gegenübergestellt, der wohl als Positivbeispiel oder Modell eines nicht depressiven Menschen dienen soll. Schon zu Beginn der „Therapie“ mit MoodGYM verwundert die Aussage, dass das Programm auf der Kognitiven Verhaltenstherapie und der Interpersonellen Therapie basiert. Eine interpersonelle Therapie, bei der es zu keinem interpersonellen Kontakt kommt, erscheint zumindest paradox. Solch ein Programm mit seinen vorgefertigten und erschreckend vereinfachten Pseudo-Antworten muss einem existenziell leidenden Menschen mehr als Hohn denn als Hilfe vorkommen, wird es doch weder der menschlichen Individualität des Patienten noch der Komplexität seiner Probleme gerecht. Über die Frustration der geringen Passung zwischen ihrer Situation und den Figuren berichten Betroffene: When they [the characters] were relevant to me it was fine, you know, but when they weren’t it was so frustrating. (zitiert nach [5], S.82) Zahlreiche Studien (s. z.B. [6]) weisen auf den Zusammenhang zwischen sozialer Isolation, Einsamkeit und Depression hin. Insgesamt haben sich innerhalb einer Generation eine große Menge an täglichen Sozialkontakten, z.B. am Bankschalter oder beim Fahrkartenkauf, ohnehin schon durch den Einsatz von Computern und Automaten drastisch reduziert. Den psychisch kranken Menschen vor einen Bildschirm zu setzen scheint unangemessen, zumal wir wissen, dass im Gegenteil Programme, die ihn wieder unter Menschen bringen und sein Zugehörigkeitsgefühl zu einer Gruppe fördern, hilfreich sind [7]. Das Outcome einer Psychotherapie wird auf komplexe Art und Weise von der zur Anwendung kommenden Technik, der Therapeutenadhärenz (die nicht zu hoch und nicht zu niedrig sein sollte), der Kompetenz des Therapeuten, der therapeutischen Beziehung und Patientenvariablen beeinflusst [8]. In diesem komplexen Prozess sind eine Intuition, eine Flexibilität und ein Einfühlungsvermögen gefragt, die ein Computer nicht aufbringen kann. Die Psychotherapie ist, das zeigt sich spätestens in diesem Argument, ein komplexerer und auch menschlicherer Vorgang als jedes Brettspiel und kann nicht durch einen Computer ersetzt werden, wie auch folgende Aussage eines Betroffenen verdeutlicht: If you’re feeling like that, then a computer telling you something isn’t going to make any difference. Whereas somebody seeing you and seeing the state that you’re in can make a big difference ... slight physical things, just the words that she used ... you know, the verbal cuddle, which is what you need. (zitiert nach [5], S.82) In diesem Zusammenhang verwundert es nicht, dass die Unterstützung durch einen Therapeuten die Effektstärke internetbasierter kognitiver Verhaltenstherapie deutlich steigert [9], ein weiteres Indiz für die herausragende Stellung des FaktorsMensch. Nun könnte gegen alle oben genannten Argumente eingewendet werden, dass computerbasierte Psychotherapie nicht dazu gedacht ist, den Therapeuten zu ersetzen, sondern nur als Add-on genutzt zu werden. Hierzu zwei Überlegungen: Wenn es tatsächlich nur als Add-on genutzt wird, stellt sich die Frage, welchen Zusatznutzen zu einem Therapeuten aus Fleisch und Blut der Computer bringen soll, denn nichts, das in den Programmen vermittelt wird, könnte nicht besser, menschlicher und authentischer vom Therapeuten selbst vermittelt werden. Wahrscheinlicher ist aber, dass diese Programme durchaus in Zukunft einen Teil der psychiatrisch/psychotherapeutischen Aufgaben übernehmen sollen. Ein Hinweis hierfür in Deutschland ist das Sponsoring durch eine große Krankenkasse, andererseits haben die Jahrhunderte der Industrialisierung und die vergangenen Jahrzehnte der Digitalisierung gezeigt, dass jeder Job, der durch einen Maschine ausgeführt werden kann, früher oder späComputerbasierte Therapien: Eine Alternative in der modernen Psychotherapie? – Kontra

Periventricular white matter lesion and incomplete MRZ reaction in a male patient with anti-N-methyl-d-aspartate receptor encephalitis presenting with dysphoric mania

Several findings suggest that there may be an overlap of anti-N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis with neuromyelitis optica spectrum disorders or acute demyelinating encephalomyelitis (ADEM)-like demyelination. We present a case of a patient with anti-NMDAR antibody encephalitis, who on MRI featured a single prominent T2-hyperintensive white matter lesion in the periventricular region, adjacent to the anterior horn of the left lateral ventricle. In view of the lesion location and the cerebrospinal fluid (CSF) findings (incomplete MRZ (measles, rubella and varicella zoster) reaction, lymphocytic pleocytosis, intrathecal IgG and IgM synthesis; absence of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies), the presence of a multiple sclerosis-like immune response was discussed. This case appears to add evidence to the hypothesis of an overlap between anti-NMDAR antibody encephalitis and other inflammatory central nervous system diseases.

Jack Kerouac Revisited: "Madness" in On the Road Between Stigma and Glorification.

Abstract On the Road is a classic American novel that appeared at a time of great political, cultural, and psychiatric upheaval. Published almost 60 years ago, it still exerts great influence. We propose that the affirmative approach toward “madness” in the novel can enlighten our understanding of alternative perceptions of mental illness. The novel is analyzed with quantifying and narrative methods focusing on the concept of madness, which is a prominent theme in the novel. Stigma and glorification of madness can be found throughout the text. The positive sides and the pitfalls of an overly positive attitude toward mental illness and minority group members are discussed, including benevolent discrimination, recovery, and positive psychiatry.

Personal suffering and social criticism in T. S. Eliot’s The Waste Land and A. Ginsberg’s Howl: Implications for social psychiatry

Background: T. S. Eliot’s The Waste Land and A. Ginsberg’s Howl are two landmark poems of the 20th century which have a unique way of dealing with emotional suffering. Aims: (a) To explore the interplay between emotional suffering, conflicting relationships and societal perceptions; (b) to show the therapeutic effect of the writing process; (c) to analyse the portrayal of ‘madness’; and (d) to discuss, in contemporary psychiatric terms, the ‘solutions’ offered by the poets. Method: Qualitative research with a narrative, hermeneutic approach. Results: Against the background of wartime/genocide and postwar disillusionment, close relationships are projected onto societal perceptions. Concepts of (self-)control, compassion, empowerment and self-efficacy are offered as solutions to overcome feelings of despair. Conclusion: In a time of perceived societal and environmental crises, both poems help us understand people’s fears and how to counteract them. Besides biological approaches, the narrative approach to the suffering human being has not lost its significance.

Intersections of discrimination due to unemployment and mental health problems: the role of double stigma for job- and help-seeking behaviors

PurposeThe everyday lives of unemployed people with mental health problems can be affected by multiple discrimination, but studies about double stigma—an overlap of identities and experiences of discrimination—in this group are lacking. We therefore studied multiple discrimination among unemployed people with mental health problems and its consequences for job- and help-seeking behaviors.MethodsEveryday discrimination and attributions of discrimination to unemployment and/or to mental health problems were examined among 301 unemployed individuals with mental health problems. Job search self-efficacy, barriers to care, and perceived need for treatment were compared among four subgroups, depending on attributions of experienced discrimination to unemployment and to mental health problems (group i); neither to unemployment nor to mental health problems (group ii); mainly to unemployment (group iii); or mainly to mental health problems (group iv).ResultsIn multiple regressions among all participants, higher levels of discrimination predicted reduced job search self-efficacy and higher barriers to care; and attributions of discrimination to unemployment were associated with increased barriers to care. In ANOVAs for subgroup comparisons, group i participants, who attributed discrimination to both unemployment and mental health problems, reported lower job search self-efficacy, more perceived stigma-related barriers to care and more need for treatment than group iii participants, as well as more stigma-related barriers to care than group iv.ConclusionsMultiple discrimination may affect job search and help-seeking among unemployed individuals with mental health problems. Interventions to reduce public stigma and to improve coping with multiple discrimination for this group should be developed.

Psychosis Is Mutable over Time: A Longitudinal Psychopathology Study

Background: A neurobiologically informed, system-specific psychopathological approach has been suggested for use in schizophrenia. However, to our knowledge, such an approach has not been used to prospectively describe the course of schizophrenia. Sampling and Methods: We assessed psychopathology in a well-described sample of 100 patients with schizophrenia or schizoaffective disorder with the Bern Psychopathology Scale (BPS) at 6-month intervals for up to 18 months. The BPS groups symptoms into the 3 domains language, affectivity and motor behaviour; each domain is rated as being normal, inhibited or disinhibited. In addition, we collected qualitative psychopathological data in the form of case reports. Results: Forty-eight patients completed at least 2 assessments over the course of at least 1 year. Of these, 16 patients (33.3%) showed a bipolar course pattern (i.e., a switch from inhibited to disinhibited or vice versa) in 1 domain and 6 patients (12.5%) in more than 1 domain. Shifts from 1 dominant domain to another were seen frequently (n = 20, 41.7%), but shifts between 1 dominant domain and a combination of dominant domains were more common (n = 33, 68.8%). Conclusions: The course of schizophrenia is heterogeneous and shows frequent changes in psychopathology. This should be taken into account in the communication with patients and in the research on underlying illness mechanisms and treatment. A major limitation of this study is the small sample size.

A Longitudinal Approach to Biological Psychiatric Research: The PsyCourse Study

In current diagnostic systems, schizophrenia and bipolar disorder are still conceptualized as distinct categorical entities. Recently, both clinical and genomic evidence have challenged this Kraepelinian dichotomy. There are only few longitudinal studies addressing potential overlaps between these conditions. Here, we present design and first results of the PsyCourse study (N = 891 individuals at baseline), an ongoing transdiagnostic study of the affective‐to‐psychotic continuum that combines longitudinal deep phenotyping and dimensional assessment of psychopathology with an extensive collection of biomaterial. To provide an initial characterization of the PsyCourse study sample, we compare two broad diagnostic groups defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) classification system, that is, predominantly affective (n = 367 individuals) versus predominantly psychotic disorders (n = 524 individuals). Depressive, manic, and psychotic symptoms as well as global functioning over time were contrasted using linear mixed models. Furthermore, we explored the effects of polygenic risk scores for schizophrenia on diagnostic group membership and addressed their effects on nonparticipation in follow‐up visits. While phenotypic results confirmed expected differences in current psychotic symptoms and global functioning, both manic and depressive symptoms did not vary between both groups after correction for multiple testing. Polygenic risk scores for schizophrenia significantly explained part of the variability of diagnostic group. The PsyCourse study presents a unique resource to research the complex relationships of psychopathology and biology in severe mental disorders not confined to traditional diagnostic boundaries and is open for collaborations.

Contents Vol. 49, 2016

Founded 1897 as ‘Monatsschrift für Psychiatrie und Neurologie’, continued 1957–1967 as ‘Psychiatria et Neurologia’, continued 1968–1983 as ‘Psychiatria Clinica’ Founders: C. Wernicke and Th. Ziehen Successors: K. Bonhoeffer (1912–1938), J. Klaesi (1939–1967), E. Grünthal (1953–1973), N. Petrilowitsch (1968–1970), Th. Spoerri (1971–1973), P. Berner (1974–1999), E. Gabriel (1974–2004), Ch. Mundt (2000–2011)