Roar Fosse

Electroconvulsive Treatment: Hypotheses about Mechanisms of Action

No consensus has been reached on the mode of action of electroconvulsive treatment (ECT). We suggest that two features may aid in the delineation of the involved mechanisms. First, when effective, ECT would be likely to affect brain functions that are typically altered in its primary recipient group, people with severe depression. Central among these are the frontal and temporal lobes, the hypothalamus-pituitary-adrenal (HPA) stress axis, and the mesocorticolimbic dopamine system. Second, the involved mechanisms should be affected for a time period that matches the average endurance of clinical effects, which is indicated to be several days to a few weeks. To identify effects upon frontal and temporal lobe functioning we reviewed human studies using EEG, PET, SPECT, and fMRI. Effects upon the HPA axis and the dopamine system were assessed by reviewing both human and animal studies. The EEG studies indicate that ECT decelerates neural activity in the frontal and temporal lobes (increased delta and theta wave activity) for weeks to months. Comparable findings are reported from PET and SPECT studies, with reduced cerebral blood flow (functional deactivation) for weeks to months after treatment. The EEG deceleration and functional deactivation following ECT are statistically associated with reduced depression scores. FMRI studies indicate that ECT flattens the pattern of activation and deactivation that is associated with cognitive task performance and alters cortical functional connectivity in the ultra slow frequency range. A common finding from human and animal studies is that ECT acutely activates both the HPA axis and the dopamine system. In considering this evidence, we hypothesize that ECT affects the brain in a similar manner as severe stress or brain trauma which activates the HPA axis and the dopamine system and may compromise frontotemporal functions.

A critical assessment of the equal-environment assumption of the twin method for schizophrenia

The classical twin method (CTM) is central to the view that schizophrenia is ~80% heritable. The CTM rests on the equal-environment assumption (EEA) that identical and fraternal twin pairs experience equivalent trait-relevant environmental exposures. The EEA has not been directly tested for schizophrenia with measures of child social adversity, which is particularly etiologically relevant to the disorder. However, if child social adversity is more similar in identical than fraternal pairs in the general twin population, the EEA is unlikely to be valid for schizophrenia, a question which we tested in this study. Using results from prior twin studies, we tested if intraclass correlations for the following five categories of child social adversity are larger in identical than fraternal twins: bullying, sexual abuse, physical maltreatment, emotional neglect and abuse, and general trauma. Eleven relevant studies that encompassed 9119 twin pairs provided 24 comparisons of intraclass correlations, which we grouped into the five social exposure categories. Fisher’s z-test revealed significantly higher correlations in identical than fraternal pairs for each exposure category (z ≥ 3.53, p < 0.001). The difference remained consistent across gender, study site (country), sample size, whether psychometric instruments were used, whether interviewing was proximate or distant to the exposures, and whether informants were twins or third persons. Combined with other evidence that the differential intraclass correlation for child social adversity cannot be explained by evocative gene–environment covariation, our results indicate that the CTM does not provide any valid indication of genomic effects in schizophrenia.

Basal Exposure Therapy: A New Approach for Treatment-Resistant Patients with Severe and Composite Mental Disorders

New treatment approaches are needed for patients with severe and composite mental disorders who are resistant to conventional treatments. Such treatment-resistant patients often have diagnoses of psychotic or bipolar disorders or severe personality disorders and comorbid conditions. In this study, we evaluate basal exposure therapy (BET), a novel ward-integrated psychotherapeutic approach for these patients. Central to BET is the conceptualization of undifferentiated existential fear as basic to the patients’ problem, exposure to this fear, and the therapeutic platform complementary external regulation, which integrates and governs the totality of interventions throughout the treatment process. BET is administered at a locked-door ward with 6 patient beds and 13.5 full-time employees, including a psychiatrist and 2 psychologists. Thirty-eight patients who had completed BET were included, all but two being female, mean age 29.9 years. Fourteen patients had a diagnosis of schizophrenia or schizoaffective disorder (F20/25), eight had bipolar disorder or recurrent depressive disorder (F31/33), eight had diagnoses in the F40–48 domain (neurotic, stress-related, and somatoform disorders), five were diagnosed with emotionally unstable personality disorder (F60.3), and three patients had other diagnoses. Twenty of the patients (53%) had more than one ICD-10 diagnosis. Average treatment time in BET was 13 months, ranging from 2 to 72 months. Time-series data show significant improvements in symptoms and functioning from enrollment to discharge, with effect sizes at 0.76 for the Dissociation Experience Scale, 0.93 for the Brief Symptom Inventory, 1.47 for the Avoidance and Action Questionnaire, and 1.42 and 1.56, respectively, for the functioning and symptom subscales of the Global Assessment of Functioning Scale. In addition, the patients used significantly less antiepileptic, antipsychotic, anxiolytic, and antidepressant medications at discharge than at treatment enrollment. Patient improvement across treatment was associated with the following duration of time in BET, the successful completions of the exposure component of BET, positive changes in experiential avoidance as measured with the Acceptance and Action Questionnaire, and high symptom levels and low levels of functioning at treatment start. The findings indicate that BET may be a promising inpatient psychotherapeutic approach for previously treatment-resistant patients with severe and comorbid conditions.

Psychotherapy in schizophrenia: a retrospective controlled study

ABSTRACT Introduction: Although pharmacological interventions have been the mainstay of treatment for schizophrenia, there has been a growing recognition of the importance of psychotherapy. Aims: To investigate whether a novel psychotherapeutic approach, dialog therapy (DT), has an effect beyond standard psychiatric treatment (ST) in schizophrenia. Methods: Twenty-four patients diagnosed with schizophrenia and treated with DT and 24 patients matched on age, sex, and diagnosis receiving ST were included in the study. Results: At follow-up after a mean of 4 years and 1 month, the DT group had significantly higher scores on the GAF functions (GAF-F) and GAF symptoms (GAF-S) subscales compared to the ST group. Effect sizes (Cohen’s d) were very large, 238 for GAF-S and 241 for GAF-F. The number and doses of psychoactive drugs were significantly lower in the DT group compared to the ST group at follow-up, despite a shorter time in psychotherapy in the DT group. Conclusions: This study provides preliminary evidence that dialog therapy may lead to improvements in symptoms and functioning compared to standard psychiatric treatment.

Reduksjon av unngåelsesatferd og innleggelser grunnet villet egenskade etter Basal Eksponeringsterapi

Basal eksponeringsterapi (BET) er en behandlingsmodell spesielt utviklet for pasienter med alvorlige og sammensatte psykiske lidelser. Karakteristisk for pasientgruppen er psykosesymptomer, dissosiasjon, spiseforstyrrelser og emosjonell ustabilitet i kombinasjon med gjentatte episoder med villet egenskade (VE) og selvmordsforsok. I en retro spektiv journalgjennomgang for 27 pasienter sammenliknet vi innleggelser knyttet til VE i somatikk og psykisk helsevern 12 maneder for og etter BET. Faerre pasienter ble innlagt med VE etter BET (12 av 27) enn for BET (22 av 27), en nedgang pa 45 %. Antall innleggelser knyttet til VE sank fra 123 til 47, en nedgang pa 62 %. Parallelt fant vi en nedgang i pasientenes unngaelse av uonskede indre opplevelser (“experiential avoidance”) malt med Acceptance and Action Questionnaire (AAQ). Fa innleggelser med VE etter BET var knyttet til bade en nedgang i AAQ fra inntak til utskrivning og lave AAQ-skarer ved utskrivning. Funnene er i trad med at behandlingstilnaerminger som vektlegger aksept for indre opplevelser kan vaere et alternativ til behandling rettet mot symptomreduksjon for denne pasientgruppen. Basal Exposure Therapy (BET) is an inpatient treatment modality developed for patients with severe and complex mental disorders. Characteristics of the patient group are psychotic symptoms, dissociation, eating disorders and emotional instability in combination with repeated self-harm and suicide attempts. In this retrospective study based on electronic patient records, we compared the number of admissions related to deliberate self-harm in both somatic and psychiatric hospitals 12 months before and after BET for 27 patients. Fewer patients were admitted to hospitals with deliberate self-harm after BET (12 of 27) compared to before BET (22 of 27), a 45 % reduction. The number of hospitalizations associated with deliberate self-harm decreased from 123 to 47, a 62 % reduction. This decline occurred in parallel with a reduction in the patients’ experiential avoidance as measured with the Acceptance and Action Questionnaire (AAQ). A low number of admissions related to deliberate self-harm after BET was associated with a reduction in AAQ scores from admission to discharge as well as with low AAQ scores at discharge. The fi ndings are consistent with the view that treatment approaches emphasizing acceptance of unwanted private events may be viable alternatives to a focus on symptom reduction in this patient group.

Predictors of suicide in the patient population admitted to a locked-door psychiatric acute ward

Objective No prior study appears to have focused on predictors of suicide in the general patient population admitted to psychiatric acute wards. We used a case-control design to investigate the association between suicide risk factors assessed systematically at admission to a locked-door psychiatric acute ward in Norway and subsequent death by suicide. Method From 2008 to 2013, patients were routinely assessed for suicide risk upon admission to the acute ward with a 17-item check list based on recommendations from the Norwegian Directorate of Health and Social Affairs. Among 1976 patients admitted to the ward, 40 patients, 22 men and 18 women, completed suicide within December 2014. Results Compared to a matched control group (n = 120), after correction for multiple tests, suicide completers scored significantly higher on two items on the check list: presence of suicidal thoughts and wishing to be dead. An additional four items were significant in non-corrected tests: previous suicide attempts, continuity of suicidal thoughts, having a suicide plan, and feelings of hopelessness, indifference, and/or aggression. A brief scale based on these six items was the only variable associated with suicide in multivariate regression analysis, but its predictive value was poor. Conclusion Suicide specific ideations may be the most central risk markers for suicide in the general patient population admitted to psychiatric acute wards. However, a low predictive value may question the utility of assessing suicide risk.

Schizophrenia: A critical view on genetic effects

The main justification for molecular genetics studies of enduring psychosis (schizophrenia) are high heritability estimates obtained from classical twin studies. The classical twin method rests upon the equal environment assumption (EEA), which holds that reared-together identical and fraternal twin pairs grow up experiencing equally similar environmental exposures. However, a review of prior twin studies shows that identical twins are more similar than fraternal twins on childhood exposures that are central to the etiology of psychosis. Such exposures include bullying, sexual abuse, physical maltreatment, emotional neglect and abuse, and general trauma. An additional assumption presented by twin researchers, that the differential intraclass correlation for child social adversities can be explained by evocative gene–environment covariation, is not consistent with the available evidence. Moreover, due to an array of methodological problems and questionable assumptions, adoption studies provide misleading indications in support of genetic effects. As a result, direct studies of DNA variations in schizophrenia must stand on their own ground. Possible minor findings from such molecular genetics studies, when combined with the available evidence of environmental effects, support a stress-based sociopsychobiological model of schizophrenia etiology.

Violence in Acute Psychiatric Patients: A Cumulative Increased Risk with Polysubstance Abuse?

While comorbidity of serious mental illness (SMI) and substance abuse increases violence risk, less is known about additional effects of multiple substance abuse. By using a check list, data on substance abuse, violence, diagnoses, and Perceived Threat Control Override symptoms (TCO) were extracted from electronic patient files in 146 male patients who were extensive users of acute psychiatric services. Variables that were significant in univariate analysis were entered into a stepwise multivariate regression analysis. Odds ratios for violence increased from 5.3 in patients who abused one substance to 153.4 with the abuse of four or five substances (Step 1). The effect was moderated in Step 2 by having a diagnosis of mood disorder (OR = .17). In Step 3, only a trend indicated that one TCO component, “others control my thoughts and feelings,” increased the risk of violence (OR = 3.7). The positive effect sizes for polysubstance abuse were about two times larger in Step 3 than in Step 1. The findings indicate that including the number of abused substances may improve violence risk assessment in patients with SMI.