Susanne Harder

Supportive Psychodynamic Psychotherapy versus Treatment as Usual for First-Episode Psychosis: Two-Year Outcome

During recent decades, the field of treatment of schizophrenia has lacked empirical, systematic outcome studies that support psychodynamic psychotherapy as an evidence-based intervention for patients with schizophrenia. The Danish schizophrenia project (DNS) compared psychodynamic psychotherapy for psychosis with standard treatment in patients with a first-episode schizophrenia spectrum disorder. The study was designed as a prospective, comparative, longitudinal multi-site investigation of consecutively referred patients who were included during two years. The patients were treated with either manualized individual supportive psychodynamic psychotherapy (SPP) in addition to treatment as usual or with treatment as usual alone (TaU). Symptoms and functional outcomes were measured using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF). The study included 269 consecutively admitted patients, age 18–35, of whom 79% remained in the study after two years. The intervention group improved significantly on measures of both PANSS and GAF scores, with large effect sizes at two years follow-up after inclusion. Further, improvement on GAFfunction (p = 0.000) and GAFsymptom (p = 0.010) significantly favored SPP in combination with TaU over TaU alone. In spite of limitations, this study speaks in favor of including supportive psychodynamic psychotherapy in the treatment for patients with schizophrenic first-episode psychoses.

The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with relatively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psychotherapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjectivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersubjective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.

Attachment in Schizophrenia—Implications for Research, Prevention, and Treatment

Attachment is a promising area for elucidating psychosocial mechanisms important for development, prevention, and treatment of schizophrenia. This report gives a short summary of studies of attachment in psychosis. It was found that dismissing and disorganized forms of attachment were over-represented in psychosis. Evidence pointed to associations between a dismissing attachment pattern and positive psychotic symptoms, negative symptoms, and poor engagement with services. Furthermore, insecure attachment was found to predict impaired recovery from negative symptoms. Possible major risk processes in development linking dismissing attachment to symptom development were externalizing and deactivation of affects and poor mentalization. For a disorganized form of attachment, possible risk mechanisms were heightened stress-sensitivity and dissociation. Based on this initial evidence, further research in attachment in psychosis focusing on these risk mechanisms seems warranted. In addition, the evidence supported a focus on attachment-related risk processes to enhance the prevention and treatment of psychosis.

Psychosis and the dynamics of the psychotherapy process

The role of psychotherapy in the treatment of psychoses remains controversial but there is improving acceptance that an understanding of the dynamics of the psychological processes involved in treatment and in the disorder itself may be important. Psychosis is understood as a detachment of the ‘self’ from the ‘world which results in changed abilities in inter-subjective relating to oneself and others. This understanding has led to guidelines for psychotherapists who engage in treatment of psychoses and these are summarized in this article. As a result of the disturbance in the inter-subjective process, a therapeutic relationship is disrupted and a therapeutic alliance is not assured. Therapists have to pay particular attention to the empathic aspects of the interaction as they attempt to integrate affects to restore meaning to the inner life of the patient. The psychodynamics of this process are described with additional discussion about the role of cognitive interventions and their limitations.

Caregiver distress in first-episode psychosis: the role of subjective appraisal, over-involvement and symptomatology

AbstractBackground Caregivers of persons with first-episode psychosis (FEP) often report high levels of distress. Preventing long-term or chronic distress within the whole family is an important focus of early intervention for psychosis. However, a more comprehensive understanding of the psychological factors involved is needed.AimsTo examine the impact of subjective appraisals and expressed emotion on caregiver distress in FEP.MethodWithin a cross-sectional design, 154 caregivers of 99 persons with FEP in a clinical epidemiological sample completed a series of questionnaires to examine potential predictors of caregiver distress.ResultsThirty-seven percent of caregivers were suffering from clinically significant distress. A linear mixed model analysis found that, after controlling for caregiver socio-demographic factors, service-user symptoms and global functioning, emotional over-involvement and subjective appraisal of caregiving were significant predictors of caregiver distress.ConclusionCaregiver distress is significant in the early phase of illness, and this seems to be more related to their subjective appraisal and over-involvement, than to variations in symptoms and global functioning of the person diagnosed with FEP. This lends further support to the stress-appraisal coping model and the cognitive model of caregiving in FEP, and highlights supportive interventions aimed at handling unhelpful cognitions and behaviors.

Five-year follow-up of supportive psychodynamic psychotherapy in first-episode psychosis: long-term outcome in social functioning.

Objectives: The long-term outcomes of several approaches to intervention targeting social functioning in schizophrenia are not well documented. Contemporary supportive psychodynamic psychotherapy (SPP) aims to improve social functioning. The aim of the present study was to investigate the long-term outcome of SPP in a prospective, longitudinal, comparative, multicenter investigation of successively referred patients diagnosed with first-episode schizophrenia spectrum disorder. Method: Manualized SPP for up to 3 years as a supplement to standard treatment (ST) were compared to ST alone and followed up for 5 years (N = 269). The SPP targeted interpersonal relationships, emotion regulation, social cognition, and self-coherence. Results: Significant between-group effects in favor of SPP+ST on social functioning, overall symptoms, and positive psychotic symptoms were found during the period of active SPP intervention. These differential effects, however, were not sustained after end of additional SPP at 5-year follow-up. Conclusion: The findings are in line with results from other approaches targeting social functioning in schizophrenia and support SPP as a valuable treatment. Further research into the curative elements of SPP is needed.

The association between working alliance and clinical and functional outcome in a cohort of 400 patients with first-episode psychosis: a cross-sectional study.

OBJECTIVE Working alliance between patients with a first-episode psychosis and their case manager is regarded as a key element in specialized early intervention services. The impact of this patient-case manager dyad on functional and clinical outcome is unknown. We aimed to investigate if a strong working alliance was associated with fewer clinical symptoms and better social functioning. METHOD In a cross-sectional design, patients with first-episode schizophrenia spectrum disorders (ICD-10, F20-29) were included after 18 months of treatment (N = 400). Baseline data were collected between June 2009 and December 2011. Symptoms were assessed using Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS), Global Assessment of Functioning (GAF), Brief Assessment of Cognition in Schizophrenia (BACS), Working Alliance Inventory (WAI), and General Self-Efficacy (GSE). Linear regression analyses were adjusted for age, sex, cognition, and self-efficacy. RESULTS Results revealed significant associations between working alliance and fewer negative (β = -0.12; 95% CI, -0.19 to -0.04) and disorganized symptoms (β = -0.06; 95% CI, -0.11 to -0.01), and between working alliance and better social functioning (β = 1.45; 95% CI, 0.55 to 2.36). General self-efficacy mediated the effect of working alliance, explaining 14%-18% of the variance in associated outcomes. Global level of cognitive functioning, compliance, and self-efficacy influenced clinical and functional outcome more strongly than working alliance. CONCLUSIONS Better working alliance was weakly associated with fewer negative and disorganized symptoms and better social functioning. A strong working alliance may be a prerequisite for adherence to the specialized early intervention services treatment, providing the basis for positive treatment outcome. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00914238.

Cultural differences in infant development during the first year: A study of Danish infants assessed by the Bayley-III and compared to the American norms

The aim of this study was to examine whether significant developmental differences existed between a Danish sample of infants and the American norms as measured by the Bayley Scales of Infant Development–III. Longitudinal data was collected at 4, 7, 10 and 13 months for 45 Danish infants. The results showed significant differences between scores of the Danish infants and the American norms regarding cognitive, language and motor functioning. Specifically, Danish infants were at all ages of assessment significantly delayed in their development of receptive language when compared to the American norms. One explanation for this is suggested to be the nature of Danish sound structure which makes Danish harder to learn. The results of the present study underline the need to be cautious when using developmental scales in countries where no local norms exist.

Mother-infant interaction in schizophrenia: transmitting risk or resilience? A systematic review of the literature

PurposeThe parent–infant relationship is an important context for identifying very early risk and resilience factors and targets for the development of preventative interventions. The aim of this study was to systematically review studies investigating the early caregiver–infant relationship and attachment in offspring of parents with schizophrenia.MethodsWe searched computerized databases for relevant articles investigating the relationship between early caregiver–infant relationship and outcomes for offspring of a caregiver with a diagnosis of schizophrenia. Studies were assessed for risk of bias.ResultsWe identified 27 studies derived from 10 cohorts, comprising 208 women diagnosed with schizophrenia, 71 with other psychoses, 203 women with depression, 59 women with mania/bipolar disorder, 40 with personality disorder, 8 with unspecified mental disorders and 119 non-psychiatric controls. There was some evidence to support disturbances in maternal behaviour amongst those with a diagnosis of schizophrenia and there was more limited evidence of disturbances in infant behaviour and mutuality of interaction.ConclusionsFurther research should investigate both sources of resilience and risk in the development of offspring of parents with a diagnosis of schizophrenia and psychosis. Given the lack of specificity observed in this review, these studies should also include maternal affective disorders including depressive and bipolar disorders.

Links Among High EPDS Scores, State of Mind Regarding Attachment, and Symptoms of Personality Disorder

Underlying persistent psychological difficulties have been found to moderate potential adverse effects of maternal postpartum depression (PPD) on parenting and infant development. The authors examined whether mothers presenting postpartum depressive symptoms showed higher levels of personality pathology and more insecure state of mind regarding attachment compared to nondepressed mothers. Participants (N = 85) were assessed with the Edinburgh Postnatal Depression Scale (EPDS), the Present State Examination, the Adult Attachment Interview, and the Structured Clinical Interview for DSM-IV Axis II. Mothers with high EPDS scores were more likely to have a preoccupied insecure state of mind and to have personality disorder compared with mothers scoring below clinical cutoff. Furthermore, multiple regression analysis showed that personality disorder and AAI classification were independently related to EPDS score, and that these two factors together accounted for 48% of the variance in EPDS score. Findings are discussed in terms of heterogeneity in PPD populations and underline the importance of examining potential coexisting psychological difficulties when studying PPD.