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The purpose of this systematic literature review is to provide an exhaustive summary of current research to explore the prospects of compassion-based approaches in treating persons with Schizophrenia Spectrum Disorders (SSD). Thereby, studies investigating the relationship between clinical parameters and self-compassion in SSD, as well as the acceptability, feasibility, and effects of compassion-based approaches for individuals with SSD were considered. The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Eight studies were included for qualitative synthesis. The results indicate an important role of self-compassion for several clinical parameters, including negative associations to positive symptoms, negative symptoms, cognitive disorganization, and emotional distress. All studies reported good acceptability and feasibility. Regarding the clinical effectiveness of compassion-based approaches, a variety of clinical benefits, such as improvements of mood, affect regulation, positive symptoms, negative symptoms, cognitive disorganization, and variables relating to psychological recovery were found in individuals with SSD. It is concluded that compassion-based approaches are a promising form of intervention in the treatment of SSD. However, further research, especially randomized controlled trials, in this field is needed to understand the full potential of compassion-based approaches for individuals with SSD., Author(s): Selin Mavituna [sup.1] , Eric Hahn [sup.2] , Inge Hahne [sup.2] , Niklas Bergmann [sup.2] , Marieke Pijnenborg [sup.1] , Thi Minh Tam Ta [sup.2] , Lana Tafelski [sup.3] [...]

Background: Patients with a mental illness are more likely to develop, and die from, cardiovascular diseases (CVD), necessitating optimal CVD-risk (CVR)-assessment to enable early detection and treatment. Whereas psychiatrists use the metabolic syndrome (MetS)-concept to estimate CVR, GPs use absolute risk-models. Additionally, two PRIMROSE-models have been specifically designed for patients with severe mental illness. We aimed to assess the agreement in risk-outcomes between these CVR-methods. Methods: To compare risk-outcomes across the various CVR-methods, we used somatic information of psychiatric outpatients from the PHAMOUS-, and MOPHAR-database, aged 40–70 years, free of past or current CVD and diabetes. We investigated: (1) the degree-of-agreement between categorical assessments (i.e. MetS-status vs. binary risk-categories); (2) non-parametric correlations between the number of MetS-criteria and absolute risks; and (3) strength-of-agreement between absolute risks. Results: Seven thousand twenty-nine measurements of 3509 PHAMOUS-patients, and 748 measurements of 748 MOPHAR-patients, were included. There was systematic disagreement between the categorical CVR-assessments (all p < 0.036). Only MetS-status versus binary Framingham-assessment had a fair strength-of-agreement (κ = 0.23–0.28). The number of MetS-criteria and Framingham-scores, as well as MetS-criteria and PRIMROSE lipid-scores, showed a moderate-strong correlation (τ = 0.25–0.34). Finally, only the continuous PRIMROSE desk and lipid-outcomes showed moderate strength-of-agreement (ρ = 0.91). Conclusions: The varying methods for CVR-assessment yield unequal risk predictions, and, consequently, carry the risk of significant disparities regarding treatment initiation in psychiatric patients. Considering the significantly increased health-risks in psychiatric patients, CVR-models should be recalibrated to the psychiatric population from adolescence onwards, and uniformly implemented by health care providers. Trial registration: The MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014 (NL4779). [ABSTRACT FROM AUTHOR]

Autism Diagnostic Observation Schedule (ADOS) module 4 was investigated in an independent sample of high-functioning adult males with an autism spectrum disorder (ASD) compared to three specific diagnostic groups: schizophrenia, psychopathy, and typical development. ADOS module 4 proves to be a reliable instrument with good predictive value. It can adequately discriminate ASD from psychopathy and typical development, but is less specific with respect to schizophrenia due to behavioral overlap between autistic and negative symptoms. However, these groups differ on some core items and explorative analyses indicate that a revision of the algorithm in line with Gotham et al. (J Autism Dev Disord 37: 613-627, 2007) could be beneficial for discriminating ASD from schizophrenia. (Contains 1 figure and 4 tables.)

Accessible Summary: What is known on the subject?: To date, the majority of the research regarding innovative psychosocial interventions in psychiatry focuses upon the development and effectiveness of the interventions. Despite the fact that these are important clinical and scientific contributions, only a small percentage of the evidence‐based interventions reach clinical practice.Cognitive Adaptation Training (CAT) is an effective psychosocial intervention to increase daily functioning and cognitive functioning in people diagnosed with severe mental illness (SMI) in inpatient and outpatient psychiatric care.Despite knowledge on the intervention's effectiveness, systematic use of CAT in the daily routine of mental health nurses is insufficient. What the paper adds to existing knowledge?: To date, no research is available that describes the factors associated to the implementation of CAT from a nursing perspective.This research also adds to the literature on rehabilitation in people diagnosed with SMI in an inpatient setting.The results contribute to the science of implementing interventions in long‐term psychiatric care and may help future interventions in their implementation process. What are the implications for practice?: This study highlights that multiple factors need to be considered when implementing an intervention in routine care and that it is a complicated process.Future implementation initiatives require ongoing training and supervision of CAT specialists, appointment of local champions to increase commitment among nursing staff and inclusion and commitment of management to overcome organizational barriers.Without acknowledging the presence of barriers to implementation and considering strategies to overcome these barriers, sustainable implementation is likely to be unsuccessful. Introduction: Evidence‐based interventions in psychiatry often fail to reach clinical practice. Cognitive Adaptation Training (CAT) is an evidence‐based psychosocial intervention that aims to improve daily functioning of people diagnosed with a severe mental illness. Implementation of CAT remains challenging, despite demonstrated effectiveness. Aim: Identifying facilitators and barriers of CAT on the intervention, nursing, and organizational levels, and investigating relationships between capability, opportunity, motivation, and appraisal using the COM‐B model. Method: The Measurement Instrument for Determinants of Innovations and CAT‐specific questions were administered to 46 nurses. The relationship among capability, opportunity, motivation and appraisal was calculated using the Pearson's r correlation coefficient. Results: Nine barriers (mostly organizational level) and 13 facilitators (mostly intervention and nursing level) were identified. Significant moderate correlations were found between capability and opportunity, capability and motivation, capability and appraisal and a strong correlation between motivation and appraisal. Discussion: The results suggest that barriers at the organizational level should be removed and facilitators at intervention and nursing levels may be exploited to improve implementation. Implications for practice: Future implementation initiatives require ongoing training and supervision of CAT specialists, appointment of local champions to increase commitment among nursing staff and inclusion and commitment of management to overcome organizational barriers. [ABSTRACT FROM AUTHOR]

Objective: In the general population cannabis use is associated with better cardiometabolic outcomes. Patients with severe mental illness frequently use cannabis, but also present increased cardiometabolic risk factors. We explore the association between cannabis use and cardiometabolic risk factors in patients with severe mental illness.Method: A total of 3169 patients with severe mental illness from a Dutch cohort were included in the study. The association of cannabis use with body mass index, waist circumference, blood pressure, cholesterol, triglycerides, glucose, glycated hemoglobin and Positive and Negative Syndrome Scale was examined with separate univariate AN(C)OVA. Changes in metabolic risk factors and Positive and Negative Syndrome Scale were examined after a follow-up interval of 9-24 months, for patients who continued, discontinued, started or were never using cannabis between the two assessments.Results: Cannabis users at baseline had lower body mass index, smaller waist circumference, lower diastolic blood pressure, and more severe psychotic symptoms than non-users. Patients who discontinued their cannabis use after the first assessment had a greater increase in body mass index, waist circumference, diastolic blood pressure and triglyceride concentrations than other patients, and the severity of their psychotic symptoms had decreased more compared to continued users and non-users.Conclusion: Extra attention should be paid to the monitoring and treatment of metabolic parameters in patients who discontinue their cannabis use. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to estimate the effects of lifestyle interventions on bodyweight and other cardiometabolic risk factors in people with psychotic disorders. Additionally, the long-term effects on body weight and the effects on depressive symptoms were examined. Material and Methods: We searched four databases for randomized controlled trials (RCTs) that compared lifestyle interventions to control conditions in patients with psychotic disorders. Lifestyle interventions were aimed at weight loss or weight gain prevention, and the study outcomes included bodyweight or metabolic parameters. Results: The search resulted in 25 RCTs -only 4 were considered high quality- showing an overall effect of lifestyle interventions on bodyweight (effect size (ES) = −0.63, p<0.0001). Lifestyle interventions were effective in both weight loss (ES = −0.52, p<0.0001) and weight-gain-prevention (ES = −0.84, p = 0.0002). There were significant long-term effects, two to six months post-intervention, for both weight-gain-prevention interventions (ES = −0.85, p = 0.0002) and weight loss studies (ES = −0.46, p = 0.02). Up to ten studies reported on cardiometabolic risk factors and showed that lifestyle interventions led to significant improvements in waist circumference, triglycerides, fasting glucose and insulin. No significant effects were found for blood pressure and cholesterol levels. Four studies reported on depressive symptoms and showed a significant effect (ES = −0.95, p = 0.05). Conclusion: Lifestyle interventions are effective in treating and preventing obesity, and in reducing cardiometabolic risk factors. However, the quality of the studies leaves much to be desired. [ABSTRACT FROM AUTHOR]

Impaired Theory of Mind (ToM) has been repeatedly reported as a feature of psychotic disorders. ToM is crucial in social interactions and for the development of social behavior. It has been suggested that reasoning about the belief of others, requires inhibition of the self-perspective. We investigated the neural correlates of self-inhibition in nineteen low psychosis prone (PP) and eighteen high PP subjects presenting with subclinical features. High PP subjects have a more than tenfold increased risk of developing a schizophrenia-spectrum disorder. Brain activation was measured with functional Magnetic Resonance Imaging during a ToM task differentiating between self-perspective inhibition and belief reasoning. Furthermore, to test underlying inhibitory mechanisms, we included a stop-signal task. We predicted worse behavioral performance for high compared to low PP subjects on both tasks. Moreover, based on previous neuroimaging results, different activation patterns were expected in the inferior frontal gyrus (IFG) in high versus low PP subjects in self-perspective inhibition and simple response inhibition. Results showed increased activation in left IFG during self-perspective inhibition, but not during simple response inhibition, for high PP subjects as compared to low PP subjects. High and low PP subjects showed equal behavioral performance. The results suggest that at a neural level, high PP subjects need more resources for inhibiting the self-perspective, but not for simple motor response inhibition, to equal the performance of low PP subjects. This may reflect a compensatory mechanism, which may no longer be available for patients with schizophrenia-spectrum disorders resulting in ToM impairments. [ABSTRACT FROM AUTHOR]

Abstract: While there is emerging evidence that dissociation is linked with trauma history and possibly symptoms in schizophrenia, it remains unclear whether dissociation represents a symptom dimensions in its own right in schizophrenia and as such is uniquely related to other features of illness. To explore this issue the current study sought to find out whether dissociation was uniquely related to an index of social cognition closely linked to social functioning, namely affect recognition. We hypothesized that dissociation would be linked with affect recognition because symptoms of dissociation may uniquely disrupt processes which are expected to be needed for correctly recognizing emotions. The sample contained 49 participants diagnosed with a schizophrenia spectrum disorder who were in a non-acute phase of disorder. Participants were concurrently administered the Bell–Lysaker Emotion Recognition Task, the Dissociative Experiences Scale, the Post Traumatic Stress Disorder Checklist and the Positive and Negative Symptoms Scale. Stepwise linear regression analyses were performed in which dissociative symptoms were forced to enter after the other symptoms in order to predict deficits in affect recognition. These analyses revealed that greater levels of dissociative symptoms predicted poorer recognition of negative emotions over and above that of positive, negative, cognitive and PTSD symptoms. Results are consistent with the possibility that dissociation represents a unique dimension o f psychopathology in schizophrenia which may be linked to function. [Copyright &y& Elsevier]

Background: Introduction: As a human being we give meaning to our stories, in relation to the social and physical context. For people with severe and complex mental health needs, who have been dependent on (intensive) residential psychiatric support for a long time, it is possible that talents and qualities disappear because this part of their identity has been buried under a long psychiatric history. This can result in people’s identity becoming limited to ‘patient’, and the experience of life as meaningless. Objectives: For these service-users, few interventions aimed at personal recovery are available that match their cognitive and communicative skills. In this project, we developed a new psychosocial intervention to stimulate self-reflection and personal recovery. Methods: The development of the intervention took place through a “usercentred-design process” (UCD). UCD is an iterative design process in which the needs and wishes of the user are the starting point, and they remain central in the product design circle. Throughout the whole design process, service users, significant others, mental health professionals, peer support workers, artists, and researchers collaborate in order to design a first testable prototype. For each step of design process, we organized focus group meetings and brainstorm sessions with all stakeholders as well as individual interviews with service users. Based on the input in these meetings and interviews, the design was adapted. This was done for each consecutive step, which made the whole design process iterative by nature. Results: A new psychosocial intervention entitled “This Is Me” was developed as a “journey of discovery” through the lives of service users at both verbal and non-verbal levels. From the UCD process four basic principles underlying the intervention were disentangled that have been incorporated in the intervention: 1) “gaining new experiences”, 2) “attention for (self) stigma”, 3) “equal treatment as a person”, 4) “uniqueness of the individual”. This resulted in an intervention in which service-users, together with a teammate, engage in new experiences. Moreover, they are prompted to reflect on these experiences upon their return. With this process, we aim to support people in (re)discovering roles, talents and characteristics to broaden the identity from ‘patienthood’ to ‘personhood’. Discussion: Conclusions: UCD was a useful method for the development of a new psychosocial intervention targeting identity for people with complex mental health needs. The process resulted into new knowledge about factors that are important in the (re)development of identity. In addition, we will present the first results of a pilot study in which we assessed the feasibility and effectiveness of the intervention. [ABSTRACT FROM AUTHOR]

Background: Healthy metacognition involves several capacities, including the ability to integrate information about the self and others in order to formulate ways of coping with social challenges and psychological distress. Multiple studies have demonstrated that reduced general metacognitive capacity is predictive of the development and persistence of overall negative symptom burden. However, there have been no published analyses investigating how specific sub-components of metacognition influence the expression of individual negative symptoms. We aggregated individual participant data from studies reporting measures of subtypes of metacognitive functioning and examined the strength of association with specific negative symptoms. Methods: PsycINFO, EMBASE, MEDLINE, Cochrane Library and grey literature databases were searched for eligible studies. Forwards and backwards citation searching and contacting of study authors revealed additional datasets not identified in the original search. Included studies assessed negative symptoms and metacognition using interview-based measures in participants aged 16 years or older. Selection was restricted to quantitative research, excluding case studies, and only English language publications were screened. Experimental and observational studies were screened sequentially at title, abstract and full-text level to determine whether they met search criteria. A second reviewer independently screened a proportion of records to check the reliability of inclusion/exclusion judgements (Cohen’s Kappa = 0.74). Participant data and metadata of included studies were extracted and compiled combining original author and report information for all pre-specified outcomes where available. The proposed plan for the systematic review and meta-analyses was also preregistered on PROPSERO (CRD42019130678). Results: 97 unique reports were identified, of which 30 included negative symptom specific hypotheses. Samples overlapped substantially across publications with these 97 reports corresponding to 30 unique datasets. The raw individual participant level data for 23 of the 30 unique datasets was obtained. Preliminary analyses investigated the relationship between components of metacognition measured with the MAS-A (Lysaker et al., 2005), and the original negative symptoms subscale score of the PANSS (Kay et al., 1987) to maximise available data. We will discuss the results, which suggest that there are distinct relationships between subscales of metacognition and negative symptoms. We will also discuss the limitations of these results including a limited scope for analysing covariates due to the computational complexity of the models used, and difficulties in handling the diversity of data present in the meta-analysis. We will also discuss why high heterogeneity might be present, and provide further support for analysis investigating the relationship between individual negative symptoms and components of metacognition. Discussion: The data suggest there is complexity in the relationship between components of metacognition and individual negative symptoms. It is for subsequent analyses to determine whether individual negative symptoms have distinct relationships with each metacognitive capacity, and whether the variation in the strength of these associations could explain the high heterogeneity observed. [ABSTRACT FROM AUTHOR]

Background: Young people with a psychotic disorder have the same social goals as their healthy peers, but their social networks are smaller, they participate less often in leisure activities and are less successful in work and education. Current treatments have only moderate effects on social functioning. Virtual Reality (VR) has a great potential to improve the social functioning of young people with psychosis. With VR, individuals can practice with simulations of difficult social situations in a safe and personalized way. Therefore, we aimed to develop and investigate feasibility of a novel VR treatment (VR-SOAP) for improving social contacts, leisure activities and social participation of young people with a psychotic disorder. Methods: As a first step, a literature search of causes of impaired social functioning was conducted. Underlying relationships and mechanisms of the causes were identified. The causes of impaired social functioning were translated into concepts for the VR modules. The concepts were translated into requirements for the VR modules. Subsequently, the software and the treatment manual were developed in an iterative process with a team of experiential experts, psychosis therapists, researchers, VR experts and software engineers. The final prototype will be tested in a small pilot study with three therapists and six patients. In order to determine the feasibility and acceptability of the treatment and to evaluate and improve the treatment protocol using input from therapists and patients. Results: Several determinants of impaired social functioning were identified: negative symptoms, impaired social cognition, paranoid ideations, social anxiety, low self-esteem, self-stigma and poor communication skills. These causes are multifaceted, but at the same time interrelated and overlapping. VR-SOAP was designed as five modules that address these causes, four optional modules (1–4) and one fixed module (5). The treatment is personalized and takes the specific individual contributing causes into account. Patient and therapist select two out of four optional modules. In module 1 (Negative symptoms) patients will focus on increasing their motivation and pleasure in dealing with amotivation and anhedonia. In module 2 (Social cognition) patients will practice with recognizing facial emotions and interpreting social situations. Module 3 (Paranoid ideations) consists of exposure exercises and behavioural experiments testing harm expectancies. In module 4 (Self-esteem and self-stigma) patients will focus on positive aspects of the self and challenge self-criticism. All patients will end with module 5 (Communication and Interaction skills), in which experiences, knowledge and skills from other modules are integrated and applied in role-plays. Currently, the pilot feasibility study is ongoing. Preliminary results will be presented. Discussion: VR-SOAP is a promising new intervention for enhancing the social functioning of young adults with psychosis. VR is very useful for practising new social behaviour. It enables patients to practice with realworld social situations in a safe and gradual way. In the coming years, a single-blind randomized controlled trial will be conducted to test the effect of VR-SOAP on social contacts, leisure activities and social participation. [ABSTRACT FROM AUTHOR]

Background: Aiming to improve the quality of care for patients with a psychotic disorder, the ongoing Pharmacotherapy Monitoring Outcome Survey (PHAMOUS) started in 2006 in four large mental health care organizations in the Northern Netherlands, by adding it to the at that time mandatory Routine Outcome Monitoring program. However, since the cuts in the financial budgets for mental health care, research nurses are increasingly experiencing time-pressure in the assessments. The Positive and Negative Syndrome Scale (PANSS), part of the assessment, is a time-consuming interview, taking approximately 30 minutes. Therefore, we developed and validated a short self-report questionnaire assessing positive psychotic symptoms, the Brief Positive Symptoms Questionnaire (BPSQ). Methods: The BPSQ was added to PHAMOUS and filled in once by patients in four mental health care institutions in 2017 and 2018. The BPSQ consists of nine items and takes about 2–3 minutes to complete. It was validated against the PANSS positive scale and two items of the Health of the Nations Outcome Scale (HoNOS), with item 6 assessing the problems that patients experience due to hallucinations and delusions and item 8 assessing further mental and behavioural problems. Results: BPSQ data were obtained from n=287 patients (mean age 47.1 years, 67.6% male). The PANSS was assessed in n=244 and HoNOS data were available for n=156 patients. Scores of one patient were considered unreliable and thus removed from the data set. The BPSQ had a Cronbach’s alpha of .81. Spearman’s correlation coefficient of the BPSQ and the PANSS positive scale was significant (ρ(243) = .63, p < .05). Correlations between the BPSQ and HoNOS items 6 and 8 were significant (ρ(155) = .488, p < .05 and ρ(155) = .251, p < .05 respectively). Post hoc analysis showed that the more severely psychotic the patients were, the less the BPSQ and the PANSS positive scale were corresponding. Discussion: Given the medium correlation of the BPSQ with the PANSS positive scale and the low concurrent validity with the two relevant HoNOS items, we argue that the widely used and validated PANSS is indispensable in the PHAMOUS assessment of positive symptoms in a chronic population with psychotic disorders. Replication of this study in first-episode psychotic patients is recommended. [ABSTRACT FROM AUTHOR]

Background: Individuals with a psychotic disorder are at an increased risk of becoming the victim of a crime. A body-oriented resilience therapy with elements of kickboxing (‘BEATVIC’) aimed at preventing victimization by addressing putatively underlying factors was developed. One of these factors is social cognition, particularly facial affect processing. The current study investigated neural effects of BEATVIC using two face processing tasks. Methods: Participants were randomized to either BEATVIC or a ‘Befriending’ control group consisting of social group meetings. Twentyseven patients (BEATVIC n=14; Befriending n=13) completed an Emotional Faces task and the Wall of Faces task during fMRI, pre and post intervention. General linear model (GLM) analyses and Independent component analyses (ICA) were performed to define networks and investigate group*time effects. Results: Voxelwise GLM analyses yielded no differences between groups over time. On a network level (ICA) we found overall increased activation of the salience network to angry and fearful faces in BEATVIC compared to Befriending. A trend towards significance (p=0.05) for increased activation of the (medial) visual network to (a group of predominantly) angry faces, and decreased deactivation (p=0.08) in the sensorimotor network in response to fearful faces in BEATVIC was observed. Discussion: Increased activation of the salience network may suggest an increased alertness for potentially dangerous faces. Trend findings of the visual network and the sensorimotor network which are formally statistically insignificant may be regarded as tentative and strongly warrant further investigation to allow for more definite conclusions. Increased activation of the visual network might suggest more elaborate processing of visual information. Decreased deactivation in the sensorimotor network might indicate a reduced tendency for “freezing” and enhanced action readiness in response to indirect threat. [ABSTRACT FROM AUTHOR]

Background: Social cognitive deficits are common in people with a psychotic disorder, and may play an important role in social dysfunction. Social cognition training (SCT) has emerged in the past two decades as a way to improve social cognition through strategy training and repeated practice. Several reviews and meta-analyses have indicated that SCT improves social cognition, but several important questions remain. This meta-analysis addresses three of these questions: Methods: Search results from clinical databases were systematically reviewed by two independent raters. SCTs from included publications were categorized according to their focus (targeted or broad-based) and their inclusion of CRT (with or without). Network meta-analysis was used, since it allows for comparison of more than two treatments, and comparison of any chosen pair of interventions - even those not directly investigated in the literature. It estimates the treatment effect by inference from a network of evidence (i.e., effectAB = effectAC – effectBC), and combines this indirect evidence with original comparisons to estimate treatment effects. For each treatment arm, a pre-post effect size was determined and pairwise comparisons for each combination of study arms were calculated. With network meta-analysis, all SCTs were compared to treatment as usual (the chosen reference group). Meta-regression was used to evaluate the moderating effects of study (methodological quality, total intervention time, use of groups, static/dynamic measures, inclusion of CRT) and participant (age, illness duration, medication dose, gender) characteristics. Follow-up efficacy was investigated using multivariate meta-analysis. Results: Compared to TAU, emotion perception was improved most by targeted SCT without CRT (Cohen’s d=.68) and broad-based SCT without CRT (d=.46). All treatments improved social perception (active control, d=.98, targeted SCT with and without CRT, d=1.36 and d=1.38, broad-based SCT with and without CRT, d=1.35 and d=1.45). Only broad-based SCT without CRT improved ToM (d=.42) more than TAU. Social functioning was significantly improved only by broad-based SCT (without CRT, d=.82, with CRT, d=.41). None of the SCTs significantly improved attribution, general social cognition and psychotic symptoms, compared to TAU. Individual SCT worked better for emotion perception, but SCT in a group was more effective for social functioning. A higher percentage of male participants in a study predicted worse outcomes on functioning and psychotic symptoms. At follow-up, a moderate effect on social functioning (d=.66) was found, but not on psychotic symptoms. Social cognition could not be investigated quantitatively at follow-up due to insufficient data, but qualitative analysis suggested persisting effects. Discussion: While targeted SCT is the most effective for emotion perception and social perception, broad-based SCT produced the best overall outcomes. Using CRT did not enhance SCT effects. Our results suggest that (particularly broad-based approaches to) SCT produce generalized, enduring effects, but more methodologically sound research is necessary to investigate key questions that remain, especially regarding mechanisms of treatment. [ABSTRACT FROM AUTHOR]

Background Clinical insight is impaired in the majority of individuals with schizophrenia (Dam, 2006) and is associated with poorer outcome (Lincoln et al. 2007). Impaired insight cannot be pinpointed to abnormalities of isolated brain areas, as earlier studies on cortical structure and insight found abnormalities in a distributed network of brain regions (Pijnenborg et al. in prep). Getting a better understanding of the neural substrate of impaired insight might help in finding better treatment options to improve insight. Typically, brains are characterized by small-world topology, reflected by a balance between information segregation (i.e. short distances between nodes) and integration (i.e. high clustering of nodes). Several studies have shown less characteristics of small-world topology in patients with schizophrenia. In this study, we used tools of graph theory to investigate whether there are less characteristics of small-world topology of individual structural networks in patients with a psychotic disorder compared to healthy individuals, and whether this is related to interindividual differences in insight. Methods T1-weighted images of 114 patients with a psychotic disorder (76% males; mean age=33.67, SD=10.86) and 54 healthy controls (63% males; mean age=35.11, SD=10.76) were acquired with a 3T Philips Intera MRI-scanner. Clinical insight was measured with item G12 of the PANSS (Kay et al. 1987). In a subsample of 62 patients, clinical insight was also measured with the Schedule of Assessment of Insight – Expanded (SAI-E; Kemp & David, 1997), and cognitive insight with the Beck Cognitive Insight Scale (BCIS; Beck et al. 2004). Brain images were segmented using SPM12. Individual gray matter similarity networks were created from gray matter segmentations using a previously described method (Tijms et al. 2012). We calculated the following graph metrics: path length, clustering coefficient, betweenness centrality, lambda (i.e. normalized path length), gamma (i.e. normalized clustering coefficient) and small-world property (i.e. gamma/lambda) using the Brain Connectivity Toolbox.8 Differences in graph metrics between patients and healthy individuals were investigated with ANCOVA's. The associations between insight and graph metrics were calculated with partial correlations. Education and total gray matter were entered as covariates in all analyses. Results We found significantly lower clustering coefficient (F(1,165)=17.90, pFDR<0.001) and higher betweenness centrality (F(1,165)=7.910, punc=0.006, pFDR=0.018) in patients compared to healthy controls. In addition, we found that poorer ability to relabel symptoms (SAI-E subscale) correlated with higher betweenness centrality (rs=-0.359, punc=0.005, pbonf=0.04). Discussion Our result of less clustering indicates less effective integration of information and a more random topology of networks of patients with a psychotic disorder. Our findings of higher betweenness centrality values in patients compared to healthy individuals, and higher betweenness centrality values in patients with poorer ability to attribute symptoms to the illness indicate increased hub-characteristics of regions in these patients. Hubs are central regions that interact with many other regions and facilitate integration. Hub regions make graphs more resilient toward pathological damage but are also the weakest points of these networks. We will further investigate this relationship by examining which brain regions show this relationship specifically. Learning more about abnormalities of underlying structural networks by examining small-world property may help in getting a better understanding of impaired insight and finding potential biomarkers. [ABSTRACT FROM AUTHOR]

Purpose: Cognitive Adaptation Training (CAT) is a psychosocial intervention with demonstrated effectiveness. However, no validated fidelity instrument is available. In this study, a CAT Fidelity Scale was developed and its psychometric properties, including interrater reliability and internal consistency, were evaluated., Methods: The fidelity scale was developed in a multidisciplinary collaboration between international research groups using the Delphi method. Four Delphi rounds were organized to reach consensus for the items included in the scale. To examine the psychometric properties of the scale, data from a large cluster randomized controlled trial evaluating the implementation of CAT in clinical practice was used. Fidelity assessors conducted 73 fidelity reviews at four mental health institutions in the Netherlands., Results: After three Delphi rounds, consensus was reached on a 44-item CAT Fidelity Scale. After administration of the scale, 24 items were removed in round four resulting in a 20-item fidelity scale. Psychometric properties of the 20-item CAT Fidelity Scale shows a fair interrater reliability and an excellent internal consistency., Conclusions: The CAT fidelity scale in its current form is useful for both research purposes as well as for individual health professionals to monitor their own adherence to the protocol. Future research needs to focus on improvement of items and formulating qualitative anchor point to the items to increase generalizability and psychometric properties of the scale. The described suggestions for improvement provide a good starting point for further development., Competing Interests: None., (© 2022 The Authors.)