BACKGROUND AND HYPOTHESIS:Psychosis prevention can be supported by tools that facilitate the early detection of individuals at clinical high risk (CHR-P) and predicting their clinical outcomes. We aimed to use clinical, genetic, and environmental data to: (1) predict case-control status as a proof-of-concept for CHR-P detection, and (2) predict transition to psychosis. STUDY DESIGN:We used data from the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions: a multicenter cohort study comprising 344 CHR-P individuals and 67 healthy controls. To predict CHR-P status, we used environmental (Psychosis Polyrisk Score [PPS]) and genetic (polygenic risk score for schizophrenia [PRS]) measures with logistic regression (LR) and random forest (RF). To predict transition to psychosis, we used clinical, environmental, and genetic measures with Cox proportional hazards model and random survival forest. Primary outcomes were discrimination (C-index) and calibration (intercept and slope) in repeated nested cross-validation. Clinical utility was assessed with decision curve analysis. STUDY RESULTS:For detection of CHR-P, both PPS (LR:C = 0.91, 95% CI, 0.87-0.94, intercept = 1.46, slope = 0.73; RF:C = 0.77, 95% CI, 0.61-0.90, intercept = -0.53, slope = 0.42) and PPS + PRS (LR:C = 0.89, 95% CI, 0.85-0.92, intercept = 1.45, slope = 0.73; RF:C = 0.78, 95% CI, 0.65-0.89, intercept = -0.24, slope = 0.44) had excellent discrimination performance, whereas PRS performed substantially worse (LR:C = 0.60, 95% CI, 0.52-0.67, intercept = 1.63, slope = 0.81; RF:C = 0.57, 95% CI, 0.41-0.72, intercept = -0.84, slope = 0.10). All models over-estimated risk in individuals with low observed risk. Prognosis model performance was poor (C ≤ 0.65). CONCLUSIONS:CHR-P detection may be improved by using the PPS, though evidence is needed from more representative detection settings. However, we did not find evidence that baseline clinical, environmental and/or genetic data enhanced the prediction of psychosis onset.

Background:We examined the course of cognitive performance in first-episode psychosis (FEP) compared to healthy controls (HC), and whether this varied across subgroups of patients defined by premorbid functioning (PMF) trajectories, using a clustering approach. Methods:Data were collected in 302 FEP and 136 HC subjects participating in PSYSCAN (HEALTH.2013.2.2.1-2-FEP). K-means clustering (Euclidean distance) was used to cluster longitudinal trajectories of different PMF domains simultaneously. Since PMF was assessed retrospectively using the Premorbid Adjustment Scale (PAS), findings should be interpreted with caution, although PAS ratings have shown reasonable validity against prospective data. Results:As expected, FEP showed impaired performance across all cognitive domains compared to HC. We identified four trajectories of PMF: a normal premorbid developmental trajectory (globally-normal, 21 %), stable intermediate PMF across domains (stable-intermediate, 29 %), stable poor or deteriorating PMF in the academic domain (normal-social/poor-academic, 29 %), and a globally impaired group with poor/deteriorating PMF across domains (globally-poor, 21 %). These clusters showed distinct levels of post-onset impairments in sustained visual attention, visual working memory and emotion recognition. Conclusions:This study confirms a positive association between PMF and cognitive performance in the early years following psychosis onset. It aligns with findings that individuals later diagnosed with schizophrenia already show developmental deficits/lags from childhood to early adolescence compared to normally developing children. As PMF can be considered a proxy for cognitive reserve, our results suggest that higher reserve acts as a buffer against cognitive decline and supports better performance on sustained visual attention, complex visual working memory, and aspects of emotion recognition.

Background:Cognitive impairments are a hallmark of schizophrenia-spectrum disorders (SSD), contributing to poor treatment outcomes and a key treatment target. The Brief Assessment of Cognition in Schizophrenia (BACS) battery is a validated tool designed to evaluate affected core domains in SSD. The present study evaluated psychometric properties of the German version of the BACS in a representative sample of individuals with SSD and healthy control subjects. Methods:N = 107 individuals with SSD and n = 175 healthy controls were assessed with the German version of the BACS. Diagnosis was confirmed with the Mini International Neuropsychiatric Interview according to DSM-V. Validity was assessed through pair-wise comparisons between SSD individuals and healthy controls and by using receiver operating characteristic analysis. Internal consistency as a measure of reliability was evaluated using McDonald's Omega and Cronbach's Alpha in addition to factor and principal component analysis. Results:All individuals with SSD exhibited significantly lower z-scores across all BACS subtests and BACS composite scores (Z < -1.5) compared to healthy controls. ROC analysis revealed good diagnostic accuracy with an AUC of 0.83 (95%CI: 0.78,0.88, sensitivity = 0.75, specificity = 0.75). Similar results were observed in sub-cohorts comprising clinically stable SSD patients and those with younger ages (18-35 years old). A unidimensional structure, supported by McDonald's Omega (ω = 0.72) and principal component analysis, confirmed robust internal reliability. Conclusions:The German BACS demonstrates strong validity and internal reliability when assessed in a representative case-control sample. This study provides an extensive normative dataset for individuals with SSD in German-speaking populations, facilitating future research and clinical assessments of cognition.

Abstract Objectives Cognitive impairment is a common feature of psychiatric disorders. The Screen for Cognitive Impairment in Psychiatry (SCIP) has been developed for routine screening of psychiatric patients and is available in several languages. The German version (SCIP-G) was used in 3 studies: 1. to investigate the feasibility, reliability and validity of the SCIP-G [Sachs et al. Schizophr. Res. Cogn. 2021: 25, 100197], 2. to perform a confirmatory factor analysis [Sachs et al. Schizophr. Res. Cogn. 2022: 29, 100259], and 3. to assess patients before and after standard inpatient treatment including cognitive training. Methods Study 1 included patients with schizophrenia or schizoaffective psychosis and thirty healthy controls matched for sex, age and education. In study 3, all patients received modern pharmacotherapy plus cognitive remediation using the COGPACK® software package version 6.06; 54 patients were diagnosed with F2 (schizophrenia, schizotypal and delusional disorder) based on ICD-10 research criteria. They were compared with 39 patients meeting criteria for bipolar disorder (F30 and F31) and 50 for depression (F32 and F33). Results In Study 1, significant differences in cognitive performance were found between patients and healthy controls on both versions of the SCIP. The SCIP discriminated effectively between patients and controls. In Study 2, a two-factor solution yielded a good model fit (χ² = 6.7, df = 3, p =.08, χ²/df = 2.2). In study 3, the total SCIP score showed significant improvement after treatment in all three diagnostic groups (p<.001), with no statistically significant interaction between total SCIP score and diagnostic group (p =.860). Conclusion Our data suggest that the SCIP-G is a valid and reliable instrument for the assessment of cognitive impairment. Good model fit can be achieved with a two-factor solution for the SCIP. Inpatient treatment consisting of pharmacotherapy and cognitive training improved cognitive deficits. This improvement in cognitive performance was observed to a similar extent in patients with schizophrenia, bipolar disorder and major depression and were accompanied by improvements in functional outcome.

OBJECTIVE:Relapse prevention is a major goal of schizophrenia treatment. However, there is no standard definition of relapse. To address this, the authors reviewed recent approaches and developed consensus criteria to operationally define relapse. METHODS:To evaluate current criteria, a systematic review was performed of randomized controlled trials of relapse conducted from 2012 to 2024. To develop consensus criteria, the authors used a multiphase Delphi approach involving over 100 experts from 37 countries, including people with lived experience of relapse. RESULTS:The review showed only two pairs of studies that used the same criteria. Clinical judgment alone was sufficient to define relapse in 85% of studies, and 58% used relative symptom change. The recommended criteria cover the pre-baseline, baseline, and relapse components with optimum and minimum criteria and provide a reporting checklist. The recommendations include using standardized, validated measures that can be applied across settings, and using absolute symptom change. The authors also identify criteria that should not be used and make reporting recommendations, including for specific symptom domains (positive, negative, or cognitive) and across symptom domains, hospitalization, home treatment, and risky, violent, or suicidal behavior. CONCLUSIONS:There are limitations and heterogeneity in current definitions of relapse, which limit study comparisons, potentially bias meta-analyses, and question the validity of some studies. Adopting the consensus recommendations for a standardized approach should improve the validity and reliability of study outcomes, facilitate cross-study comparisons, and also standardize research into risk factors for relapse.

BACKGROUND:Brain volume alterations in those at clinical high risk (CHR) of psychosis have been reported in many studies. However, the association between these alterations and the longitudinal trajectory of changes in symptoms and functioning remains unexplored. STUDY DESIGN:T1-weighted magnetic resonance imaging (MRI) scans were acquired from 226 CHR and 65 healthy controls (HC) recruited from the EU-GEI high-risk study. Five a priori regions of interest were examined and segmented using FreeSurfer: total gray matter (GM) volume, anterior cingulate cortex (ACC), hippocampus, fusiform gyri, and insula. Brain volumes in the CHR and HC groups were compared at baseline. In the CHR group, linear mixed models were used to investigate the association between baseline brain volume and longitudinal changes in positive symptoms, negative symptoms, and functioning over a 2-year follow-up period. We also compared CHR participants who later transitioned to psychosis (CHR-T, n = 48) and those who did not (CHR-NT, n = 178) in terms of their trajectory of symptoms and functioning. STUDY RESULTS:Compared with HC, CHR participants had lower total GM and fusiform volume at baseline. Lower total GM and hippocampus volume at baseline were associated with higher levels of positive symptoms at baseline and follow-up in CHR individuals, and lower baseline hippocampus volume also predicted future transition. CHR-T and CHR-NT individuals demonstrated distinct symptoms and functioning trajectories over time. CONCLUSION:Our findings suggest that CHR individuals show baseline differences in brain structure compared to HC, which may also predict changes in positive symptoms over the subsequent 2 years.

Adverse childhood experiences (ACEs) are common in people at clinical high-risk for psychosis (CHR), however, the relationship between ACEs and long-term clinical outcomes is still unclear. This study examined associations between ACEs and clinical outcomes in CHR individuals. 344 CHR individuals and 67 healthy controls (HC) were assessed using the Childhood Trauma Questionnaire (CTQ), the Bullying Questionnaire and the Childhood Experience of Care and Abuse (CECA). CHR were followed up for up to 5 years. Remission from the CHR state, transition to psychosis (both defined with the Comprehensive Assessment of an At Risk Mental State), and level of functioning (assessed with the Global Assessment of Functioning) were assessed. Stepwise and multilevel logistic regression models were used to investigate the relationship between ACEs and outcomes. ACEs were significantly more prevalent in CHR individuals than in HC. Within the CHR cohort, physical abuse was associated with a reduced likelihood of remission (OR = 3.64, p = 0.025). Separation from a parent was linked to an increased likelihood of both remission (OR = 0.32, p = 0.011) and higher level of functioning (OR = 1.77, p = 0.040). Death of a parent (OR = 1.87, p = 0.037) was associated with an increased risk of transitioning to psychosis. Physical abuse and death of a parent are related to adverse long-term outcomes in CHR. The counter-intuitive association between separation from a parent and outcomes may reflect the removal of a child from an adverse environment. Future studies should investigate whether interventions targeting the effect of specific ACEs might help to improve outcomes in this population.

BACKGROUND:Recent stressful life events (SLE) are a risk factor for psychosis, but limited research has explored how SLEs affect individuals at clinical high risk (CHR) for psychosis. The current study investigated the longitudinal effects of SLEs on functioning and symptom severity in CHR individuals, where we hypothesized CHR would report more SLEs than healthy controls (HC), and SLEs would be associated with poorer outcomes. METHODS:The study used longitudinal data from the EU-GEI High Risk study. Data from 331 CHR participants were analyzed to examine the effects of SLEs on changes in functioning, positive and negative symptoms over a 2-year follow-up. We compared the prevalence of SLEs between CHR and HCs, and between CHR who did (CHR-T) and did not (CHR-NT) transition to psychosis. RESULTS:CHR reported 1.44 more SLEs than HC (p < 0.001), but there was no difference in SLEs between CHR-T and CHR-NT at baseline. Recent SLEs were associated with poorer functioning and more severe positive and negative symptoms in CHR individuals (all p < 0.01) but did not reveal a significant interaction with time. CONCLUSIONS:CHR individuals who had experienced recent SLEs exhibited poorer functioning and more severe symptoms. However, as the interaction between SLEs and time was not significant, this suggests SLEs did not contribute to a worsening of symptoms and functioning over the study period. SLEs could be a key risk factor to becoming CHR for psychosis, however further work is required to inform when early intervention strategies mitigating against the effects of stress are most effective.

Background and Hypothesis Cognition has been associated with socio-occupational functioning in individuals at Clinical High Risk for Psychosis (CHR-P). The present study hypothesized that clustering CHR-P participants based on cognitive data could reveal clinically meaningful subtypes.Study Design A cohort of 291 CHR-P subjects was recruited through the multicentre EU-GEI high-risk study. We explored whether an underlying cluster structure was present in the cognition data. Clustering of cognition data was performed using k-means clustering and density-based spatial clustering of applications with noise. Cognitive subtypes were validated by comparing differences in functioning, psychosis symptoms, transition outcome, and grey matter volume between clusters. Network analysis was used to further examine relationships between cognition scores and clinical symptoms.Study Results No underlying cluster structure was found in the cognitive data. K-means clustering produced "spared" and "impaired" cognition clusters similar to those reported in previous studies. However, these clusters were not associated with differences in functioning, symptomatology, outcome, or grey matter volume. Network analysis identified cognition and symptoms/functioning measures that formed separate subnetworks of associations.Conclusions Stratifying patients according to cognitive performance has the potential to inform clinical care. However, we did not find evidence of cognitive clusters in this CHR-P sample. We suggest that care needs to be taken in inferring the existence of distinct cognitive subtypes from unsupervised learning studies. Future research in CHR-P samples could explore the existence of cognitive subtypes across a wider range of cognitive domains.

Several multivariate prognostic models have been published to predict outcomes in patients with first episode psychosis (FEP), but it remains unclear whether those predictions generalize to independent populations. Using a subset of demographic and clinical baseline predictors, we aimed to develop and externally validate different models predicting functional outcome after a FEP in the context of a schizophrenia-spectrum disorder (FES), based on a previously published cross-validation and machine learning pipeline. A crossover validation approach was adopted in two large, international cohorts (EUFEST, n = 338, and the PSYSCAN FES cohort, n = 226). Scores on the Global Assessment of Functioning scale (GAF) at 12 month follow-up were dichotomized to differentiate between poor (GAF current < 65) and good outcome (GAF current ≥ 65). Pooled non-linear support vector machine (SVM) classifiers trained on the separate cohorts identified patients with a poor outcome with cross-validated balanced accuracies (BAC) of 65-66%, but BAC dropped substantially when the models were applied to patients from a different FES cohort (BAC = 50-56%). A leave-site-out analysis on the merged sample yielded better performance (BAC = 72%), highlighting the effect of combining data from different study designs to overcome calibration issues and improve model transportability. In conclusion, our results indicate that validation of prediction models in an independent sample is essential in assessing the true value of the model. Future external validation studies, as well as attempts to harmonize data collection across studies, are recommended.

IntroductionIn this study we assessed the contribution of psychopathology, including the two domains of negative symptoms (motivational deficit and expressive deficit), processing speed as an index of neurocognition, and emotion recognition, as an index of social cognition, to poor functional outcomes in people with schizophrenia.MethodsThe Positive and Negative Syndrome Scale was used to evaluate positive symptoms and disorganization and the Brief Negative Symptom Scale to assess negative symptoms. The Symbol Coding and the Trail Making Test A and B were used to rate processing speed and the Facial Emotion Identification Test to assess emotion recognition. Functional outcome was assessed with the Personal and Social Performance Scale (PSP). Regression analyses were performed to identify predictors of functional outcome. Mediation analyses was used to investigate whether social cognition and negative symptom domains fully or partially mediated the impact of processing speed on functional outcome.ResultsOne hundred and fifty subjects from 8 different European centers were recruited. Our data showed that the expressive deficit predicted global functioning and together with motivational deficit fully mediated the effects of neurocognition on it. Motivational deficit was a predictor of personal and social functioning and fully mediated neurocognitive impairment effects on the same outcome. Both motivational deficit and neurocognitive impairment predicted socially useful activities, and the emotion recognition domain of social cognition partially mediated the impact of neurocognitive deficits on this outcome.ConclusionsOur results indicate that pathways to functional outcomes are specific for different domains of real-life functioning and that negative symptoms and social cognition mediate the impact of neurocognitive deficits on different domains of functioning. Our results suggest that both negative symptoms and social cognition should be targeted by psychosocial interventions to enhance the functional impact of neurocognitive remediation.

Introduction In recent decades, there has been increasing interest in neurocognitive function, including non-social and social cognition. Cognitive impairment has a significant impact on functional outcome, especially in schizophrenic disorders, but also in affective and other psychiatric disorders. Objectives It is our aim to present the assessment and measurement of cognitive dysfunction through adequate instruments and to evaluate the effects of combining pharmacotherapy and cognitive remediation. Methods A review of the modern literature is undertaken and results of own investigations using the Screen for Cognitive Impairment in Psychiatry (SCIP, Sachs G et al. Schizophr Res Cogn. 2021 May 12;25:100197; Sachs G et al. Schizophr Res Cogn. 2022 Jun 6;29:100259) are presented and evaluated. Results Our data show that it is possible to capture cognitive dysfunction in clinical practice. Conclusions After a differentiated assessment of cognitive dysfunction, a specific combination of pharmacotherapy and cognitive remediation should be applied to patients with schizophrenia and affective disorders. Disclosure of Interest None Declared

The presence of artificial light at night has emerged as an anthropogenic stressor in recent years. Various sources of light pollution have been shown to affect circadian physiology with serious consequences for metabolic pathways, possibly disrupting pineal melatonin production with multiple adverse health effects. The suppression of melatonin at night may also affect human mental health and contribute to the development or exacerbation of psychiatric disorders in vulnerable individuals. Due to the high burden of circadian disruption in affective disorders, it has been hypothesized that light pollution impacts mental health, mainly affecting mood regulation. Hence, the aim of this review was to critically summarize the evidence on the effects of light pollution on mood symptoms, with a particular focus on the role of circadian rhythms in mediating this relationship. We conducted a narrative review of the literature in the PubMed, Scopus, and Web of Science datasets. After the screening process, eighteen papers were eligible for inclusion. The results clearly indicate a link between light pollution and the development of affective symptoms, with a central role of sleep disturbances in the emergence of mood alterations. Risk perception also represents a crucial topic, possibly modulating the development of affective symptoms in response to light pollution. The results of this review should encourage a multidisciplinary approach to the design of healthier environments, including lighting conditions among the key determinants of human mental health.

Zusammenfassung Die Schizophrenie ist eine schwere psychiatrische Störung, die mit Positiv- und Negativsymptomen sowie kognitiven Beeinträchtigungen einhergeht. Durch die Fortschritte in der Pharmakologie seit den 1950er-Jahren ist es möglich geworden, die Erkrankung deutlich positiv zu beeinflussen: Antipsychotika können die Positivsymptome der Schizophrenie sowie die Agitation in der akuten Psychose deutlich verbessern. In den letzten Jahren hat das Thema der kognitiven Beeinträchtigung im Zusammenhang mit Schizophrenie (Cognitive impairment associated with schizophrenia [CIAS]) zunehmend an Bedeutung gewonnen. Dieser Artikel soll einen Überblick über die neuesten Entwicklungen in Diagnostik und Therapie geben. Dazu gehören die Beschreibung umfassender kognitiver Testbatterien und kurzer Screeninginstrumente, die für den klinischen Alltag relevant sind, sowie die Vorstellung von Maßnahmen zur kognitiven Remediation und neuen pharmakologischen Ansätzen.

Despite the functional impact of cognitive deficit in people with psychosis, objective cognitive assessment is not typically part of routine clinical care. This is partly due to the length of traditional assessments and the need for a highly trained administrator. Brief, automated computerised assessments could help to address this issue. We present data from an evaluation of PsyCog, a computerised, non-verbal, mini battery of cognitive tests. Healthy Control (HC) (N = 135), Clinical High Risk (CHR) (N = 233), and First Episode Psychosis (FEP) (N = 301) participants from a multi-centre prospective study were assessed at baseline, 6 months, and 12 months. PsyCog was used to assess cognitive performance at baseline and at up to two follow-up timepoints. Mean total testing time was 35.95 min (SD = 2.87). Relative to HCs, effect sizes of performance impairments were medium to large in FEP patients (composite score G = 1.21, subtest range = 0.52–0.88) and small to medium in CHR patients (composite score G = 0.59, subtest range = 0.18–0.49). Site effects were minimal, and test-retest reliability of the PsyCog composite was good (ICC = 0.82–0.89), though some practice effects and differences in data completion between groups were found. The present implementation of PsyCog shows it to be a useful tool for assessing cognitive function in people with psychosis. Computerised cognitive assessments have the potential to facilitate the evaluation of cognition in psychosis in both research and in clinical care, though caution should still be taken in terms of implementation and study design.

Background: Cognitive impairment is a relevant problem in psychiatry and can be well assessed with a cross-diagnostic test such as the Screen for Cognitive Impairment in Psychiatry (SCIP). The aim of our pilot study is to assess cognitive impairment in acute psychiatric inpatients diagnosed with psychotic disorders, bipolar disorder and depression using the German version of the SCIP (SCIP-G). We also investigate whether cognitive dysfunction improves over the course of the inpatient treatment, where patients are offered a combination of pharmacological treatment and cognitive remediation. Methods: A total of 143 adult inpatients were included in the study. Cognitive testing was performed using two different forms of the SCIP-G. All patients received state-of-the-art pharmacotherapy and cognitive remediation using the COGPACK® software package version 6.06. Results: Based on the ICD-10 Criteria for Research, 54 patients were given an F2 diagnosis (schizophrenia and schizotypal and delusional disorders). Thirty-nine patients met the criteria for bipolar disorder (F30 and F31) and fifty for depression (F32 and F33). At baseline, a significant difference was observed between the SCIP total scores of the F2 and F32/33 patients (p < 0.001) and between the F2 and F30/31 groups (p = 0.022). At the second measurement time point, the SCIP total score showed significant improvement in all three groups (p < 0.001), and there was no statistically significant interaction between SCIP total score and diagnostic groups (p = 0.860). Conclusions: Cognitive dysfunction is present in psychiatric disorders and can be easily assessed during an inpatient hospital stay. In our sample, patients with a psychotic disorder were more cognitively impaired at baseline than patients with an affective disorder. Inpatient treatment, consisting of pharmacotherapy and cognitive remediation, improved cognitive deficits. Patients with psychotic disorders, bipolar disorder and depression showed similar improvements in cognitive performance.

BackgroundWe examined the course of illness over a 12-month period in a large, international multi-center cohort of people with a first-episode schizophrenia spectrum disorder (FES) in a naturalistic, prospective study (PSYSCAN).MethodPatients with a first episode of schizophrenia, schizoaffective disorder (depressive type) or schizophreniform disorder were recruited at 16 institutions in Europe, Israel and Australia. Participants (N = 304) received clinical treatment as usual throughout the study.ResultsThe mean age of the cohort was 24.3 years (SD = 5.6), and 67 % were male. At baseline, participants presented with a range of intensities of psychotic symptoms, 80 % were taking antipsychotic medication, 68 % were receiving psychological treatment, with 46.5 % in symptomatic remission. The mean duration of untreated psychosis was 6.2 months (SD = 17.0). After one year, 67 % were in symptomatic remission and 61 % were in functional remission, but 31 % had been readmitted to hospital at some time after baseline. In the cohort as a whole, depressive symptoms remained stable over the follow-up period. In patients with a current depressive episode at baseline, depressive symptoms slightly improved. Alcohol, tobacco and cannabis were the most commonly used substances, with daily users of cannabis ranging between 9 and 11 % throughout the follow-up period.ConclusionsThis study provides valuable insight into the early course of a broad range of clinical and functional aspects of illness in FES patients in routine clinical practice.

Regular Article Influence of cannabis use on incidence of psychosis in people at clinical high risk Lucy A. Chester, Lucia R. Valmaggia, Matthew J. Kempton, Edward Chesney, Dominic Oliver, Emily P. Hedges, Elise Klatsa, Daniel Stahl, Mark van der Gaag, Lieuwe de Haan, Barnaby Nelson, Patrick McGorry, G. Paul Amminger, Anita Riecher-Rössler, Erich Studerus, Rodrigo Bressan, Neus Barrantes-Vidal, Marie-Odile Krebs, Birte Glenthøj, Merete Nordentoft, Stephan Ruhrmann, Gabriele Sachs, Philip McGuire and for the EU-GEI High Risk Study Group Psychiatry and Clinical Neurosciences 2023; 77: 469–477

Transference phenomena such as bodily sensations, feelings and associations that observers experience in themselves have already been shown in previous studies to be suitable for learning more about processes in analytic groups. For this study, we compared the manifest interactions of around 100 participants in a large group that took place in Altaussee, Austria, in spring of 2022 in the context of the Covid pandemic and the Russian threat of war with the content-analyzed perceptions of 10 observers. Above all, it proved important to express and share personal fears – according to the observers’ associations, the group became a mirror of society affected by the pandemic, war and the movement of refugees. The mature processing of the threatening feelings of fear and anger is striking. Divisions are dissolved, images of the enemy are scrutinized and aspects of own perpetratorship are recognized. In the group, it is possible to look together at the threatening aspects, which is also reflected in the transference feelings of the observers. Parallel to a case-by-case „regression in the service of the ego“, evil-punishing superego parts are weakened: not being allowed to feel good oneself in times of war and global crisis. Some aspects of the manifest group harmony were perceived by the observers as exaggerated, some aspects of the regression as denying reality, some aspects of the insular setting as sectarian. In a mature way of dealing with external pressures, the knowledge of threats seems to be shifted from the constantly agonizingly conscious to the co-conscious, where it remains available when needed without dominating the state of mind. At the same time, it is not blocked from perception, i.e. it is not denied, split off and repressed. Tolerance of ambiguity is developed as a resource that strengthens personal resilience and everyday competence in society: the participants reflect on their basic ethical attitude of human solidarity as well as their ability to abstain from unproductive actionism as well as their ability to endure powerlessness.