To explore clinical and demographic characteristics impacting patient functioning by determining extent of overlap in factors driving change in Personal and Social Performance (PSP) and other clinical outcomes.

Addressing maladherence in schizophrenia Abstract. To prevent neurotoxic and demoralizing relapses in the course of schizophrenia maladherence was shown as one of the most important factors. Empirical evidence is presented and organized in a conceptual four level framework to organize an individually tailored approach to promote adherence more effectively and prevent the demoralizing function of classical insight by neglecting the underlying motivational processes in routine care. This four level framework to address maladherence encompasses (a) functional analysis of (mal-)adherence as an instrumental goal oriented behaviour, (b) addressing dysfunctional attitudes related to disorder and treatment,

Zusammenfassung. Mangelnde Behandlungsbereitschaft ist der gewichtigste Einzelfaktor für Rückfälle bei schizophrenen Störungen. Rückfälle ihrerseits wirken als kumulativ fortschreitende Recovery vernichtende neurotoxische Prozesse. In dieser Übersicht wird die Abkehr von klassischer einsichtsfördernder edukativer Intervention gefordert. Auf der Basis neuer Forschungsergebnisse wird ein heuristisches Vier-Ebenen-Modell zur individuell zugeschnittenen Verbesserung von Behandlungsbereitschaft vorgestellt: Ausgehend von (a) einer Motivationsdiagnostik (Bedingungs- und Problemanalyse von Adhärenz, Exploration behandlungsrelevanter Erwartungen) werden (b) Einstellungs- (individuelle Krankheits- und Behandlungserfahrungen sowie Folgeerwartungen), (c) Beziehungs- und (d) Verhaltensaspekte von Behandlungsbereitschaft als intentionales Verhalten durch differenzielle Strategien fokussiert (Anreize und Befähigungsaspekte).

Zusammenfassung. Die Behandlung schizophrener Störungen ist immer noch eine grosse Herausforderung, die die akute Behandlung, die Langzeitbehandlung als auch die Früherkennung betrifft. Neue Ansätze in der Diagnostik und Therapie können helfen, den Verlauf positiv zu beeinflussen.

Zusammenfassung. Gerade in der frühen ersten Erkrankungsphase entscheidet sich oft die Langzeitprognose schizophrener Störungen, d.h. wie vollständig Symptome und die Neuroplastizität einschränkende Rückfälle aus dem Leben der Betroffenen rausgehalten werden können und wie die soziale und berufliche Integration erfolgt, entscheidet sich hier. Daher kommt wirksamen Interventionen gerade in dieser sog. „critical period“ eine entscheidende Bedeutung zu. Der Artikel referiert hierzu Grenzen und Möglichkeiten aktueller Ansätze, die auf dem „Menuplan“ in dieser Krankheitsphase stehen sollten und was bei Ersterkrankungen im Unterschied zu wiederholt erkrankten Menschen zu beachten ist. Die Behandlungsmöglichkeiten haben sich gerade hier in den letzten Jahren weiterentwickelt: Es geht um die frühe Optimierung der antipsychotischen Therapie mit Wirkungsmaximierung und Nebenwirkungsminimierung, den Einsatz von langwirksamen Antipsychotika von Anfang an zur Minimierung von akzidentieller Malcompliance und konsekutiver Verhinderung von Rückfällen. Weiterhin besteht die Notwendigkeit, störungs- und problemspezifische Verhaltenstherapie zu ergänzen, um eine personalisierte, individualisierte Medizin zu realisieren, die durch eine entwicklungspsychologische und selbstkonzeptbezogene Dimension gekennzeichnet ist. Neben der Sekundär- (Verhinderung neuroplastizitätsvernichtender Rückfälle) stellt hier die Tertiärprophylaxe (frühe Verhinderung von Chronifizierungsprozessen) ein wichtiges Ziel dar.

Zusammenfassung. Ausgehend von einer Darstellung von Häufigkeit und Folgen von Maladhärenz als wichtigster Rückfallfaktor und Rückfällen als progredient „Recovery“ vernichtendem neurotoxischem Prozess wird die Abkehr von klassischer einsichtsfördernder Edukation gefordert. Auf der Basis neuer Forschungsergebnisse wird ein Vier-Ebenen-Modell zur Verbesserung von Behandlungsbereitschaft vorgestellt: Ausgehend von (a) einer Motivationsdiagnostik (Bedingungs- und Problemanalyse von Adhärenz, Exploration behandlungsrelevanter Erwartungen) werden (b) Einstellungs- (individuelle Krankheits- und Behandlungserfahrungen sowie Folgeerwartungen) (c) Beziehungs- und (d) Verhaltensaspekte von Behandlungsbereitschaft als intentionales Verhalten fokussiert (Anreize und Befähigungsaspekte).

Thought and language disorders are a main feature of schizophrenia. The aim of the study is to explore the impact of thought disorder on therapeutic alliance and personal recovery because of its interference with verbal communication. Thought disorder, positive and negative symptoms (Positive and Negative Syndrome Scale), functioning (Modified Global Assessment of Functioning scale), insight (Scale to Assess Unawareness of Mental Disorder), attachment insecurity (Psychosis Attachment Measure), therapeutic alliance (Scale to Assess the Therapeutic Relationship), and personal recovery (Recovery Assessment Scale, Integration Sealing-Over Scale) were assessed in 133 outpatients with schizophrenia or schizoaffective disorder at baseline and twelve months later. The data were analyzed by hierarchical multiple linear regression. Higher levels of thought disorder were significantly associated with lower clinicians' ratings, but not with patients' ratings of therapeutic alliance. In addition, lower clinicians' ratings of therapeutic alliance were significantly linked to a more sealing over and less integrative recovery style. In fact, the lower therapeutic alliance ratings mediated the association between thought disorder and a sealing over recovery style. The results highlight the importance of considering thought disorder in treatment of schizophrenia and schizoaffective disorder which may interfere with therapeutic alliance and treatment efforts towards recovery.

Background: The recovery framework has found its way into local and national mental health services and policies around the world, especially in English speaking countries. To promote this process, it is necessary to assess personal recovery validly and reliably. The Recovery Assessment Scale (RAS) is the most established measure in recovery research. The aim of the current study is to examine the factor structure of the German version of the RAS (RAS-G).Methods: One hundred and fifty-six German-speaking clients with schizophrenia or schizoaffective disorder from a community mental health service completed the RAS-G plus measures of recovery attitudes, self-stigma, psychotic symptoms, depression, and functioning. A confirmatory factor analysis of the original 24-item RAS version was conducted to examine its factor structure, followed by reliability and validity testing of the extracted factors.Results: The CFA yielded five factors capturing 14 items which showed a substantial overlap with the original subscales Personal Confidence and Hope, Goal and Success Orientation, Willingness to Ask for Help, Reliance on Others, and No Domination by Symptoms. The factors demonstrated mean to excellent reliability (0.59-0.89) and satisfactory criterial validity by positive correlations with measures of recovery attitudes and functioning, and negative correlations with measures of self-stigma, and psychotic and depressive symptoms.Conclusions: The study results are discussed in the light of other studies examining the factor structure of the RAS. Overall, they support the use of the RAS-G as a means to promote recovery oriented services, policies, and research in German-speaking countries. (C) 2016 Elsevier Masson SAS. All rights reserved.

Objective: This study was designed to explore the efficacy and tolerability of oral paliperidone extended release (ER) in a sample of patients who were switched to flexible doses within the crucial first 5 years after receiving a diagnosis of schizophrenia. Methods: Patients were recruited from 23 countries. Adults with nonacute but symptomatic schizophrenia, previously unsuccessfully treated with other oral antipsychotics, were transitioned to paliperidone ER (3–12 mg/day) and prospectively treated for up to 6 months. The primary efficacy outcome for patients switching for the main reason of lack of efficacy with their previous antipsychotic was at least 20% improvement in Positive and Negative Syndrome Scale (PANSS) total scores. For patients switching for other main reasons, such as lack of tolerability, compliance or ‘other’, the primary outcome was non-inferiority in efficacy compared with the previous oral antipsychotic. Results: For patients switching for the main reason of lack of efficacy, 63.1% achieved an improvement of at least 20% in PANSS total scores from baseline to endpoint. For each reason for switching other than lack of efficacy, efficacy maintenance after switching to paliperidone ER was confirmed. Statistically significant improvement in patient functioning from baseline to endpoint, as assessed by the Personal and Social Performance scale, was observed ( p < 0.0001). Treatment satisfaction with prior antipsychotic treatment at baseline was rated ‘good’ to ‘very good’ by 16.8% of patients, and at endpoint by 66.0% of patients treated with paliperidone ER. Paliperidone ER was generally well tolerated, with frequently reported treatment-emergent adverse events being insomnia, anxiety and somnolence. Conclusions: Flexibly dosed paliperidone ER was associated with clinically relevant symptomatic and functional improvement in recently diagnosed patients with non-acute schizophrenia previously unsuccessfully treated with other oral antipsychotics.

Lack of insight is a major target in the treatment of schizophrenia. However, insight may have undesirable effects on self-concept and motivation that can hinder recovery. This study aimed to examine the link between insight, self-stigma, and demoralization as predictors of symptoms and functioning. Insight, self-stigma, depressive and psychotic symptoms, and functioning were assessed among 133 outpatients with schizophrenia at baseline and 12 months later. The data were analyzed by hierarchical multiple linear regressions. More insight at baseline and an increase in self-stigma over 12 months predicted more demoralization at follow-up. Insight at baseline was not associated with any outcome variable, but self-stigma at baseline was related to poorer functioning and more positive symptoms at follow-up. More demoralization at baseline predicted poorer functioning 12 months later. Demoralization did not mediate the relationship between self-stigma at baseline and functioning after 1 year. Given the decisive role of self-stigma regarding recovery from schizophrenia, dysfunctional beliefs related to illness and the self should be addressed in treatment. Different psychotherapeutical approaches are discussed.

Lack of insight is a major target in the treatment of schizophrenia. However, insight may have undesirable effects on self-concept and motivation that can hinder recovery. This study aimed to examine the link between insight, self-stigma, and demoralization as predictors of symptoms and functioning. Insight, self-stigma, depressive and psychotic symptoms, and functioning were assessed among 133 outpatients with schizophrenia at baseline and 12 months later. The data were analyzed by hierarchical multiple linear regressions. More insight at baseline and an increase in self-stigma over 12 months predicted more demoralization at follow-up. Insight at baseline was not associated with any outcome variable, but self-stigma at baseline was related to poorer functioning and more positive symptoms at follow-up. More demoralization at baseline predicted poorer functioning 12 months later. Demoralization did not mediate the relationship between self-stigma at baseline and functioning after 1 year. Given the decisive role of self-stigma regarding recovery from schizophrenia, dysfunctional beliefs related to illness and the self should be addressed in treatment. Different psychotherapeutical approaches are discussed.

Von Leitkrankheiten in der Medizin erwartet man, dass sie Positionierung und ggf. Umorientierung eines Faches bestimmen. Wohl kaum eine Erkrankung aus dem Spektrum psychischer Erkrankungen hat die Psychiatrie und Psychotherapie nach innen und nach außen in dermaßen starker Weise geprägt wie die Schizophrenie.

Development and delivery of evidence-based treatment for schizophrenia is not only important for recovery of the patients but also by health economic reasons. Cognitive-behavioural interventions are tailored to illness characteristics and phase of treatment and not only problem focussed. Evidence based treatment programs are developed to address building of strong and trustful therapeutic relationship, enhancement of treatment adherence and functional adjustment to the disorder (recovery as a motivational process), improvement of social cognition and social skills as well as neurocognition respective social support by relatives or to cope with residual symptoms of the illness.

Die Verbesserung der Versorgung schizophrener Storungen hat fur die Betroffenen aber auch gesundheits- okonomisch und volkswirtschaftlich hohe Relevanz. Neben einer individuell zugeschnittenen moglichst wirksamen und vertraglichen antipsychotischen Pharmakotherapie haben die letzten Jahre eine zunehmende Anzahl von als wirksam belegten storungs- und problemspezifischen verhaltenstherapeutischen Behandlungsansatzen hervorgebracht. Sie zielen dabei auf eine Verbesserung der Behandlungsvoraussetzungen wie Forderung von Behandlungsbereitschaft und nicht-resignative Krankheitsakzeptanz sowie von therapeutischer Beziehungsqualitat, Verbesserung der sozialen Kognition und Neurokognition, von sozialer Unterstutzung und Reintegration am Arbeitsplatz sowie Umgang mit Antipsychotika-resistenter Restsymptomatik.

OBJECTIVE:Low levels of insight are a risk factor for treatment nonadherence in schizophrenia, which can contribute to poor clinical outcome. On the other hand, high levels of insight have been associated with negative outcome, such as depression, hopelessness, and lowered quality of life. The present study investigates mechanisms underlying the association of insight and depressive symptoms and protective factors as potential therapeutic targets.METHODS:One hundred and forty-two outpatients with schizophrenia or schizoaffective disorder (35.2% women, mean age of 44.83 years) were studied using questionnaires and interviews to assess insight, depressive symptoms, recovery attitude, and illness appraisals with regard to course, functional impairments, and controllability. Psychotic and negative symptoms were assessed as control variables. The cross-sectional data were analyzed using structural equation models and multiple linear regression analyses with latent variables.RESULTS:Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. The association of negative symptoms with depressive symptoms was not significant. The relationship between insight and depressive symptoms was mediated by the participants' perception of their illness as being chronic and disabling, as well as suppressed by their expectation of symptom control due to treatment. Finally, the association of insight and depressive symptoms was less pronounced in the patients with a positive recovery attitude than in those without this protective factor.CONCLUSIONS:To achieve recovery, which includes symptom reduction, functional improvement, and subjective well-being, it is necessary to prevent depressive symptoms as indicators of a demoralization process, which may arise as a consequence of growing insight. Possible treatment strategies focusing on changes of dysfunctional beliefs about the illness and the self and inducing a positive recovery attitude are discussed.

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.