The effectiveness of adapted schema therapy for cluster C personality disorders in older adults - integrating positive schemas.

INTRODUCTION: Schema therapy (ST) is an efficacious psychotherapy for personality disorders (PDs) in adults. The first empirical support for the effectiveness of ST in older adults with cluster C PDs was provided recently. ST partly focusses on the positive, but there is an increasing awareness of imbalance in the ST community because of the emphasis on negative schemas versus attention to positive schemas. Positive schemas may be important vehicles of therapeutic change in psychotherapy with older people, as it may help strengthen the healthy adult mode, and it might also help change a negative life review. Suggestions were made to increase the efficacy and feasibility of ST in older adults, including adjusting the case conceptualisation, modifying the experiential techniques, making use of the patient's wisdom and reactivating positive schemas. The aim of the current study is to investigate the feasibility and effectiveness of adapted individual ST for older adults. METHODS/DESIGN: A multiple baseline design is used with positive and negative core beliefs as primary outcome measures. Ten older adults (age > 60 years) with cluster C PDs are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying randomly from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions. Symptomatic distress, schema modes, early maladaptive schemas (EMS) and early adaptive schemas (EAS) are secondary outcome measures. PD will be diagnosed before baseline and after treatment phase. EAS are assessed with the Dutch version of the Young Positive Schema Questionnaire (YPSQ). DISCUSSION: To the best of our knowledge, this is the first empirical study in which positive schemas are integrated in ST treatment to examine the efficacy of an adapted form of ST for older adults. This is in line with wider developments supporting the integration of positive schema's into ST. It offers the possibility to improve the effectiveness of ST in older adults. TRIAL REGISTRATION: The Netherlands National Trial Register NL8346, registered 1 February 2020.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: Protocol of a multiple-baseline study.

BACKGROUND: The treatment of borderline personality disorder (BPD) has been examined extensively in adults up to the age of fifty in the past quarter of a century, but there is still a world to discover in treating BPD in older adults. The aim of the study is to investigate the effectiveness of schema therapy in older adults with BPD. METHODS/DESIGN: A multiple baseline design is used in which participants are randomly assigned to baseline length. The primary outcome measure is assessed weekly and consists of the credibility of negative core beliefs. Secondary outcome measures are quality of life, psychological distress, early maladaptive schemas, schema modes, severity of BPD symptoms and meeting the criteria for BPD. Ten older adults (age > 60 years) with BPD are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions. DISCUSSION: To our knowledge, this is the first empirical study of the effectiveness of psychotherapeutic treatment for BPD in older adults. Because of the different manifestation of BPD in later life, besides section II DSM-5 criteria, the alternative, dimensional model for personality disorders of DSM-5 is used to assess BPD in older adults. TRIAL REGISTRATION: The Netherlands National Trial Register NTR7107. Registered 11 March 2018.

Human resources required for antimicrobial stewardship teams: a Dutch consensus report.

SCOPE: Antimicrobial stewardship teams are responsible for implementing antimicrobial stewardship programmes (ASP). However, in many countries, lack of funding challenges this obligation. A consensus procedure was performed to investigate which structural activities need to be performed by Dutch stewardship teams and how much time (and thus full-time equivalent (FTE) labor) is needed to perform these activities. METHODS: In 2015, an electronic survey, based on a nonsystematic literature search and interviews with seven experienced stewardship teams, was sent to 21 stewardship teams that performed an ASP. This was followed by a semistructured face-to-face consensus meeting. Fourteen stewardship teams completed the survey (18% of Dutch acute-care hospitals), and 13 participated in the consensus meeting. RECOMMENDATIONS: The hours needed each year are dependent on hospital size and number of stewardship objectives monitored. If all activities are performed at a minimal base (one stewardship objective; minimal staffing standard), time investment was estimated to be 1393 to 2680 hours annually in the early phase, corresponding with 0.87 (300 beds) to 1.68 FTE (1200 beds), with a further increase to minimally 1.25 to 3.18 FTE in the following years with three stewardship objectives monitored (optimal staffing standards during the first few years of implementing an ASP). This consensus on required human resources provides a directive for structural financial support of stewardship teams in the Dutch context. Some stewardship activities (and related time investments) might be specific to the Dutch context and hospital setting. To develop standards for other settings, our methodology could be applied.

[Autism or personality disorder in older adults? Guidelines for the differential diagnosis]. / Handvatten voor differentiële diagnostiek bij autisme of persoonlijkheidsstoornis bij ouderen.

Autism spectrum disorders and personality disorders are common, also in the elderly. Differential diagnosis is complex, especially if an undiagnosed autism spectrum disorder or personality disorder is suspected. We discuss two cases and conclude the article with suggestions for the differential diagnosis.

Mindfulness and eating behaviour styles in morbidly obese males and females.

BACKGROUND: Morbid obesity is a highly prevalent condition that is associated with a high risk of various diseases and high health care costs. Understanding determinants of eating behaviours that are characteristic of many morbidly obese persons is important for the development of new interventions aimed at changing eating behaviour after bariatric surgery. Dispositional mindfulness seems promising as one such potential determinant. Therefore, the association between mindfulness and eating behaviour was examined in females and males with morbid obesity. METHODS: Outpatients with morbid obesity who were candidates for bariatric surgery (N = 335; 78.8% female) completed the Dutch Eating Behaviour Questionnaire (DEBQ), the Freiburg Mindfulness Inventory (FMI) and the Hospital Anxiety and Depression Scale (HADS), in addition to the collection of relevant demographic and medical data. RESULTS: Three separate multiple regression analyses with three eating behaviour styles (restrained, emotional, external) as dependent variables showed that mindfulness was positively associated with restrained eating behaviour (Beta = .28, p ≤ .001), and negatively associated with emotional (Beta = -.22, p ≤ .001) and external (Beta = -.32, p ≤ .001) eating behaviours, independent of sex, age, educational level, Body Mass Index and affective symptoms. CONCLUSION: Dispositional mindfulness was associated with more restrained, and less emotional and external eating behaviour in morbidly obese outpatients, above and beyond affective symptoms. Future studies, establishing the causal direction of the associations, are needed.

Eating style, television viewing and snacking in pre-adolescent children.

INTRODUCTION: Television viewing is considered to be a risk factor for overweight in children because of its association with reduced physical activity and increased calorie intake. OBJECTIVE: The aim of the present study is to examine whether eating styles affect the relationship between television viewing (TV-viewing) and snacking. METHOD: In a sample of 962 pre-adolescents, self-reported television viewing and snacking were assessed in relation to dietary restraint, external eating and emotional eating, as measured with the child version of the Dutch Eating Behavior Questionnaire. With regression analyses we assessed the possible moderating role of emotional, external and restrained eating on the relation between TV-viewing and snacking. In all analyses we controlled for age, sex, BMI and the possible confounding effects of the other eating styles. RESULTS: Emotional eating, and not dietary restraint or external eating, moderated the relationship between TV-viewing and snacking. CONCLUSION: TV-viewing seems to be more strongly related to snacking in children with higher levels of emotional eating. TV-viewing may also be a risk factor for the development of emotional eating.

[Lithium levels need to be monitored: discrepancies between guidelines and practice]. / Controles bij de behandeling met lithium: de richtlijn en de klinische praktijk.

BACKGROUND: Since lithium can affect the thyroid gland and the kidneys, it is important to perform regular checks on levels of lithium, creatinine and thyroid-stimulating hormone (TSH). AIM: To investigate whether psychiatrists and general practitioners (GPs) perform the required checks twice a year on the levels of lithium, creatinine and tsh in accordance with the Dutch guidelines on bipolar disorder as laid down in 2001. METHOD: The study was based on data that the clinical-chemical laboratory had regarding the lithium checks performed in 2004 in GPs' practices or by the mental health authority in Apeldoorn and the surrounding area. About 250,000 people live in this region. RESULTS: Some of the psychiatrists (11%) and GPs (about 25%) did not check lithium levels as frequently as recommended in the guidelines of 2001. The GPs checked significantly less frequently that the psychiatrists. Both the GPs and the psychiatrists monitored creatinine and TSH less frequently than recommended in the guidelines, creatinine was monitored in 65.8 and 61.2% and TSH in 68.3 and 58% respectively. CONCLUSION We recommend that a warning system be installed in the laboratory which will alert the doctor when a patient has missed a check. Another suggestion is that lithium should be prescribed only by psychiatrists, and not by GPs.

[Drop-out from clinical psychotherapeutic treatment of personality problems]. / Drop-out bij klinisch psychotherapeutische behandeling van persoonlijkheidsproblematiek.

BACKGROUND: Drop-out is a serious problem in psychotherapy. Earlier studies have shown that the main factors associated with drop-out are young age, low socio-economic status and pathological symptoms such as severity of the problems and problematic substance-abuse. AIM: To investigate patient's and pathological characteristics that predict drop-out among patients with predominantly personality problems. METHOD: Patient's characteristics and pathological characteristics of 372 subjects were ascertained via a retrospective study by means of four databases: intake letters, scid-ii personality questionnaires, scid-i and ii interviews and discharge letters. The association between these characteristics and drop-out was tested by means of bivariate and multivariate analysis. results The drop-out rate was 33.3 %. The main predictors of drop-out were young age, a low Global Assessment of Functioning (gaf)-score and the existence of problematic substance-abuse at discharge. The degree and severity of axis i disorders and the nature of personality problems made hardly any contribution to the prediction of drop-out. CONCLUSION: These findings indicate that more attention needs to be given to the existence of substance-abuse before psychotherapy begins. Drop-out is still a problem and is difficult to predict and hard to influence.

The dual pathway model of overeating. Replication and extension with actual food consumption.

van Strien et al. [van Strien, T., Engels, R. C. M. E., van Leeuwe, J., Snoek, H. M. (2005). The Stice model of overeating: tests in clinical and non-clinical samples. Appetite, 45, 205-213] extended the negative affect pathway of Stice's dual pathway model of overeating Stice [Stice, E. (1994). Review of the evidence for a sociocultural model of bulimia nervosa and an exploration of the mechanisms of action. Clinical Psychology Review, 14(7), 633-661] successfully with the variables lack of interoceptive awareness and emotional eating. This study aimed to replicate these findings in a sample of female college students with food consumption as the measure for overeating. Structural equation modeling was used to test the original and the extended model and both models fitted. In the extended model, the relation between negative affect and consumption seemed to run only via lack of interoceptive awareness and emotional eating.

The Team Climate Inventory: application in hospital teams and methodological considerations.

OBJECTIVE: To test the validity, reliability and discriminating capacity of an instrument to assess team climate, the Team Climate Inventory (TCI), in a sample of Dutch hospital teams. The TCI is based on a four-factor theory of team climate for innovation. DESIGN: Validation study. SETTING: Hospital teams in The Netherlands. PARTICIPANTS: 424 healthcare professionals; 355 nurses working in 22 nursing teams and 69 nurses and doctors working in 14 quality-improvement teams. MAIN OUTCOME MEASURES: Exploratory and confirmatory factor analyses, Pearson's product moment correlations, internal homogeneity of the TCI scales based on Cronbach alpha, and the TCI capability to discriminate between two types of healthcare teams, namely nursing teams and quality-improvement teams. RESULTS: The validity test revealed the TCI's five-factor structure and moderate data fit. The Cronbach alphas of the five scales showed acceptable reliabilities. The TCI discriminated between nursing teams and quality-improvement teams. The mean scores of quality-improvement teams were all significantly higher than those of the nursing teams. CONCLUSION: Patient care teams are essential for high-quality patient care, and team climate is an important characteristic of successful teams. This study shows that the TCI is a valid, reliable and discriminating self-report measure of team climate in hospital teams. The TCI can be used as a quality-improvement tool or in quality-of-care research.

Neither restrained eating nor tendency toward overeating predict food consumption after tension induction.

The present study investigates whether the so-called disinhibition effect is better accounted for by tendency toward overeating than by restraint. The rationale was that in mood-induction studies, so far, the disinhibition effect has only been found in studies that applied the Restraint Scale and hardly ever in studies that used other restraint scales. Tension was induced by the public-speaking method in half of 86 female college students before they participated in an alleged taste test. The Restraint Scale (RS), the Three-Factor Eating Questionnaire (TFEQ) and the Dutch Eating Behaviour Questionnaire (DEBQ) were used to measure restraint and tendency toward overeating. No differences were found between the tension and the control condition as to the amounts of food the participants ate. Also no proof of the disinhibition effect was obtained and, remarkably, tendency toward overeating did not predict the amount of food eaten. Possible explanations for these results are offered in the discussion.

[In-house apartments: an attempt to handle complex chronic psychiatric disorders]. / Inleunappartementen: een poging om complexe chronische psychiatrische problematiek hanteerbaar te maken.

SUMMARY: A ward of the ggnet, a mental health centre in Apeldoorn, has developed a unique way of coping with often complex and severe problems of patients with chronic psychiatric disorders. It has created a one-person facility, called an in-house apartment. The in-house apartments have been evaluated and appear to be an effective way of dealing with some patients with complex chronic psychiatric disorders - specific types of psychiatric disorders and personality problems.

Clinical indicators: development and applications.

Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a quotient. After a try-out, the measurements and reporting should follow. The report contains an in-depth analysis of causal and contributing factors associated with the measured results. A description of the clinical circumstances and a correction for case mix should be included to allow for a justified interpretation. The indicators must be part of an improvement strategy, for which comparison feedback is often used. We give examples of indicator development and applications in oncology, diabetes care, and the use of antibiotics for treating pneumonia. We explain how comparison with reference data can be used to construct improvement programmes.

Development of quality indicators for diagnosis and treatment of patients with non-small cell lung cancer: a first step toward implementing a multidisciplinary, evidence-based guideline.

BACKGROUND: While developing and distributing clinical practice guidelines are important in optimising clinical healthcare, insight into actual care is necessary to achieve successful implementation. Developing quality indicators may be the first step to becoming aware of actual care. The Dutch national practice guideline Non-small cell lung cancer: staging and treatment is one of the first clinical, multidisciplinary guidelines for oncology in the Netherlands for which quality indicators were developed systematically. We describe indicator development based on this guideline as a practical experience. METHODS: To develop a set of indicators for diagnosis and treatment of patients with non-small cell lung cancer, we systematically achieved consensus on the basis of a national, multidisciplinary, evidence-based guideline and the opinions of professionals and patients. After the researchers extracted the recommendations from the guideline, we carried out a so-called Rand-modified-Delphi procedure. This consisted of three rounds: a national panel of professionals and representatives of the national patient organization scored all recommendations, the professionals had a consensus meeting, and the final set of indicators was e-mailed for a last check. Subsequently, some clinimetric characteristics of this final set were assessed in a practice test. RESULTS: Thirty-two of 83 recommendations were selected in the first round. After the consensus meeting, 8 recommendations met the final criteria and were incorporated into 15 indicators, which were tested in practice. The most successful indicators for quality improvement are indicators that are measurable, have potential for improvement, have a broad range between practices and are applicable to a large part of the population. CONCLUSIONS: For successful implementation of evidence-based guidelines, each new guideline should be developed and tested with a set of indicators based on the guideline. The procedure we describe can serve as an example for other new guidelines.

Local influence to detect influential data structures for generalized linear mixed models.

This article discusses the generalization of the local influence measures for normally distributed responses to local influence measures for generalized linear models with random effects. For these models, it is shown that the subject-oriented influence measure is a special case of the proposed observation-oriented influence measure. A two-step diagnostic procedure is proposed. The first step is to search for influential subjects. A search for influential observations is proposed as the second step. An illustration of a two-treatment, multiple-period crossover trial demonstrates the practical importance of the detection of influential observations in addition to the detection of influential subjects.

Mammalian target of rapamycin is a direct target for protein kinase B: identification of a convergence point for opposing effects of insulin and amino-acid deficiency on protein translation.

Growth factor induced activation of phosphoinositide 3-kinase and protein kinase B (PKB) leads to increased activity of the mammalian target of rapamycin (mTOR). This subsequently leads to increased phosphorylation of eIF4E binding protein-1 (4EBP1) and activation of p70 ribosomal S6 protein kinase (p70(S6K)), both of which are important steps in the stimulation of protein translation. The stimulation of translation is attenuated in cells deprived of amino acids and this is associated with the attenuation of 4EBP1 phosphorylation and p70(S6K) activation. It has been suggested that PKB regulates mTOR function by phosphorylation although direct phosphorylation of mTOR by PKB has not been demonstrated previously. In the present work, we have found that PKB directly phosphorylates mTOR and, using phosphospecific antibodies, we have shown this phosphorylation occurs at Ser(2448). Insulin also induces phosphorylation on Ser(2448) and this effect is blocked by wortmannin but not rapamycin, consistent with the effect being mediated by PKB. Amino-acid starvation rapidly attenuated the reactivity of the Ser(2448) phosphospecific antibody with mTOR and this could not be restored by either insulin stimulation of cells or incubation with PKB in vitro. Our findings demonstrate that mTOR is a direct target for PKB and support the conclusion that regulation of phosphorylation of Ser(2448) is a point of convergence for the counteracting regulatory effects of growth factors and amino acid levels.

Defect in long-term activation of phosphatidylinositol 3-kinase by insulin in vivo: studies in insulin-resistant hHTg rats.

OBJECTIVE: To study the regulation of phosphatidylinositol (PI) 3-kinase by insulin in vivo in hereditary hypertriglyceridemic and insulin resistant rat (hHTg). METHODS: Total and insulin receptor substrate-1 (IRS-1) associated PI 3-kinase activities were measured in skeletal muscles and adipose tissue after an intense insulin induced glucose utilization as accomplished by 90 min euglycemic hyperinsulinemic clamp. RESULTS: In quadriceps femoris muscle, no stimulation of total or IRS-1 associated PI 3-kinase activities was found after hyperinsulinemia in both hHTg and control rats. In contrast, in soleus muscle of control rats total PI 3-kinase activity was stimulated by insulin (P<0.001), while any such effect was not found in hHTg rats. IRS-1 associated PI 3-kinase activity in soleus muscle was significantly decreased in hHTg rats when compared to control rats (P<0.001), but was not affected by insulin. In white adipose tissue (WAT), both the total (P<0.05) and IRS-1 associated PI 3-kinase activities (P<0.001) were increased after 90 min hyperinsulinemia in control animals but not in hHTg animals. CONCLUSIONS: Long-term activation of PI 3-kinase activity by insulin in vivo involves IRS-1 in white adipose tissue, but not in skeletal muscle which implies tissue specificity. The impairment in the PI 3-kinase activation by insulin in hHTg rats may participate in insulin resistance of these animals.

Two naturally occurring insulin receptor tyrosine kinase domain mutants provide evidence that phosphoinositide 3-kinase activation alone is not sufficient for the mediation of insulin's metabolic and mitogenic effects.

We have recently reported (1) that two naturally occurring mutants of the insulin receptor tyrosine kinase domain, Arg-1174 --> Gln and Pro-1178 --> Leu (Gln-1174 and Leu1178, respectively), both found in patients with inherited severe insulin resistance, markedly impaired receptor tyrosine autophosphorylation, with both mutant receptors being unable to mediate the stimulation of glycogen synthesis or mitogenesis by insulin when expressed in Chinese hamster ovary cells. However, these mutations did not fully prevent IRS-1 phosphorylation in response to insulin in these cells, suggesting that IRS-1 alone may not be sufficient to mediate insulin's metabolic and mitogenic effects. In the present study, we have demonstrated that these mutations also impair the ability of the insulin receptor to activate the transcription factor Elk-1 and promote GLUT4 translocation to the plasma membrane. Although at low concentrations of insulin, the mutant receptors were impaired in their ability to stimulate the tyrosine phosphorylation of IRS-1, at higher insulin concentrations we confirmed that the cells expressing the mutant receptors showed significantly increased tyrosine phosphorylation of IRS-1 compared with parental nontransfected cells. In addition, at comparable insulin concentrations, the association of the p85alpha subunit of phosphoinositide 3-kinase (PI3-kinase) with IRS-1 and the enzymatic activity of IRS-1-associated PI3-kinase were significantly enhanced in cells expressing the mutant receptors. In contrast, no significant stimulation of the tyrosine phosphorylation of Shc, GTP loading of Ras, or mitogen-activated protein kinase phosphorylation was seen in cell lines expressing these mutant receptors. Thus, no activation of any measurable mitogenic or metabolic response was detectable, despite significant insulin-induced phosphorylation of IRS-1 and its association with PI3-kinase in cells stably expressing the mutant insulin receptors. These findings suggest that PI3-kinase activation alone may be insufficient to mediate a wide range of the metabolic and mitogenic effects of insulin. Additionally, the data provide support for the notion that insulin activation of Ras is more closely linked with Shc, and not IRS-1, phosphorylation.

Presence of gonadotropin-releasing hormone (GnRH) binding sites and compounds with GnRH-like activity in the ovary of African catfish, Clarias gariepinus.

GnRH binding was characterized in the African catfish ovary by use of an analog of salmon GnRH (sGnRH- ; [D-Arg6, Trp7, Leu8, Pro9-NEt]-GnRH) as a labeled ligand. Binding of sGnRH-A to catfish ovarian membrane preparation was found to be saturable, displaceable, reversible, and dependent on time, temperature, and tissue concentration. Optimal binding was achieved after 70 min of incubation at room temperature (approximately 22 degrees C) at pH 7.6. Addition of unlabeled sGnRH-A displaced the bound 125I-sGnRH-A in a dose-related manner. Hill plot as well as Scatchard analysis indicated the presence of one class of high-affinity binding sites with a equilibrium dissociation constant (Kd) of 0.27 +/- 0.036 nM. Bound 125I-sGnRH-A was also found to be displaceable by catfish GnRH (cfGnRH; [His5, Leu7, Asn8]-GnRH), chicken GnRH-II (cGnRH-II; [His5, Trp7, Tyr8]-GnRH), and salmon GnRH (sGnRH; [Trp7, Leu8]-GnRH); all the peptides were found to bind with lower affinities than sGnRH-A to the catfish ovarian GnRH binding sites. Further experiments using ovarian extracts indicated the presence of compounds with GnRH-like activity in the ovary of African catfish. The crude ovarian extract was found to stimulate pituitary gonadotropin release from goldfish pituitary, as well as displacing 125I-sGnRH-A binding in the catfish ovary. HPLC analysis of the catfish ovarian extract revealed the presence of two fractions that bind specifically to the catfish ovary and release gonadotropin from cultured goldfish pituitary. These fractions include an early eluting peak that does not correspond with the retention time of known GnRH forms in addition to a fraction that co-elutes with the mammalian GnRH. Overall, the study provided characterization of GnRH binding sites in the catfish ovary, and evidence for the presence of compounds with GnRH-like activity in the catfish ovary.