Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors.

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

[The impasse known as ADHD]. / De impasse die ADHD heet.

There are two extreme views within psychiatry when it comes to etiopathogenesis. At one extreme is the naturalistic vision; at the other extreme is a perception of psychiatric diagnoses as social constructions. There are also different perspectives on ADHD: historical, social, psychological and neurobiological. In this article, I will try to find a position between the two extremes to sketch the context of the current ADHD debate from the different perspectives. I conclude that a one-sided neurobiological view of ADHD lacks adequate foundation; it does not support the psychiatrist who is struggling with complicated ADHD issues in daily practice, and does not respond adequately to the very real problems of the people concerned and their families. We do not know exactly how to address the issue of ADHD in children and adults. Traditionally in medicine, to abstain in case of doubt is a virtue.

Moving Perspectives on Patient Competence: A Naturalistic Case Study in Psychiatry.

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.

[Should diagnosis and classification be kept separate in psychiatry?]. / Diagnostiek en classificatie scheiden in de psychiatrie. Hoe de DSM-5 zinvol ingezet kan worden voor het vak.

BACKGROUND: In medicine it is common practice to diagnose patients before classifying their symptoms. In psychiatry, however, the two procedures cannot be kept separate; they overlap and are interlinked. AIM: To discuss relevant classification systems and the relationship between diagnosis and classification and to find out what kind of relationship is the best one for psychiatry. METHOD: The literature was searched and a conceptual analysis was performed on the basis of relevant literature, manuals and principles formulated by psychiatrists. RESULTS: It is argued that deliberation, an important part of the diagnostic process, can only play a significant role if diagnosis and symptom classification are kept completely separate. In this process of deliberation there should be a role for clinical phenomena such as improvement of symptoms, worsening of symptoms, objectification and reification, and psychiatrists should have the opportunity to consider whether these aspects really belong to the field of psychiatry. CONCLUSION: In psychiatry the relationship between diagnosis and symptom classification is not clear-cut. However, since deliberation plays a major role in psychiatric diagnosis, it is important that psychiatrists continue to keep diagnosis separate from symptom classification. Unlike other medical specialists, psychiatrists sometimes classify an illness before making a diagnosis. Existing guidelines and an all-embracing guideline regarding diagnosis need to be harmonised. Confusion and misdiagnosis could be reduced if classifications from two classification systems were to be included in medico-psychiatric diagnosis.

A systematic review of the literature about competence and poor insight.

OBJECTIVE: Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders. METHOD: A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted. RESULTS: Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients. CONCLUSION: Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent.

[Perspectives on patient competence in psychiatry: cognitive functions, emotions and values]. / Perspectieven op wilsbekwaamheid in de psychiatrie: cognitieve functies, emoties en waarden.

BACKGROUND: Informed consent, a central concept in the doctor-patient relationship, is only valid if it is given by a competent patient. AIM: To review the literature on competence or decision-making capacity in psychiatry. METHOD: We studied the international literature and relevant Dutch material such as health acts and medical guidelines. RESULTS: We found a consensus in the literature about the assessment criteria and the basic principles, but we did not find any consensus about the exact definition of competence. We review a number of perspectives on competence. The conceptualisations of competence, particularly in the field of psychiatry, are still being debated. The best known clinical tool to assess patients' capacities to make treatment decisions is the MacArthur Competence Assessment Tool (MacCAT). CONCLUSION: There are three perspectives on competence: a cognitive perspective, a perspective concerning emotions and a perspective relating to values. Further research is needed in order to make the conceptual debate on competence relevant to psychiatric practice.

[Clozapine use and abrupt smoking cessation; a potentially life-threatening combination]. / Clozapinegebruik en abrupt stoppen met roken; een potentieel levensbedreigende combinatie.

A 58-year-old man was in a period of 3 weeks twice admitted to a general hospital with symptoms of clozapine intoxication, i.e. loss of consciousness. We are of the opinion that the patient developed clozapine intoxication because he had been prescribed clozapine (300 mg/day) and at the same time had suddenly stopped smoking. The link is confirmed in the literature. We therefore recommend that clozapine-dosage be adjusted to a patient's smoking behaviour.

Degradation of antimicrobial histatin-variant peptides in Staphylococcus aureus and Streptococcus mutans.

Histidine-free variants of salivary histatin 5 have a broad antimicrobial activity against various bacteria. In relation to a possible therapeutic application, we were interested in the susceptibility of these small peptides (14 amino acids long) to microbial proteinases and whether this affects their antimicrobial activity. Analyses by SDS-PAGE of supernatants of peptide-bacteria incubation showed a reduction in protein bands within 15 minutes' incubation, as a result of cellular internalization. Degradation products of dhvar1 and dhvar2 appeared within one hour in the supernatants of Streptococcus mutans and Staphylococcus aureus. In contrast, the variants dhvar3 and dhvar4 were more resistant to degradation under the same conditions. MALDI-TOF analyses identified cleavage of dhvar1 and dhvar2 at Glu(6). The N-terminal peptide part (1-6) of dhvar1 and 2 showed no bactericidal activity, while peptide fragment (7-14) showed a highly reduced bactericidal activity.

Histatin 5 and derivatives. Their localization and effects on the ultra-structural level.

Histatins, a family of cationic peptides present in saliva, are active against the opportunistic yeast Candida albicans. The mechanism of action is still unclear. Histatin 5 and more potent synthetic variants, dhvar4 and dhvar5, were used to study localization and effects on morphology on the ultra-structural level. Although all peptides induced leakage, no association with the plasma membrane, indicative for permanent pores, was observed with immuno-gold-labeling. Freeze-fracturing showed severe changes of the plasma membrane. Together with, for the dhvars, the loss of intracellular integrity, this suggests that leakage may be a secondary effect rather than an effect of formation of permanent pores.

Effects of histatin 5 and derived peptides on Candida albicans.

Three anti-microbial peptides were compared with respect to their killing activity against Candida albicans and their ability to disturb its cellular and internal membranes. Histatin 5 is an anti-fungal peptide occurring naturally in human saliva, while dhvar4 and dhvar5 are variants of its active domain, with increased anti-microbial activity. dhvar4 has increased amphipathicity compared with histatin 5, whereas dhvar5 has amphipathicity comparable with that of histatin 5. All three peptides caused depolarization of the cytoplasmic and/or mitochondrial membrane, indicating membranolytic activity. For the variant peptides both depolarization and killing occurred at a faster rate. With FITC-labelled peptides, no association with the cytoplasmic membrane was observed, contradicting the formation of permanent transmembrane multimeric peptide pores. Instead, the peptides were internalized and act on internal membranes, as demonstrated with mitochondrion- and vacuole-specific markers. In comparison with histatin 5, the variant peptides showed a more destructive effect on mitochondria. Entry of the peptides and subsequent killing were dependent on the metabolic state of the cells. Blocking of the mitochondrial activity led to complete protection against histatin 5 activity, whereas that of dhvar4 was hardly affected and that of dhvar5 was affected only intermediately.

Evaluation of the use of xanthan as vehicle for cationic antifungal peptides.

Oral candidiasis frequently occurs in individuals with dry mouth syndrome (xerostomia), in immunocompromised patients and in denture wearers. The aim of this study was to develop a formulation which will prolong the retention time of antimicrobial agents at the site of application. The activity against Candida albicans of a synthetic cationic peptide dhvar 1, based on the human fungicidal salivary peptide histatin 5, was tested either in a mixture with the bioadhesive polymer xanthan, or after covalent coupling to this polymer. The presence of xanthan resulted in an increase of the LC50 value of the peptide from 2.6 (S.D.=0.6) to 5.8 (S.D.=4.0). Covalent coupling caused an additional increase of the LC50 value to 18.4 (S. D.=6.7). Coupling caused a reduction of the viscosity and elasticity of the xanthan solution related to the applied concentration of the coupling agent. Incubation of the peptide with clarified human whole saliva resulted in proteolytic degradation of the peptide. In the presence of xanthan the degradation occurred more slowly. It was concluded that xanthan is an appropriate vehicle for antimicrobial peptides in a retention increasing formulation.