Relations between changes in safety behavior, paranoid ideations, cognitive biases, and clinical characteristics of patients with a psychotic disorder over time.

BACKGROUND: Safety behaviors, both positive (maladaptive coping behavior) and negative (avoidance behavior), are used by people with paranoid delusions to avoid perceived threats. Safety behaviors contribute to the persistence of paranoid delusions by preventing disconfirmation of threat beliefs and may influence other psychiatric symptoms. This study investigated how changes in safety behaviors are related to changes in paranoid ideation, social anxiety, depression, cognitive biases and self-esteem over time. METHODS: This study included 116 patients diagnosed with a psychotic disorder (DSM-IV) and at least moderate levels of paranoid ideations (GTPS >40).The data were collected as part of a multi-center randomized controlled trial where patients were randomized to VR-CBT (n = 58) or treatment as usual (TAU; n = 58). Assessments were completed at baseline (T0), after three months (T3) and after six months (T6). For all variables, change scores between T0 and T3 and T3 and T6 were calculated and Pearson correlations between change scores were computed. RESULTS: A decrease in total safety behavior was related to diminished paranoid ideation, social anxiety, and depression. No significant temporal associations were found between changes in safety behavior and changes in cognitive biases and self-esteem. Similar but less robust results were found for respectively negative safety behavior and positive safety behavior. CONCLUSION: Dropping safety behavior can be specifically targeted in behavioral interventions. Whereas there appears to be a relation with reduction in anxiety, paranoia, and depressive symptoms, changes in safety behavior do not seem to align with changes in cognitive thinking processes.

Exploring the role of clinical and demographic characteristics on the effects of virtual reality cognitive behavioral therapy for psychosis: A moderator analysis.

BACKGROUND: Virtual Reality cognitive behavioral therapy (VR-CBT) has proven to be an effective treatment method for paranoia and anxiety in psychosis. However, it is unknown, which individuals benefit most from VR-CBT. Previous studies examined factors affecting the treatment effect of regular CBTp, including illness duration, paranoia, depression, and pre-therapy avoidance behaviors, but results are inconsistent. The study aims to investigate the factors that influence the effectiveness of VR-CBT. METHODS: A total of 95 participants with a psychotic disorder and at least moderate paranoia (GTPS >40) were included in this explorative study. Data were collected as part of a multicenter randomized controlled trial in which participants were assigned to VR-CBT or treatment as usual (TAU). The VR-CBT group received 16 sessions of individual treatment. A moderator analysis was conducted to examine the influence of baseline demographic (age, gender, and education level) and clinical characteristics (duration of illness, paranoia, anxiety, depression, safety behavior, self-esteem, and social functioning) on treatment effects of paranoia and anxiety as measured with questionnaires and the experience sampling method (ESM) directly after treatment (12 weeks after baseline). RESULTS: More use of safety behavior at baseline resulted in greater benefits of VR-CBT on paranoid ideation and ESM paranoia. A higher age was associated with greater benefits of VR-CBT on social anxiety but not paranoia outcomes. There was no consistent evidence of moderation by any of the other sociodemographic or clinical variables for paranoid ideation and social anxiety. CONCLUSIONS: Our findings suggest that a diverse spectrum of patients, with different backgrounds and symptom severity may be able to benefit from VR-CBT. VR-CBT can be recommended to a broad spectrum of patients with psychotic disorders, and particularly those with high levels of safety behaviors, including severe avoidance, seem to benefit more.

Virtual reality cognitive-behavioural therapy versus cognitive-behavioural therapy for paranoid delusions: a study protocol for a single-blind multi-Centre randomised controlled superiority trial.

BACKGROUND: Seventy per cent of patients with psychotic disorders has paranoid delusions. Paranoid delusions are associated with significant distress, hospital admission and social isolation. Cognitive-behavioural therapy for psychosis (CBTp) is the primary psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve the effectiveness of CBTp. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is superior to waiting list. As a next step, a direct comparison with CBTp is needed. The present study aims to investigate whether VRcbt is more effective and cost-effective than regular CBTp in treating paranoid delusions and improving daily life social functioning of patients with psychotic disorders. METHODS: A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be recruited for this multicentre randomized controlled trial (RCT). Patients will be randomized to either VRcbt or standard CBTp for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8-12 week time frame. Standard CBTp also consists of maximum 16 sessions including exposure and behavioural experiments, delivered in an 8-12 week time frame. The two groups will be compared at baseline, post-treatment and six months follow-up. Primary outcome is the level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate the level of paranoid ideation and global clinical impression. DISCUSSION: Comparison of VRcbt and CBTp will provide information about the relative (cost-) effectiveness of VRcbt for this population. VRcbt may become a preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder. TRIAL REGISTRATION: Netherlands Trial Register, NL7758. Registered on 23 May 2019.

Stereotyping of medical disability claimants' communication behaviour by physicians: towards more focused education for social insurance physicians.

BACKGROUND: Physicians who hold medical disability assessment interviews (social insurance physicians) are probably influenced by stereotypes of claimants, especially because they have limited time available and they have to make complicated decisions. Because little is known about the influences of stereotyping on assessment interviews, the objectives of this paper were to qualitatively investigate: (1) the content of stereotypes used to classify claimants with regard to the way in which they communicate; (2) the origins of such stereotypes; (3) the advantages and disadvantages of stereotyping in assessment interviews; and (4) how social insurance physicians minimise the undesirable influences of negative stereotyping. METHODS: Data were collected during three focus group meetings with social insurance physicians who hold medical disability assessment interviews with sick-listed employees (i.e. claimants). The participants also completed a questionnaire about demographic characteristics. The data were qualitatively analysed in Atlas.ti in four steps, according to the grounded theory and the principle of constant comparison. RESULTS: A total of 22 social insurance physicians participated. Based on their responses, a claimant's communication was classified with regard to the degree of respect and acceptance in the physician-claimant relationship, and the degree of dominance. Most of the social insurance physicians reported that they classify claimants in general groups, and use these classifications to adapt their own communication behaviour. Moreover, the social insurance physicians revealed that their stereotypes originate from information in the claimants' files and first impressions. The main advantages of stereotyping were that this provides a framework for the assessment interview, it can save time, and it is interesting to check whether the stereotype is correct. Disadvantages of stereotyping were that the stereotypes often prove incorrect, they do not give the complete picture, and the claimant's behaviour changes constantly. Social insurance physicians try to minimise the undesirable influences of stereotypes by being aware of counter transference, making formal assessments, staying neutral to the best of their ability, and being compassionate. CONCLUSIONS: We concluded that social insurance physicians adapt their communication style to the degree of respect and dominance of claimants in the physician-claimant relationship, but they try to minimise the undesirable influences of stereotypes in assessment interviews. It is recommended that this issue should be addressed in communication skills training.

High atrial pacing impedance: efficient or wasteful? A comparison of an active and a passive fixation lead.

We compared the stimulation characteristics of two atrial fixation leads: the CPI model 4269 (n = 45) and Cordis-Telectronics model 327-752 (n = 42). The CPI lead uses an active fixation method, whereas the Cordis-Telectronics lead is fixated passively. Impedance and threshold were measured at implant and during 12 months of follow-up. P wave sensing was good with both types of leads. Follow-up of these 87 leads showed that both the impedance and threshold increased with the active leads, but not with the passive fixation leads. In the active fixation group, regardless of the high atrial pacing impedance, 93% could still be programmed to 2.5 V-0.6 msec (with a 2:1 threshold safety margin). It is concluded that the high chronic pacing impedance of the active fixation leads will be beneficial on current drain if no major increase in pacing threshold occurs simultaneously.

External vibration interference of activity based rate responsive pacemakers.

The change of the pacing rate in response to external vibration interference was assessed in four rate responsive pacemakers with a piezoelectric crystal (Medtronic Activitrax 8403, Siemens Sensolog 3, Biotronik Ergos 01, and Medtronic Legend 8417) and one with an accelerometer (CPI Excel VR 1119). They were tested in the laboratory. External vibration was simulated in vitro by exposing the different pacemakers to a controlled sinusoidal vibration force generated by a Millar pressure vibration amplifier type MGM-30 (Millar Instruments, Inc., Houston, TX, USA). All pacemakers were programmed at standard settings. Two types of vibration forces were applied: (1) one with varying amplitude but with constant vibration frequency; and (2) one with varying frequency but with constant vibration amplitude. In this manner curves of pacing rate versus vibration forces versus vibration frequency were obtained. High vibration forces and low vibration frequencies were associated with the highest pacing rate response. In this experimental setting, the pacemaker based on the accelerometer principle apparently was the least sensitive to high frequency vibrations, which are known to be related to environmental interference. It also seemed more appropriately responsive in the lower frequency range, which is more appropriate for the detection of true physiological activity.

Predictive value of the P wave at implantation for atrial fibrillation after VVI pacemaker implantation.

This study assesses the value of P wave measurements on the surface ECG at implantation, in the prediction of atrial fibrillation in VVI paced patients. From a consecutive series of 320 pacemaker implantations 172 VVI paced patients for symptomatic atrioventricular block (AVB) (n = 126; mean age 69 +/- 14) or sick sinus syndrome (SSS) (n = 56; mean age 68.6 +/- 12) and in sinus rhythm at implantation were used in this study. P wave duration in V1 is correlated with the incidence of atrial fibrillation during 5 years of follow-up. V1 at implantation was significantly longer (114.6 +/- 2.7 msec) in the patients who developed atrial fibrillation than in those who did not (91.9 +/- 2.7 msec) (P < 0.001). Although positive predictive accuracy increases progressively for higher V1 values for AVB and SSS, the negative predictive and diagnostic accuracy of V1 criteria were less in SSS. Application of the Bayes' theorem showed that in SSS the probability to develop atrial fibrillation is 33% for V1 < 110 msec and is for V1 < 90 msec still higher than that reported in DDD paced patients. In the AVB group the probability to develop atrial fibrillation is 8% for V1 < 110 msec and 6% for V1 < 100 msec. It seems, therefore, that atrial stimulation (AAI or DDD) is always indicated in SSS. In AVB with V1 < 100 msec, DDD pacing, if not needed for other indications, apparently does not offer much benefit in the prophylaxis of atrial fibrillation.

Evolution of P wave characteristics after pacemaker implantation.

This study is an investigation of the long-term effects of VVI pacing on the atrium as derived from the evolution of P wave characteristics of 285 patients. The occurrence of left and right atrial disease is demonstrated as well as the evolution of left atrial hypertrophy in some cases. A comparison is made with DDD pacing and special attention is given to the progression to atrial fibrillation.

Simultaneous bipolar pacing and sensing during EPs.

Bipolar pacing and sensing-recording on the same electrode is a problem during pacemaker implantation as well as during electrophysiological studies. A method is described that makes this possible. By using bipolar simultaneous sensing-pacing on the same electrode, the system can record local repolarization after a depolarization controlled by stimulation. The bipolar-paced evoked potential is useful as an indicator to drive a bipolar QT rate responsive pacemaker. Even more, during EPS it can be used to detect capture during tachycardia stimulation and to measure the exact refractory period.