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.