Psychiatrists' Perspectives on Prescription Decisions for Patients With Personality Disorders.

There is currently insufficient evidence for the use of a specific pharmacological treatment for personality disorders (PD). The research literature lacks a systematic exploration of clinicians' experiences of pharmacological treatment of PD. The aim of the qualitative study was to examine how psychiatrists make decisions about pharmacological treatment for patients with PD. The interviews were analyzed using inductive thematic analysis. The results showed that ambiguous guidelines had the effect that the psychiatrists often relied on their own experience, or that of their colleagues. As a basis for decisions concerning drug treatment, an interpersonal component was also identified. Some of the psychiatrists in the current study argued that medications may be part of the alliance-building with the patient and that medications were a way of tying the patient to the clinic. Our findings show that it is important to work on how the clinical guidelines should be implemented in practice.

Children subjected to family violence: A retrospective study of experiences of trauma-focused treatment.

Exposure to adverse childhood experiences is a risk factor for the development of serious psychiatric and somatic illness. Although trauma-focused therapy is effective in reducing symptoms, not all children benefit from it. To improve treatment efficacy, the children's perspective on what they perceive as helpful versus hindering is necessary. This study aimed, retrospectively, to explore how children exposed to family violence experienced treatment at the Child and Adolescent Mental Health Service. Seventeen children and youths were interviewed 4-5 years after treatment. The thematic analysis resulted in five themes: confusion, the need to feel heard, fear of consequences, feelings of pain, and identifying oneself as an agent. The results emphasize the importance of the therapeutic relationship, and that trust, genuine interest, and reciprocity are necessary for the child to engage in treatment. However, neither the child's own agency nor external obstacles such as continuous exposure to abuse should be underestimated in terms of the child's engagement.

"We have to be the link between everyone": A discursive psychology approach to defining registered nurses' professional identity.

BACKGROUND: The occupational health and safety of registered nurses is unsatisfactory, often including high work demands in combination with insufficient acknowledgement. Implicit expectations influence their working conditions, many of which are set by the nurses themselves. Therefore, we aimed to explore how professional identity was discursively constructed by Swedish registered nurses in research interviews about night shift work. DESIGN AND METHODS: Ten semi-structured interviews with registered nurses were analysed using a discursive psychology approach. The Standards for reporting qualitative research guided the reporting. RESULTS: The professional identity of registered nurses included a theoretical professional aspect as well as a unique experience-based competence. With their overview and breadth of competence, registered nurses constitute the hub of healthcare activities, also mastering tasks in the fields of other health professions. This opacity of professional boundaries is associated with boundless expectations of the registered nurse. Additionally, the professional identity stipulates always putting the patient's best interests first, and one's own needs second.

Psychiatrists' Experience of Vocational Rehabilitation for Patients with Mental Illness.

The aim of this study was to explore psychiatrists' experience of vocational rehabilitation for patients with mental illness. The study employed a qualitative design to explore psychiatrists' experience of vocational rehabilitation. Ten psychiatrists, five women and five men, 33-62 years of age (median 40), were interviewed. All of them worked with patients at Sahlgrenska University Hospital. The interviews were analyzed using inductive thematic analysis. All participants considered vocational rehabilitation to be of great importance for patients' well-being and health. The results were characterized by two opposite experiences: frustration and agency, these were the two main themes in the analysis. All narratives embraced both experiences, but some reflected more frustration and others more agency. In order for the psychiatrist to master the assignment, there is a need for further training and supervision. The psychiatrist's role, as well as other professional roles within the team, requires clarification, and the support from rehabilitation coordinators and occupational therapists should be enhanced. There is a need for improved cooperation with external actors.

Children and parents with psychosis-Balancing between relational attunement and protection from parental illness.

BACKGROUND: Few studies have explored the experiences of young children and their parents with psychosis. The aim of the present study was to explore parent and child mental health and the parent-child relationship from the perspectives of children and their parents with psychosis. METHODS: The present study had a multiperspectival qualitative design. Seven children (aged 8-15 years) and their six parents with psychosis were interviewed individually. Data were analyzed according to interpretative phenomenological analysis. RESULTS: Children were found to have a limited understanding of the parent's illness. While both parents and children described the illness as part of ordinary life and focused on improvements, there was incoherence both within and between interviews. Parent-child relationships appeared to be nonhierarchical and to vary in terms of attunement and distance, which in turn seemed to be associated with the child's well-being. CONCLUSION: The findings contribute multiperspectival insights into lived experiences of young children and parents with psychosis. Nurses are in a key position to recognize the children's needs for continuous adult support and to promote communication about the illness.

Parents with psychosis and their children: experiences of Beardslee's intervention.

To meet children's needs for information and support when a parent has a mental illness, Beardslee's family intervention was implemented in Swedish psychosis care. The present study aimed to gain understanding of how parents' with psychosis and their children experienced having taken part in Beardslee's family intervention. The study followed COREQ guidelines. Semi-structured interviews were conducted with 15 participants (8 parents with psychosis and 7 children) who had participated in the family intervention. Data were analysed with content analysis. Results showed that the parents perceived that the intervention had contributed to improved illness knowledge, communication, and understanding in the family. They also appreciated receiving support in finding an age-adapted way of explaining their illness, but asked for structured follow-ups in order to maintain communication. However, comparing parents' and children's interviews led to discrepancies in perceptions of the overall benefits of the intervention. In conclusion, parents with psychosis need continual support in talking to their children about their illness. Furthermore, discrepancies between parents' and children's interviews show the importance of multi-perspective data collection when studying intervention effects.

Mental Health Professionals' Perceptions of Parenting by Service Users with Psychosis.

Despite extensive needs, interventions for parents with psychosis are rarely offered, poorly described, and vary between offering instrumental and emotional support. To improve the design of interventions offered to families with parental psychosis, more knowledge is needed. The aim of this study was to gain knowledge about mental health professionals' perceptions of parenting by patients with psychosis. Eleven mental health professionals educated in family interventions were interviewed using a semi-structured interview guide and the material underwent inductive thematic analysis. Results showed that the professionals described the patients parenting as characterized by difficulties in providing security and predictability, taking part in and organizing family life, and to focus on the child's needs. The difficulties were described as related to specific symptoms such as voice hearing, cognitive impairments, anxiety, and paranoia. As a vast amount of research stresses the psychosocial basis of psychosis and the interpersonal causes of its symptoms, parenting difficulties in people with psychosis could benefit from being addressed from a relational perspective. Accordingly, parents with psychosis should be offered interventions that enable them to create positive parental role models, develop reflective functioning, and identify situations in which their symptoms might hinder positive parenting. Many of these needs are unmet by interventions offered in adult psychosis services today.

A patient perspective on recurrent or prolonged contact with psychiatric inpatient care for affective disorder.

BACKGROUND: The aim of this qualitative study was to explore why some patients receive recurrent or prolonged psychiatric inpatient care, based on the experiences of the patients themselves. METHODS: The participants were recruited at an outpatient clinic at the department of psychiatry for patients with affective disorders at Sahlgrenska University Hospital, Sweden. Ten patients, nine women and one man, aged 22-61 years, agreed to participate. A semi-structured interview guide was used during the interviews, which were audiotaped, transcribed, and analyzed using interpretative phenomenological analysis. RESULTS: The four themes that emerged were Difficulties in affective regulation, where the informants reported difficulty in managing their emotions, with the possible consequence of admission to inpatient care; Relational sensitivity, concerning a sensitivity to relationships with healthcare professionals and a need for a secure therapeutic rapport; Resignation, characterized by passivity and depression; and Ambivalence towards responsibility, where ambivalence about their responsibility could lead to failure to initiate change. CONCLUSIONS: More options beside inpatient care should be available in cases of an urgent need for help. A stable care structure, good cooperation, and long-term planning based on individual needs are pivotal. In the planning of psychiatric care, consideration must be given to the patient's relational sensitivity. By encouraging patients to actively seek help, we can counteract their resistance and achieve a more effective contact with psychiatric services.

Gi protein functions in thalamic neurons to decrease orofacial nociceptive response.

Orofacial pain includes neuronal pathways that project from the trigeminal nucleus to and through the thalamus. What role the ventroposterior thalamic complex (VP) has on orofacial pain transmission is not understood. To begin to address this question an inhibitory G protein (Gi) designer receptor exclusively activated by a designer drug (DREADD) was transfected in cells of the VP using adeno-associated virus isotype 8. Virus infected cells were identified by a fluorescent tag and immunostaining. Cells were silenced after injecting the designer drug clozapine-n-oxide, which binds the designer receptor activating Gi. Facial rubbing and local field potentials (LFP) in the VP were then recorded in awake, free moving Sprague Dawley rats after formalin injection of the masseter muscle to induce nociception. Formalin injection significantly increased LFP and the nociceptive behavioral response. Activation of DREADD Gi with clozapine-n-oxide significantly reduced LFP in the VP and reduced the orofacial nociceptive response. Because DREADD silencing can result from Gi-coupled inwardly-rectifying potassium channels (GIRK), the GIRK channel blocker tertiapin-Q was injected. Injection of GIRK blocker resulted in an increase in the nociceptive response and increased LFP activity. Immunostaining of the VP for glutamate vesicular transporter (VGLUT2) and gamma-aminobutyric acid vesicular transporter (VGAT) indicated a majority of the virally transfected cells were excitatory (VGLUT2 positive) and a minority were inhibitory (VGAT positive). We conclude first, that inhibition of the excitatory neurons within the VP reduced electrical activity and the orofacial nociceptive response and that the effect on excitatory neurons overwhelmed any change resulting from inhibitor neurons. Second, inhibition of LFP and nociception was due, in part, to GIRK activation.

Perceptions and Experiences of an Attachment-Based Intervention for Parents Troubled by Intimate Partner Violence.

It is known that intimate partner violence (IPV) negatively affects both parental capacity and children's well-being, but few studies have focused on the experiences of those taking part in family interventions focused on IPV. In this study, 26 parents (16 mothers and 10 fathers) with a history of IPV participated in focus groups concerning their attachment-based group intervention experience in the program Parenting and Violence. The transcripts, subjected to thematic analysis, showed that participants experienced the intervention as supportive and confirming of their role as parents. Parents described feeling more in control, more self-confident, more skilled in communicating, and more able to provide security for their children. However, they also expressed a need for continuing support to maintain their improved parenting strategies.

Role for the Ventral Posterior Medial/Posterior Lateral Thalamus and Anterior Cingulate Cortex in Affective/Motivation Pain Induced by Varicella Zoster Virus.

Varicella zoster virus (VZV) infects the face and can result in chronic, debilitating pain. The mechanism for this pain is unknown and current treatment is often not effective, thus investigations into the pain pathway become vital. Pain itself is multidimensional, consisting of sensory and affective experiences. One of the primary brain substrates for transmitting sensory signals in the face is the ventral posterior medial/posterior lateral thalamus (VPM/VPL). In addition, the anterior cingulate cortex (ACC) has been shown to be vital in the affective experience of pain, so investigating both of these areas in freely behaving animals was completed to address the role of the brain in VZV-induced pain. Our lab has developed a place escape avoidance paradigm (PEAP) to measure VZV-induced affective pain in the orofacial region of the rat. Using this assay as a measure of the affective pain experience a significant response was observed after VZV injection into the whisker pad and after VZV infusion into the trigeminal ganglion. Local field potentials (LFPs) are the summed electrical current from a group of neurons. LFP in both the VPM/VPL and ACC was attenuated in VZV injected rats after inhibition of neuronal activity. This inhibition of VPM/VPL neurons was accomplished using a designer receptor exclusively activated by a designer drug (DREADD). Immunostaining showed that cells within the VPM/VPL expressed thalamic glutamatergic vesicle transporter-2, NeuN and DREADD suggesting inhibition occurred primarily in excitable neurons. From these results we conclude: (1) that VZV associated pain does not involve a mechanism exclusive to the peripheral nerve terminals, and (2) can be controlled, in part, by excitatory neurons within the VPM/VPL that potentially modulate the affective experience by altering activity in the ACC.

Individual experiences following a 6-month exercise intervention: A qualitative study.

PURPOSE: Dropout is a common problem in various exercise interventions. The individual's experience is believed to greatly impact dropout, yet little is known about the individual experiences of taking part in exercise interventions. The aim of this study was to examine individuals' experiences following a self-determination theory-based exercise intervention in order to gain understanding of how standardized interventions can be adjusted to fit individuals' specific needs, capacities, and circumstances. METHODS: A qualitative approach with semi-structured interviews was conducted with eight informants (three male and five female) aged between 26 and 47 years, whom all had participated in a 6-month exercise intervention with individual coaching based on self-determination theory and motivational interviewing. The interviews were analyzed thematically with an inductive approach. RESULTS: Aspects that influenced the informants' motivation and participation in the exercise intervention were linked to three themes: the frames of the intervention, measurable changes, and the individual's context. The themes present information about the process and to what extent the informants felt that the intervention was adapted to fit their lives and needs. CONCLUSIONS: This study emphasizes the importance of individualizing exercise interventions to support individuals' diverse capacities and psychological needs.

Mental health professionals' views of the parents of patients with psychotic disorders: a participant observation study.

As a consequence of the deinstitutionalisation of mental health services, family members have become an important part of the care system. However, little is known about mental health professionals' perceptions of these family members. The aim of this study was to explore professionals' views of one particular group, the parents of patients with psychotic disorders. Because sensitive issues such as professionals' perceptions of parents can be difficult to capture via interviews or self-report instruments, we conducted participant observation of 20 multi-professional team meetings. The observations were carried out during 2011 at a psychiatric care unit specialised in working with patients with psychosis. Approximately 10 inpatients and outpatients were discussed in each team meeting. All conversations about the patients' parents were documented with field notes that were later analysed using inductive thematic analysis. Through the analysis, a complex and multi-faceted image emerged of parents as seen by mental health professionals. Some parents were described as a helpful resource, but others were thought to hinder treatment. Conflicts between staff members and parents were commonly due to their differing views on the treatment, particularly the medical treatment, of the patient. Other parents were described as causing the patient emotional pain and some parents were perceived as neglectful or abusive. These findings highlight the crucial role mental health professionals play in identifying families' particular needs and capacities to provide interventions that effectively address each specific situation. Professionals should also recognise families with adverse experiences and help parents fulfil their potential to become resources for their children with psychosis.

'I divide life into different dimensions, one mental and one physical, to be able to handle life, you know?' Subjective accounts of the content of psychotic symptoms.

BACKGROUND: Previous research indicates that the content of psychotic symptoms is of significant importance for the individual who experiences them. However, there are limitations concerning the use of self-report instruments for capturing experiences that are of highly personal nature. The aim of this study was to provide a deeper understanding of how individuals with psychosis make sense of the content of their psychotic symptoms. METHOD: Semi-structured interviews were conducted with 12 individuals, some of whom were experiencing active symptoms and some of whom had experienced symptoms within the last 12 months. The interviews explored the individuals' understanding of psychotic symptoms in terms of the content and the possible meaning of the content. All participants were patients at a unit specializing in psychosis. The study applied interpretive phenomenological analyses to highlight the subjective understanding of the content of psychotic symptoms. RESULTS: Interpersonal experiences were a consistent theme in participants' understanding of the content of their psychotic symptoms. Grandiose content was understood as being related to lack of relationships and helplessness, whereas harassing content was related to experiences of being abused. Commanding content was linked to emotional consequences of intrusive relationships and to distressing life events. Supportive content was viewed as a substitute for real-life persons. CONCLUSIONS: These results support previous findings suggesting that the content of psychotic symptoms is related to interpersonal experiences. The study highlights the importance of validating the patient's own knowledge and interpretations of symptoms.

Attachment styles and symptoms in individuals with psychosis.

BACKGROUND: The capacity to manage affects is rooted in early interactions with caregivers, which in adulthood are internalized as different attachment styles. Few studies have explored associations between all four attachment styles and symptoms. AIM: Our aim was to investigate the relations between the four attachment styles and psychological distress in a group of people with psychosis. METHOD: In a cross-sectional study, associations between self-reported attachment style and symptoms in a psychosis group were explored. Attachment styles were measured with the Relationship Questionnaire (RQ) and symptoms were assessed with the revised version of the Symptom Checklist (SCL-90R) RESULTS: The analyses showed a significant positive association between preoccupied attachment and the severity of symptoms. Furthermore, the analyses indicated significant positive associations between preoccupied attachment and the subscales measuring depression, anxiety, interpersonal sensitivity, paranoia and psychoticism. We also found significant positive associations between fearful attachment and both interpersonal sensitivity and psychoticism. CONCLUSION: The associations between attachment styles and symptoms found here are consistent with those of previous studies. It could be important for clinicians to identify patients' attachment styles. Such knowledge would help mental health professionals to understand better the patients' capacity to handle distress and help professionals to address interventions aiming to target each patient's specific needs.

Effects of the two-way communication checklist (2-COM): a one-year cluster randomized study in a group of severely mentally ill persons.

BACKGROUND: In a health-care service with the emphasis on improvement related to functioning and well-being, the communication process between patient and professionals is essential. There is a lack of research on this matter. AIM: The aim was to investigate, in a group of severely mentally ill persons, whether the use of a simple communication tool could influence the sense of empowerment, satisfaction with care, therapeutic alliance and unmet needs. METHOD: The study had a cluster randomized design. The intervention was a communication tool (2-COM) applied in two teams during one year. In a comparison group of two other teams, the treatment was as usual. At baseline, after six months, and after one year, assessments were made. RESULTS: After one year the 2-COM groups seemed to have a larger reduction in unmet needs compared to the treatment-as-usual group. However, there were large problems with attrition in the study, and it was not possible to draw relevant conclusions. CONCLUSIONS: The methodological problems were substantial, and the study may be considered as a pilot study. In a main study the researchers ought to take control over the selection of patients on the basis of the experiences from this study.

Life history interviews with 11 boys diagnosed with attention-deficit/hyperactivity disorder who had sexually offended: a sad storyline.

Little is known of the possible relationship between a diagnosis of attention-deficit/hyperactivity disorder (ADHD) and sexually offensive behavior in adolescents. Our aim was to understand how adolescents with ADHD who had sexually offended described their childhood experiences and spoke about their diagnostic symptoms. The boys' early lives and relations were unpredictable, and emotional, physical, and sexual limits had been crossed. However, many boys saw themselves or their diagnosis, rather than their parents, school, or "society," as the underlying cause of their behavior. They used different strategies, for example repressing memories or regarding traumatic experiences as normal, to manage their lives. Most boys had difficulty with emotions and expressed sadness or frustration through anger. They spoke of being inattentive and restless in school and impulsive before and during their sexual offenses. The psychiatric assessment was described as a "messy" experience that strengthened their belief that something was wrong with them. Some had incorporated neuropsychiatric language into otherwise limited vocabularies and tended to use their diagnostic symptoms to excuse their offenses. The focus in the assessment on the boys themselves and their behaviors may darken their understandings of themselves, their experiences of abuse, and the offenses they have committed. Further research is needed into the possible consequences of a diagnosis of ADHD on adolescents' self-image and sense of self-control.