Measurement Based Care in a first episode psychosis program: Development of an algorithm of care based on the Clinical Global Impressions Scale.

INTRODUCTION: Adherence to therapeutic guidelines in psychiatry is anchored and facilitated by rating scales. However, they are rarely used in routine care, particularly for psychotic disorders. Consequently, adherence to treatment guidelines are not ideal and patient outcomes are often sub-optimal. In this study, we used the clinician-rated Clinical Global Impressions Scale (CGI) to implement a measurement-based care (MBC) approach and derive indices of quality of care at a first episode psychosis (FEP) program. METHODS: At the individual level, an algorithm was created using CGI scores and their changes over time to define the concept of Patient Requiring Clinical Attention (PRCA) that encompasses several categories (e.g. episode of severity, treatment inertia, or treatment resistance). At the service level, CGI scores were used to derive several indices of quality of care: severity of illness and its change over time, conformity to the use of low doses of antipsychotic medications, and clozapine offer index. RESULTS: 135 Patients were included in this study of whom 19 patients were identified as PRCA. Of these, 12 (63%) received timely medication, and 7 (37%) were suspected cases of therapeutic inertia. Additionally, 15 patients met criteria for treatment resistance of whom 7 were offered clozapine (47%). At the service level, the average CGI improved by 2 points from baseline to month 1 and average doses of antipsychotic medications prescribed were in line with prescription guidelines for FEP patients. CONCLUSION: The proposed CGI-based treatment algorithm and service evaluation strategy can help to optimize quality care and services for patients.

Pragmatic implementation of the Clinical Global Impression Scale of Severity as a tool for measurement-based care in a first-episode psychosis program.

INTRODUCTION: Measurement-based care (MBC) is an evidence-based practice wherein clinical decisions are informed by patient data collected throughout treatment. MBC has yielded superior patient outcomes compared to standard care. However, the implementation of MBC in the day-to-day practice, particularly in psychotic disorders, poses several challenges. This study evaluates the clinician-rated Clinical Global Impressions Scale of Severity (CGI-S), for MBC implementation at a first-episode psychosis program. METHODS: The CGI-S was evaluated in the context of routine care on fidelity to practice, inter-rater reliability among psychiatrists and concurrent validity with scales measuring different domains of psychopathology (SAPS, SANS, GAF, BPRS, PANSS-6). RESULTS: A high fidelity to practice (67%) and inter-rater reliability was found (rwg = 0.92). CGI-S correlations were significant and strongest with BPRS (r = 0.55; p < 0.01), GAF (r = 0.53; p < 0.01), SAPS (r = 0.52, p < 0.01), and PANSS-6 (r = 0.41; p < 0.05) scores. However, correlations with SANS and PANSS-6 Negative sub-scale were weak. CONCLUSION: Findings suggest the CGI may be used to overcome important barriers towards MBC implementation within the context of first episode psychosis. However, as suggested by data, further improvements in capturing negative symptoms by rating clinicians are needed. TWITTER: A novel strategy for measurement-based care to optimize treatment for individuals with first episode psychosis and related psychotic disorders.

Generalizing Duchenne to sad expressions with binocular rivalry and perception ratings.

Discrete emotion theories emphasize the modularity of facial expressions, while functionalist theories suggest that a single facial action may have a common meaning across expressions. Smiles involving the Duchenne marker, eye constriction causing crow's feet, are perceived as intensely positive and sincere. To test whether the Duchenne marker is a general index of intensity and sincerity, we contrasted positive and negative expressions with and without the Duchenne marker in a binocular rivalry paradigm. Both smiles and sad expressions involving the Duchenne marker were perceived longer than non-Duchenne expressions, and participants rated all Duchenne expressions as more affectively intense and more sincere than their non-Duchenne counterparts. Correlations between perceptual dominance and ratings suggested that the Duchenne marker increased the dominance of smiles and sad expressions by increasing their perceived affective intensity. The results provide evidence in favor of Darwin's hypothesis that specific facial actions have a general function (conveying affect intensification and sincerity) across expressions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An algorithmic approach to the management of insomnia in patients with schizophrenia.

BACKGROUND: Insomnia is an important problem in patients with schizophrenia and is an emerging area of interest for researchers. We propose a treatment algorithm that synthesizes the various psychological and pharmacological interventions for insomnia in this population. METHODS: Our selective literature review incorporates English language articles from 4 medicine databases through May 2016. Selected articles discuss risk factors and treatments for insomnia, as well as comorbid sleep disorders that coexist in this population. RESULTS: Various lifestyle factors and comorbid sleep disorders may predispose patients with schizophrenia to insomnia. Cognitive-behavioral therapy for insomnia shows promising results in treating insomnia in patients with schizophrenia spectrum disorders. Additionally, studies of eszopiclone and melatonin have yielded significant results in short-term trials that evaluated both subjective and objective insomnia symptoms. CONCLUSIONS: We have summarized the relevant literature regarding the treatment of insomnia in this patient population and propose an algorithm comprising 6 sequential steps, beginning with the assessment of sleep complaints and medication adherence. This is followed by a targeted treatment of any co-occurring sleep disorders, and ends with psychoeducation, cognitive-behavioral therapy, and pharmacotherapy. This algorithm provides a detailed guideline to improve the assessment and therapeutic intervention for managing insomnia among patients with schizophrenia.

Theory of mind in adolescents with early-onset schizophrenia: correlations with clinical assessment and executive functions.

OBJECTIVE: We examined Theory of Mind (ToM) abilities in adolescents with early-onset schizophrenia (EOS) and their correlation with clinical findings and Executive Functions (EF). METHODS: The ToM abilities of 12 adolescents with EOS were compared with those of healthy participants matched in age and educational level. The Moving Shapes Paradigm was used to explore ToM abilities in three modalities: random movement, goal-directed movement and ToM - scored on the dimensions of intentionality, appropriateness and length of each answer. EF was tested using Davidson's Battery and the clinical psychopathology with the Positive and Negative Syndrome Scale (PANSS). RESULTS: Adolescents with EOS were significantly more impaired than controls in the three dimensions evaluated for the goal-directed and ToM modalities. Regarding the random movement modality, the only difference was in appropriateness (p<0.01). No correlation with age or level of education was evident for ToM skills. Total PANSS score was negatively correlated with appropriateness score for the goal-directed (p=0.02) and ToM modalities (p=0.01). No correlation existed between performance in the ToM Animated Tasks and positive, negative or disorganisation PANSS subscores. No correlations were found among the three scores in the Moving Shapes Paradigm and any measures of the accuracy of the three tasks assessing EF. CONCLUSION: Our results confirm previous findings of ToM deficits in adult individuals with schizophrenia and attest the severity of these deficits in patients with EOS.

[The Usefulness of Clonazepam as an Augmentative Treatment in a Case of Severe Childhood Onset Obsessive-Compulsive Disorder]. / Siddetli Bir Çocukluk Çagi Baslangiçli Obsesif Kompulsif Bozukluk Olgusunda Güçlendirme Tedavisi Olarak Klonazepam.

The goal of this study is to report on the treatment of obsessive-compulsive disorder (OCD), a chronic disabling condition that often presents during childhood and adolescence. Reports on adults using clonazepam for the treatment of OCD are more numerous than on children. Clonazepam as an augmentative treatment in OCD is still controversial. Our aim is to illustrate in a case report the efficacy of clonazepam as an augmentative treatment for severe childhood onset OCD. We report on the case of a young teenage girl with an extremely severe form of obsessive-compulsive disorder (score of 32 on the Children's Yale-Brown Obsessive Compulsive Scale), who, after a mild improvement with a combination of serotonin recapture inhibitors and second generation antipsychotics at high doses, has responded to clonazepam (3mg/day) augmentation of sertraline (200mg/day) and olanzapine (15mg/day). Clonazepam was effective not only in reducing anxiety symptoms, but also in lowering compulsions and obsessions frequency within 6 weeks with a drop in the Children's Yale-Brown Obsessive Compulsive Scale of 16 points. It may be asserted that clonazepam could be useful in the initial stage for severe OCD in young patients.

Self-perceived cognitive functioning does not correlate with objective measures of cognition in schizophrenia.

BACKGROUND: Growing interest in the study of self-perceived cognitive deficits in schizophrenia has been recently observed. The authors validated in a previous study the Subjective Scale To Investigate Cognition into Schizophrenia Tunisian Arabic Version (SSTICS_tun_arab), a self-questionnaire established to collect cognitive complaints in patients with schizophrenia. OBJECTIVE: The aim of the present study was to explore the relationship between the SSTICS_tun_arab scores and objective cognitive performances. METHODS: One hundred four patients with schizophrenia spectrum disorders were administered measures of the Positive and Negative Syndrome Scale, the Global Assessment Functioning Scale, and the Calgary Depression Scale as well as measures of the SSTICS_tun_arab and a cognitive battery. RESULTS: No correlations were found between objective neuropsychologic performances and scores of the SSTICS_tun_arab. CONCLUSIONS: Our findings support the hypothesis of independence of self-perceived cognitive functioning from objective neuropsychologic deficits in schizophrenia. They also suggest that insight of mental illness seems to be not a unitary concept but more likely to be divided in different aspects including cognitive insight.

Confirmation for a delayed inhibition of return by systematic sampling in schizophrenia.

Inhibition of return (IOR) is a phenomenon thought to reflect a mechanism to protect the organism from redirecting attention to previously scanned insignificant locations. A number of studies reported altered IOR in schizophrenia patients with a reduction of its amplitude. However, incomplete sampling of stimulus onset asynchronies (SOAs) makes data on IOR time course incomplete. We examined 14 stabilized young patients with recent onset schizophrenia and 16 healthy controls matched for gender, age, and years of education. Schizophrenia patients (13 males, 1 female) had a mean age of 26.3+/-5.8 years and a mean number of years of study of 9.6+/-3.6. Their illness had a mean duration of 147 weeks. Patients displayed moderate overall slow reaction times (387 ms) in comparison with controls (322 ms). Onset of IOR was found to be delayed in schizophrenia patients appearing between 700 and 800 ms following the cue onset while it appeared at 300 ms in controls. In patients, IOR was constant up to 1100 ms; however, its amplitude was weak with an average of 6 ms. Validity effects (overall and at each SOA value) were uncorrelated to age, years of study, duration of illness, or total or subscale scores on the Positive and Negative Syndrome Scale.

The self-assessment scale of cognitive complaints in schizophrenia: a validation study in Tunisian population.

BACKGROUND: Despite a huge well-documented literature on cognitive deficits in schizophrenia, little is known about the own perception of patients regarding their cognitive functioning. The purpose of our study was to create a scale to collect subjective cognitive complaints of patients suffering from schizophrenia with Tunisian Arabic dialect as mother tongue and to proceed to a validation study of this scale. METHODS: The authors constructed the Self-Assessment Scale of Cognitive Complaints in Schizophrenia (SASCCS) based on a questionnaire covering five cognitive domains which are the most frequently reported in the literature to be impaired in schizophrenia. The scale consisted of 21 likert-type questions dealing with memory, attention, executive functions, language and praxia. In a second time, the authors proceeded to the study of psychometric qualities of the scale among 105 patients suffering from schizophrenia spectrum disorders (based on DSM- IV criteria). Patients were evaluated using the Positive and Negative Syndrome Scale (PANSS), the Global Assessment Functioning Scale (GAF scale) and the Calgary Depression Scale (CDS). RESULTS: The scale's reliability was proven to be good through Cronbach alpha coefficient equal to 0.85 and showing its good internal consistency. The intra-class correlation coefficient at 11 weeks was equal to 0.77 suggesting a good stability over time. Principal component analysis with Oblimin rotation was performed and yielded to six factors accounting for 58.28% of the total variance of the scale. CONCLUSION: Given the good psychometric properties that have been revealed in this study, the SASCCS seems to be reliable to measure schizophrenic patients' perception of their own cognitive impairment. This kind of evaluation can't substitute for objective measures of cognitive performances in schizophrenia. The purpose of such an evaluation is to permit to the patient to express his own well-being and satisfaction of quality of life.

Candidate genes and neuropsychological phenotypes in children with ADHD: review of association studies.

BACKGROUND: We reviewed systematically the results of genetic studies investigating associations between putative susceptibility genes for attention-deficit hyperactivity disorder (ADHD) and neuropsychological traits relevant for this disorder. METHODS: We identified papers for review through the PubMed database. RESULTS: Twenty-nine studies examined 10 genes (DRD4, DAT1, COMT, DBH, MAOA, DRD5, ADRA2A, GRIN2A, BDNF and TPH2) in relation to neuropsychological traits relevant for ADHD. For DRD4, the continuous performance test (CPT) and derived tasks were the most used tests. Association of high reaction time variability with the 7-repeat allele absence appears to be the most consistent result and seems to be specific to ADHD. Speed of processing, set-shifting and cognitive impulsiveness were less frequently investigated but seem to be altered in the 7-repeat allele carriers. No effect of genotype was found on response inhibition (the stop and go/no-go tasks). For DAT1, 4 studies provide conflicting results in relation to omission and commission errors from CPT and derived tasks. High reaction time variability seems to be the most replicated cognitive marker associated with the 10-repeat homozygosity. The other genes have attracted fewer studies, and the reported findings need to be replicated. LIMITATIONS: Although we aimed to perform a formal meta-analysis, this was not possible because the number of studies using the same neurocognitive endophenotypes was limited. We referred only minimally to the various theoretical frameworks in this field of research; more detail would have been beyond the scope of our systematic review. Finally, sample sizes in most of the studies we reviewed were small. Thus, some negative findings could be attributed to a lack of statistical power, and positive results should be considered preliminary until they are replicated in extended samples. CONCLUSION: Several methodological issues, including measurement errors, developmental changes in cognitive abilities, sex, psychostimulant effects and presence of comorbid conditions, represent confounding factors and may explain conflicting results.

[Attentional impairment in children with attention deficit and hyperactivity disorder]. / Dysfonctionnements attentionnels dans le trouble hyperactivité déficit de l'attention.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is a heterogeneous disorder currently defined by clinical history and behavioral report of impairment. The Attention Network test (ANT) gives measures of different aspects of the complex process of attention. AIMS: We ask if children with Attention Deficit Hyperactivity Disorder (ADHD) will show a characteristic pattern of deficits on this test. METHODS: The sample included 40 children (M=9 years) who performed the "Attention network test". Children with an ADHD diagnosis (N=20) were compared to a control group (N=20). RESULTS: The group of children with ADHD showed slower reaction times in all conditions (mean RT=866 ms; SD=234,063). Children with ADHD showed a significant impairment in their executive control system compared to healthy subjects, with slower reaction times in incongruent conditions and lower accuracy scores (RT=1064 ms; F(1.38) p=0.02). Our results showed that spatial orienting and alerting in ADHD was no different than controls (p=0,68). ADHD group showed a greater variable response (p=0,0001). CONCLUSION: The present study showed that impairment in executive control system and variability measures are the characteristic pattern of deficits in children with ADHD.

[Adaptation of a soft-signs scale to children with autism spectrum disorders]. / Adaptatation d'une echelle des signes neurologiques a l'enfant souffrant de trouble envahissant du developpement.

BACKGROUND: Neurological soft signs (NSS) are endophenotypic markers of schizophrenia, and their high prevalence in pervasive developmental disorders (PDD) support the existence of the spectrum of psychoses. These NSS were evaluated by standardized scales which were not adapted to children with PDD. AIMS: This study aimed to propose an adaptation for children of a scale of NSS already used in adults. METHODS: 21 children with PDD (11 with autistic disorder, 10 with PDD not otherwise specified) aged 6-12 years and 21 controls matched on age, sex, and cognitive level were included. Evaluating tools were NSS scale of Krebs et al. adapted after a pilot-study with the accordance of its author; the Progressive Matrices of Raven for intellectual level, and ADI-R to confirm diagnosis. RESULTS: Patients were significantly more impaired on total score (p=0,001), motor coordination (p=0,008), motor integration (p=0,000), and sensory integration (p=0,001). There were no difference between patients and controls on abnormal movements and quality of lateralization. CONCLUSION: This adaptation of Krebs et al. scale seems to be a good tool for evaluating NSS in children, especially in those with PDD. A further validation study, including a larger sample is necessary.

[Memory impairments during child and adolescent depression]. / Les troubles mnesiques dans la depression de l'enfant et de l'adolescent.

AIM: This study aimed to evaluate basic performances on verbal memory in treatment-naïve children and adolescents with depression and in healthy control subjects. METHODS: 34 children and adolescents aged 6-16 years, suffering from a first major depressive disorder (DSM IV) and 34 controls matched on sex, age and cognitive ability were evaluated. Psychiatric diagnosis was assessed with the K-SADS-PL. The Child Depression Rating Scale (CDRS) was used to assess the severity of depression. Progressive matrices of Raven were used to evaluate intelligence. Two different cognitive tasks were administered to assess semantic and working memory: digit span test, and semantic and phonemic verbal fluency. RESULTS: A significant effect of diagnosis was found for digit span: patients showed lower performance on forward (p=0,015) and backward (p=0,002) digits. No difference was found between patients and controls on verbal fluency. The young age of the sample and the first depressive episode criteria may explain the absence of severe impairment of this type of semantic and working memory. CONCLUSION: These results support the hypothesis that memory deficits in depressive disorders are partly the result of poor encoding caused by a deficit in attention.

[Cognitive remediation therapy in schizophrenia: a case report]. / Intérêts de la remédiation cognitive par REHACOM dans la schizophrénie: à propos d'un cas.

BACKGROUND: Despite progress in chemo-therapeutics, schizophrenia remains a chronic disease with occurrence of residual symptoms and drug resistance in 60% of the cases. Besides, cognitive impairment is frequent and highly correlated to social dysfunction seen in patients with schizophrenia. Several cognitive remediation programs have been elaborated. REHACOM is one of such programs. Aim of the study is to evaluate through a case control the efficiency of REHACOM towards cognitive functions. METHODS: This program has been administered to a patient suffering from undifferentiated schizophrenia which was ameliorated after drug therapy considering positive symptoms but still was complaining from cognitive deficits causing social withdrawal. RESULTS: After following the remediation program, the patient was ameliorated considering its negative symptoms as attested by an amelioration of the PANSS negative score and considering its cognitive performances on memory, attention and executive functions. We have also noticed an improvement in his self-esteem and his quality of life. CONCLUSION: This first trial of a cognitive remediation program among our patients suffering from schizophrenia using REHACOM was encouraging. Enlarging its use and designing controlled studies will be the next step of our study.

[Evaluation of correlations between cognitive performances and clinical dimensions of schizophrenia]. / Etude des corrélations entre performances cognitives et dimensions cliniques dans la schizophrénie.

BACKGROUND: Schizophrenia is characterised by positive and negative symptoms as well as thought disorders and disorganised behaviour. Multiple cognitive deficits within the areas of memory, attention and executive functions are also associated with schizophrenia. Aim of the study was to proceed to a study of correlations between clinical dimensions of schizophrenia and cognitive functions. METHODS: The authors recruited 105 patients suffering from schizophrenia spectrum disorders (DSM IV criteria). The patients were clinically stabilised, showing no depressive state at the time of the study, with no organic brain disorders and no history of drug intake. They were clinically evaluated using the PANSS and the Calgary Depression Scale. A cognitive battery was also administered. RESULTS: Positive dimension of schizophrenia was shown to be independent from any cognitive function. Disorganisation was negatively correlated to attention, working memory, long-term verbal memory and executive functions. Negative dimension was negatively correlated with working memory and executive functions. CONCLUSION: Cognition wasn't correlated to the positive dimension of schizophrenia whereas it was correlated to the negative and to the disorganisation dimension of the disease. This is probably due to overlapping of concepts.

[Tunisian adaptation of Hopkins Verbal Learning Test , Form 1]. / Adaptation tunisienne du Hopkins Verbal Learning Test Forme 1.

BACKGROUND: Memory impairment and verbal learning are the most common cognitive deficits associated with schizophrenia. Hopkins Verbal Learning Test (HVLT) is considered to be the most reliable test to asses memory and verbal learning in this mental illness. AIMS: to create one form of the HVLT which would suit our linguistic and cultural context and to study the characteristics of this test in a group of healthy subjects. METHODS: The HVLT consists of a list of 12 words belonging to 3 semantic categories and which are read orally to the subject with an immediate and differed recall. The first part of this work was to select words from a lexical database in order to create the list of the HVLT. The test was then administered to 103 subjects aged from 17- to 45-years-old (mean=27,4; SD =7,3) and having between 1 and 20 years of education ( mean=12,2; SD=5,3). RESULTS: No statistical difference was found within performances of the HVLT across gender and sex. Whereas, years of education was found to have an impact on performances. Although statistically difference was found across level of education. CONCLUSION: Our study permitted us to create one form of the HVLT which well suits our Tunisian context and which we could use to evaluate memory functions among people suffering from schizophrenia.

[The Tunisian cognitive battery for patients with schizophrenia]. / La batterie tunisienne d'évaluation cognitive dans la schizophrénie.

BACKGROUND: Cognitive disorders are common and severe in schizophrenia. They are also correlated with the functional outcome of the disease. Cognition can not be assessed during a standard clinical interview but needs to be evaluated by means of specific cognitive tasks. Aim of the study is to construct a battery of cognitive tests which is adapted to the Tunisian cultural and linguistic context and to collect normative data in Tunisian Arabic speaking healthy subjects. METHODS: We have selected and adapted cognitive tests to our socio cultural context. Then we have proceeded to the administration of these tests within a group of healthy subjects. RESULTS: the cognitive battery is composed of 7 tests: the Hopkins Verbal Learning Test, the Token test, the Zazzo test, phonemic fluency, semantic fluency, visual working memory test and number working memory test. These tests are presented with their manual of utilisation and their normative data. CONCLUSION: The Tunisian cognitive battery is believed to permit a better cognitive assessment of patients suffering from schizophrenia. Improvement of cognitive impairments in schizophrenia is associated with a better social and professional integration of these patients.