Wolfgang Wölwer

Cel pracy: Zaburzenia lękowe są istotnymi czynnikami predykcyjnymi samobójczości i uważa się je za niezależne czynniki ryzyka prób samobójczych. Występują one często u osób z cukrzycą typu 2 (T2DM) i wiążą się z dłuższym czasem trwania cukrzycy oraz gorszymi wynikami leczenia. Celem pracy było zbadanie związków między zaburzeniami lękowymi a myślami i zachowaniami samobójczymi u osób z T2DM, ocena częstości występowania samobójczości wśród osób z T2DM w wybranych europejskich krajach oraz określenie, czy zaburzenia lękowe były predyktorami aktualnych objawów samobójczości w tej populacji, przy wykorzystaniu danych z międzynarodowego badania International Prevalence and Treatment of Diabetes and Depression study (INTERPRET-DD).Metoda: Próba badawcza obejmowała 1063 osoby dorosłe z T2DM z 6 europejskich krajów. Obecność zaburzeń lękowych i samobójczości oceniano za pomocą MINI International Neuropsychiatric Interview. Grupę uczestników z aktualnym ryzykiem samobójczym porównano z grupą uczestników bez ryzyka samobójczego.Wyniki: Uczestnicy z Niemiec częściej deklarowali objawy samobójczości niż osoby z innych krajów, natomiast osoby z Serbii i Ukrainy zgłaszały je rzadziej. Depresja i zaburzenia lękowe znacząco wpłynęły na częstsze występowanie samobójczości u osób z T2DM. Agorafobia była istotnym predyktorem samobójczości przy kontrolowaniu depresji. Osoby z T2DM i współchorobowością agorafobii mieli 4,86 razy większe szanse wystąpienia objawów samobójczości niż osoby bez agorafobii.Wnioski: Agorafobia była istotnym czynnikiem predykcyjnym samobójczości u osób z T2DM.

Background: Although clinically effective treatment is available for schizophrenia, recovery often is still hampered by persistent poor psychosocial functioning, which in turn is limited by impairments in neurocognition, social cognition, and social behavioral skills. Although cognitive remediation has shown general efficacy in improving cognition and social functioning, effects still need to be improved and replicated in appropriately powered, methodologically rigorous randomized controlled trials (RCTs). Existing evidence indicates that effects can most likely be optimized by combining treatment approaches to simultaneously address both social cognitive and social behavioral processes.Objectives: To assess whether Integrated Social Cognitive and Behavioral Skill Therapy (ISST) is more efficacious in improving functional outcome in schizophrenia than the active control treatment Neurocognitive Remediation Therapy (NCRT).Methods: The present study is a multicenter, prospective, rater-blinded, two-arm RCT being conducted at six academic study sites in Germany. A sample of 180 at least partly remitted patients with schizophrenia are randomly assigned to either ISST or NCRT. ISST is a compensatory, strategy-based program that targets social cognitive processes and social behavioral skills. NCRT comprises mainly drill and practice-oriented neurocognitive training. Both treatments consist of 18 sessions over 6 months, and participants are subsequently followed up for another 6 months. The primary outcome is all-cause discontinuation over the 12-month study period; psychosocial functioning, quality of life, neurocognitive and social cognitive performance, and clinical symptoms are assessed as secondary outcomes at baseline before randomization (V1), at the end of the six-month treatment period (V6), and at the six-month follow-up (V12).Discussion: This RCT is part of the German Enhancing Schizophrenia Prevention and Recovery through Innovative Treatments (ESPRIT) research network, which aims at using innovative treatments to enhance prevention and recovery in patients with schizophrenia. Because this study is one of the largest and methodologically most rigorous RCTs on the efficacy of cognitive remediation approaches in schizophrenia, it will not only help to identify the optimal treatment options for improving psychosocial functioning and thus recovery in patients but also allow conclusions to be drawn about factors influencing and mediating the effects of cognitive remediation in these patients.Trial Registration: ClinicalTrials.gov NCT 02678858, German Study Register DRKS 00010033

Background: Cognitive models of psychosis postulate an important role of Theory of mind (ToM) in the formation and maintenance of delusions, but research on this plausible conjecture has gathered conflicting findings. In addition, it is still an open question whether problems in emotion recognition (ER) are associated with delusions. We examined the association of problems in ToM and ER with different aspects of delusions in a large sample of patients with psychosis enrolled in a therapy trial. This also enabled us to explore the possible impact of ToM and ER on one part of patients’ social life: the quality of their therapeutic relationship.Methods: Patients with psychotic disorders and delusions and/or hallucinations (n = 185) and healthy controls (n = 48) completed a ToM picture sequencing task and an ER task. Subsequently, patients were enrolled in a randomized-controlled Cognitive Behavior Therapy (CBT) trial (ISRCTN29242879). Patients and therapists rated the quality of the therapeutic relationship during the first five sessions of therapy.Results: In comparison to controls, patients were impaired in both ToM and ER. Patients with deficits in ER experienced more severe delusional distress, whereas ToM problems were not related to delusions. In addition, deficits in ER predicted a less favorable therapeutic relationship and interactional problems viewed by the therapist. Impaired ER also moderated (increased) the negative influence of delusions on the therapeutic relationship and interactional difficulties viewed by the therapist.Conclusions: Cognitive models on the formation and maintenance of delusions should consider ER as a potential candidate that might be related to the formation and maintenance of delusional distress, whereas problems in ToM might not be directly related to delusions and secondary dimensions of delusions. In addition, problems in ER in patients with psychosis might have an impact on the quality of the therapeutic relationship and patients with problems in ER are more likely to be viewed as problematic by their therapists. Nevertheless, training ER might be a way to improve the quality of the therapeutic relationship and potentially the effectiveness of CBT or other interventions for patients with psychosis.

The German Research Network on Schizophrenia (GRNS) was funded by the Federal Ministry of Education and Research (BMBF) from 1999 to 2011

Objective. To test whether cognitive function is impaired in early states of diabetes and to identify possible risk factors for cognitive impairment. Methods. A cross-sectional analysis within the German Diabetes Study included patients with type 1 or type 2 diabetes within the first year after diagnosis or five years after study inclusion and metabolically healthy individuals. Participants underwent comprehensive metabolic phenotyping and testing of different domains of cognitive function. Linear regression models were used to compare cognition test outcomes and to test associations between cognitive function and possible influencing factors within the groups. Results. In participants with recently diagnosed diabetes, verbal memory was poorer in patients with type 2 diabetes (P = 0.029), but not in type 1 diabetes (P = 0.156), when compared to healthy individuals. Five years after diagnosis, type 2 diabetes patients also showed lower verbal memory than those with type 1 diabetes (P = 0.012). In addition to crystallized intelligence, a higher body mass index among individuals with recently diagnosed type 2 diabetes and male sex among individuals with recently diagnosed type 1 diabetes were associated with impaired verbal memory (all P < 0.05). Conclusion. Verbal memory is impaired in individuals with recently diagnosed type 2 diabetes and likely associated with higher body mass.

Beeinträchtigungen in sozial-kognitiven Prozessen treten trotz klinisch wirksamer herkömmlicher Behandlung verlaufsstabil bei schizophren Kranken auf und tragen wesentlich zu deren schlechter sozialer Funktionsfähigkeit bei. Die hierzu in den letzten zehn Jahren entwickelten sozial-kognitiven Remediationsprogramme bewirken Verbesserungen in sozial-kognitiven Leistungen mit relativ großen Effektstärken, während eine auf basale Kognitionen ausgerichtete Remediation weder notwendig noch hinreichend für eine solche Verbesserung scheint. Erste Studien weisen zudem auf eine mit der sozial-kognitiven Leistungssteigerung assoziierte Verbesserung der sozialen Funktionsfähigkeit hin, die bei insgesamt nur mittleren Effektstärken etwas stärker ausfällt als in der Literatur für basal-kognitive Remediation und soziales Fertigkeitstraining berichtet wird. Sofern sich solche vielversprechenden Effekte bestätigen und noch vergrößern lassen, könnte sozial-kognitive Remediation zukünftig eine wertvolle Ergänzung der bisherigen Behandlung schizophren Kranker darstellen. Impairments in social cognitive processes are present across the course of schizophrenia despite clinically efficacious traditional treatment and contribute to poor functional outcome. Thus, during the last decade specialised social cognitive remediation programmes have been developed, which achieve improvements in social cognition with large effect sizes. In contrast, remediation targeting basic cognition seems neither necessary nor sufficient for such improvements. Associated with improved social cognitive performance, first studies also hint to improved social functioning. Although only moderate in effect size, these improvements are still somewhat larger than those described for basic cognition training and social skills training. In the case that such promising effects can be replicated and enhanced, in future social-cognitive remediation may become a valuable complement to traditional treatment in schizophrenia.

Vielfältige Evidenz legt nahe, dass Patienten in der frühen Phase einer psychotischen Erkrankung eine spezielle Behandlungsstrategie benötigen, die ihren speziellen Bedürfnissen und Problemen in dieser „kritischen“ Phase gerecht wird. Die vorliegende Übersicht fasst diese Evidenz zusammen und stellt Frühbehandlungsansätze vor, wie sie international bereits in sehr unterschiedlicher Ausgestaltung aufgebaut wurden, sich in Deutschland jedoch erst vereinzelt im Pilotstadium befinden. Bisherige Evaluationsergebnisse weisen auf eine überlegene Wirksamkeit solcher Frühbehandlungsansätze gegenüber herkömmlicher Standardbehandlung sowohl in Bezug auf das klinische Ergebnis als auch in Bezug auf die Gesamtkosten der Behandlung. Offene Fragen bestehen jedoch vor allem noch bezüglich der Spezifität und der Nachhaltigkeit solcher Effekte sowie der wirksamen Behandlungskomponenten. Bevor ähnliche Angebote in Deutschland auf breiter Basis aufgebaut werden, sollte eine Konsentierung der unverzichtbaren Charakteristika und somit zu entsprechenden Qualitätsindikatoren erfolgen. Multifaceted evidence suggests that patients in the early phase of a psychotic disorder need a specific treatment strategy meeting their specific needs and problems in this “critical” phase of the disorder. The present review summarises this evidence and presents early treatment approaches according to already internationally established different models, while in Germany comparable concepts are only in a pilot stage. Previous evaluation studies showed a superior efficacy of such early treatment approaches compared to conventional standard treatment in terms of both clinical outcome and in relation to the total costs of treatment. Questions remain, however, especially with regard to the specificity and durability of such effects, and with regard to the effective treatment components. Before similar programmes can be broadly established in Germany, a consensus on their indispensable characteristics and appropriate quality indicators should be achieved.