Avolition and expressive deficits capture negative symptom phenomenology: implications for DSM-5 and schizophrenia research

The DSM-5 formulation presents an opportunity to refine the negative symptom assessments that are crucial for a schizophrenia diagnosis. This review traces the history of negative symptom constructs in neuropsychiatry from their earliest conceptualizations in the 19th century. It presents the relevant literature for distinguishing between different types of negative symptoms. Although a National Institute of Mental Health consensus initiative proposed that there are five separate negative symptom domains, our review of the individual items demonstrates no more than three negative symptom domains. Indeed, numerous factor analyses of separate negative symptom scales routinely identify only two domains: 1) expressive deficits, which include affective, linguistic and paralinguistic expressions, and 2) avolition for daily life and social activities. We propose that a focus on expressive deficits and avolition will be of optimum utility for diagnosis, treatment-considerations, and research purposes compared to other negative symptom constructs. We recommend that these two domains should be assessed as separate dimensions in the DSM-5 criteria.     

Determinants of subjective quality of life in depressed patients: the role of self-esteem, response styles, and social support

BACKGROUND: We aimed to assess the subjective quality of life (QOL) in depressed patients after discharge from inpatient treatment and to investigate the net impact of self-related constructs (self-esteem, response styles to depressed mood) and of social support on specific subjective QOL domains. METHOD: Four weeks after discharge from inpatient treatment, 89 unipolar depressed patients were assessed with a comprehensive battery of psychopathology and psychosocial measures. Subjective QOL was assessed using the World Health Organization Quality of Life Scale (WHOQOL-BREF). Analyses included hierarchical regressions. RESULTS: Non-remitted patients reported poorer subjective QOL than fully and partially remitted patients regarding physical and psychological health, and overall QOL. After adjusting for demographic and clinical history variables, interviewer-rated severity of depression accounted for 4% to 36% of the variance in individual QOL domain scores. Self-esteem, rumination, distraction and the existence of a partnership added further increments to the explained variance of the psychological QOL domain. Rumination, partnership, and network size of family members providing psychological crisis support also predicted subjective QOL on the social relations domain. CONCLUSION: Our results suggest that self-esteem, response styles to depressed mood, and social support characteristics contribute substantially to the psychological and social domains of subjective QOL in depressed patients. These associations are not attributable to concurrent symptom severity. Therapy with depressed patients should not only focus on symptom reduction but should help the patients to establish and maintain supportive relationships and to enhance self-appreciation and skills to cope with negative mood in order to improve psychological well-being and health-related quality of life.     

Primary lower limb lymphedema: a focus on its functional, social and emotional impact

Primary lymphedema is a rare, chronic and distressing condition with negative effects on physical, social and emotional level. The purpose of these reports was to present and discuss two different cases of primary lower limb lymphedema with a focus on its physical and mental impact and on some qualitative aspects of patients' self-reported experiences. The patients were recruited as they used occasional services within the University Hospital of Heraklion (Crete, Greece). The functional and mental impact of primary lymphedema was measured using the generic Medical Outcome Study short form-36 questionnaire and open-ended questions led to give more emphasis to patients' experiences. The analysis of short form-36 results in the first patient disclosed a significant functional impairment with a minor impact of the condition on emotional and social domains. For the second patient quality of life scores in the emotional and social domains were affected. Our findings support further the statement that physicians should pay full attention to appraise the patient's physical and emotional condition. General practitioners have the opportunity to monitor the long-term impact of chronic disorders. Posing simple open-ended questions and assessing the level of physical and mental deficits in terms of well-being through the use of specific metric tools can effectively follow-up rare conditions in the community.     

Disease perception and social behaviour in persistent rhinitis: a comparison between patients with allergic and nonallergic rhinitis

BACKGROUND: Although the understanding of the pathophysiology and pharmacology of rhinitis has increased within recent years, few studies have examined the impact of rhinitis on patients' behaviour. AIM: To compare perennial allergic rhinitis (PAR) and perennial nonallergic rhinitis (PNR) in terms of patients' perception of their disease and its psychosocial concomitants. METHODS: Thirty-one PAR patients and 32 PNR patients responded to a standard symptom list and were interviewed in-depth regarding their complaints and the impact of rhinitis on their daily lives. RESULTS: PAR and PNR patients reported similar somatic and psychosocial complaints. In both disease groups the adverse effects of rhinitis were reported to be substantially limiting, particularly in social contacts, the impact appearing to be more severe in the women. CONCLUSION: Rhinitis has a severe impact on the daily lives of patients, women reporting more severe psychosocial effects. Disease perception and social adjustment appear to not depend appreciably on whether or not an objective diagnosis of rhinitis can be established.     

Finally heard, believed and accepted--peer support in the narratives of women with fibromyalgia

Objective

The aim of the present study was to analyse how experiences of peer support were described and reflected upon several years after a group rehabilitation intervention. Moreover, we wanted to learn more about what meanings were ascribed to peer support in the narratives of women with a long history of fibromyalgia.

Method

This was a qualitative study in which narrative life story interviews of 20 women with fibromyalgia were collected and analysed to elicit the impact of peer support in their lives.

Results

We identified four main domains of experienced peer support; permission to talk, need of information, reciprocity and self-evaluation through comparison. The meanings ascribed to peer support were mainly positive, although the participants also expressed thoughts about fear of future, hopelessness and mental health issues.

Conclusions

Long-term fibromyalgia patients saw peer support as an impetus to an ongoing process of reconstruction of identity, illness acceptance and coping with fibromyalgia.

Practice implications

In addition to up-dating their knowledge about fibromyalgia and its treatment, long term patients may need arenas where they can share and compare their experiences to those of other patients with a long history of fibromyalgia.     

Psychosocial treatments for negative symptoms in schizophrenia: Current practices and future directions

Schizophrenia can be a chronic and debilitating psychiatric disorder. Though advancements have been made in the psychosocial treatment of some symptoms of schizophrenia, people with schizophrenia often continue to experience some level of symptoms, particularly negative symptoms, throughout their lives. Because negative symptoms are associated with poor functioning and quality of life, the treatment of negative symptoms is a high priority for intervention development. However, current psychosocial treatments primarily focus on the reduction of positive symptoms with comparatively few studies investigating the efficacy of psychosocial treatments for negative symptoms. In this article, we review and evaluate the existing literature on three categories of psychosocial treatments — cognitive behavioral therapy (CBT), social skills training (SST), and combined treatment interventions — and their impact on the negative symptoms of schizophrenia. Of the interventions reviewed, CBT and SST appear to have the most empirical support, with some evidence suggesting that CBT is associated with maintenance of negative symptom improvement beyond six months after treatment. It remains unclear if a combined treatment approach provides improvements above and beyond those associated with each individual treatment modality. Although psychosocial treatments show promise for the treatment of negative symptoms, there are many unanswered questions about how best to intervene. We conclude with a general discussion of these unanswered questions, future directions and methodological considerations, and suggestions for the further development of negative symptom interventions.     

A longitudinal study of mental health consumer/survivor initiatives: Part 1—Literature review and overview of the study

Mental health consumer‐run organizations are alternatives to mainstream mental health services, and they have the dual focus of supporting members and creating systems change. The existing literature suggests that these organizations have beneficial impacts on social support, community integration, personal empowerment, subjective quality of life, symptom distress, utilization of hospitals, and employment/education. However, much of this research is cross‐sectional or retrospective and has not used comparison groups, thus limiting conclusions about the effectiveness of these organizations in improving the lives of members. Although many consumer‐run organizations also have a focus on social systems change, there has been little research documenting either the nature of these activities or the system changes that result from such activities. We provide an overview of a longitudinal study of four mental health Consumer/Survivor Initiatives. The study examines both individual‐level and systems‐level activities and impacts by using both quantitative and qualitative methods with a participatory action research framework. © 2006 Wiley Periodicals, Inc.     

Communicating with older diabetes patients: self-management and social comparison

OBJECTIVE: The health status and life experiences of older diabetes patients may be highly heterogeneous, thus making their perspectives particularly relevant for developing individualized self-management plans for this population. Our earlier research showed older diabetes patients' healthcare goals and self-management behaviors are frequently shaped through social comparisons with peers/family members. The present paper explores this role of social comparison in their self-management practices and develops a conceptual model depicting the process. METHODS: Data were collected using open-ended, semi-structured interviews to elicit 28 older, type 2 diabetes patients' healthcare goals and self-management practices. Qualitative techniques were used to extract salient themes. RESULTS: Social comparison plays a salient role in routinizing older patients' self-management practices. Almost all patients assess their self-management by making "downward" comparisons with individuals doing worse than them; "upward" comparisons are rarely invoked. Occasionally patients' social comparisons lead them to adopt "normalizing" behaviors resulting in deviations from medically recommended self-care. CONCLUSION: The findings formed the basis for developing a conceptual model delineating the role of social comparison in self-management that can be beneficial for providers in tailoring educational interventions for self-management. PRACTICE IMPLICATIONS: Fostering these comparisons can help providers enhance communication on initiating and sustaining self-management practices.     

Characteristics of participants in a large group awareness training

A study was conducted to assess the psychosocial characteristics of individuals who become involved in large group awareness training (LGAT) programs. Prospective participants in The Forum, which has been classified as an LGAT, were compared with nonparticipating peers and with available normative samples on measures of well-being, negative life events, social support, and philosophical orientation. Results revealed that prospective participants were significantly more distressed than peer and normative samples of community residents and had a higher level of impact of recent negative life events compared with peer (but not normative) samples. Prospective participants also held preparticipation values more similar to those espoused by the LGAT than peer or normative samples, and the three groups failed to be distinguished by their levels of social support. The implications of the findings are considered for understanding participation in LGATs and other self-change promoting activities.     

The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study.

PURPOSE: To identify and model the effects of sleep loss and fatigue on resident-physicians' professional lives and personal well-being. METHOD: In 2001-02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics-gynecology, emergency medicine, family medicine, internal medicine, pediatrics, surgery) were recruited for the study. Residents were all in good standing in their programs. In a mixed-methods design, focus groups consisted of an average of seven (range, three to 14) individuals in the same year of training and residency program, for a total of 60 interns and 89 senior residents. Trained moderators conducted focus groups using a standardized, semistructured discussion guide. Participants also completed a 30-item quantitative questionnaire assessing sleepiness and workplace sleep attitudes that included the Epworth Sleepiness Scale (ESS). RESULTS: Residents described multiple adverse effects of sleep loss and fatigue on learning and cognition; job performance, including professionalism and task performance; and personal life, including personal well-being and relationships with spouse or significant other and family. Only 16% of the sample scored within the "normal" range on the ESS; 84% scored in the range for which clinical intervention is indicated. Sleepiness was consistent across institution, specialty, years of training, age, gender, marital status, and having children. CONCLUSIONS: More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents' abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.     

Life 20 years after unsuccessful infertility treatment

BACKGROUND: This study explores the long-term experience of involuntary childlessness among 14 Swedish women 20 years after their infertility treatment. METHODS: In-depth interviews were conducted. RESULTS: The childlessness had had a strong impact on all the women's lives and was for all a major life theme. The effects were experienced both on a personal level and on interpersonal and social levels. Half of the women were separated, and in all but one, sexual life was affected in negative and long-lasting ways. The effects of childlessness were especially increased at the time the study was conducted, as the women's peer group was entering the 'grandparent phase'. Many coped with their childlessness by caring for others, such as the children of friends or relatives, elderly parents or animals. CONCLUSION: These findings represent a small sample, but they point towards the need for developing models of counselling and support that stimulate self-reflection and strengthen personal resources and empowerment for individuals and couples experiencing involuntary childlessness.     

Andropause and quality of life: findings from patient focus groups and clinical experts

Objectives: To develop a condition-specific quality of life (QoL) questionnaire to assess the symptoms of the decline in testosterone that occurs as men age, otherwise known as the andropause. Methods: Two focus groups of patients with low testosterone levels and an expert panel of physicians in the treatment of male testosterone deficiency. Results: The patient focus groups confirmed that men are unlikely to realise they have low testosterone levels until this is diagnosed and that they are unlikely to share their experiences with peers. Both patients and physicians considered decreased energy levels and impaired sexual performance had the greatest adverse impact on well-being. Patients generally felt that testosterone replacement therapy led to improved energy levels and, to a lesser extent, improved libido and erectile function. Evaluation of the responses resulted in the identification of seven key domains (energy, emotional, social, social emotional, mental functioning, physical functioning and sexual functioning) that should be considered when assessing the impact of andropause on QoL. Conclusions: Understanding the impact of low testosterone levels on QoL is critical to diagnosis and effective treatment. The use of an andropause-specific QoL questionnaire will facilitate quantification of patient experiences and may thus improve subsequent therapy.     

精神分裂症病人及家属受歧视状况

目的：了解精神分裂症病人及其家属受歧视状况，探讨歧视对精神分裂症病人及其家属的影响。方法：应用自编问卷在北京地区对精神分裂症病人(N=225)、精神分裂症病人家属(N=230)、社区居民(N=257)和精神科医护人员(N=283)进行调查。结果：42％的病人报告他们受到了单位不公正对待，受到同事或同学歧视，被邻居看不起，并导致恋爱或婚姻失败。56%的家属报告为避免歧视把病人患精神病的事对外保密。全部4组受试中85％以上的人相信歧视会降低病人的自信心，75％以上的人相信歧视给家属造成很大的心理压力，70％以上的人相信歧视严重影响病人的生活，60％以上的人相信歧视使病人的家庭成员减少了他们应有的社交活动。与其他三组人群比较，精神科医护人员更同意精神病人及其家属受歧视是常见的现象，更相信歧视会给他们的生活带来严重影响。与病人和家属比较，对歧视现象的存在社区居民的认同较低，但他们同样认为歧视对病人和家属有消极影响。结论：精神分裂症病人遭遇到的歧视突出地表现在与个人基本社会生活密切有关的工作、婚姻和人际交往三个方面。社会歧视对病人及其家属的心理和社会生活产生了严重影响。     

Attention-deficit hyperactivity disorder symptoms and quality of life in female patients with fibromyalgia

Background/aim The present study aimed to determine the association between attention-deficit hyperactivity disorder (ADHD) symptoms severity, fibromyalgia (FM) severity, and QoL.Materials and methodsWhile the FM group consisted of 113 (74%) patients, the control group consisted of 40 (26%) individuals. FM symptom severity, ADHD symptom severity, and QoL were evaluated using the fibromyalgia impact questionnaire (FIQ), adult ADHD self-report scale (ASRS), and World Health Organization quality of life scale-brief version (WHOQOL-BREF), respectively. ResultsIt was found that the FM group had significantly higher scores on the ASRS than the control group (p < 0.05). There was a significant difference in FIQ scores and three WHOQOL-BREF domain scores between the FM alone and comorbid FM/high probability of ADHD groups (p < 0.05). We found a negative correlation between ASRS total scores and all other scale scores (except for the social relationships domain score of the WHOQOL-BREF) and a positive correlation between ASRS total scores and FIQ scores in FM patients. ADHD scores would mediate the relationship between depression severity and QoL.ConclusionsOur findings indicated that the presence of ADHD symptoms was related to greater FM symptom severity and poorer QoL. Also, ADHD scores would mediate the relationship between depression severity and QoL.     

Role of biographical experience and bodily sensations in patients' adaptation to hypertension

OBJECTIVE: To explore patients' adaptation to hypertension and to describe its impact on their sense of body, biographical experience, approach to life and daily activities. METHODS: A qualitative interview study with nine men and eight women (age: 35-50 years) with hypertension from four general practices in Denmark. The informants differed in type and duration of treatment. RESULTS: Adaptation to hypertension was influenced by the patients' biographical experiences and involved changes in body perception. The process affected patients' daily activities and they actively tested their physical abilities. Patients gradually adopted behaviour and attitudes to reduce their risk of cardiovascular disease. CONCLUSION: A diagnosis of hypertension constitutes a biographical disruption and has an impact on daily life. Patients' adaptation to hypertension combines biographical and bodily experiences. PRACTICE IMPLICATIONS: Attention to patients' biographies and images of hypertension is an important element of hypertensive treatment.     

Social domain dysfunction and disorganization in borderline personality disorder

BACKGROUND: Social dysfunction in personality disorder is commonly ascribed to abnormal temperamental traits but may also reflect deficits in social processing. In this study, we examined whether borderline and avoidant personality disorders (BPD, APD) may be differentiated by deficits in different social domains and whether disorganization of social domain functioning uniquely characterizes BPD. METHOD: Patients were recruited from psychiatric clinics in Pittsburgh, USA, to provide a sample with BPD, APD and a no-personality disorder (no-PD) comparison group. Standardized assessments of Axis I and Axis II disorders and social domain dysfunction were conducted, including a new scale of 'domain disorganization' (DD). RESULTS: Pervasive social dysfunction was associated with a 16-fold increase in the odds of an Axis II disorder. Both APD and BPD were associated with elevated social dysfunction. Romantic relationship dysfunction was associated specifically with BPD symptoms and diagnosis. DD was associated specifically with a categorical BPD diagnosis and with a dimensional BPD symptom count. CONCLUSIONS: A focus on the inherently interpersonal properties of personality disorders suggests specific mechanisms (within and across interpersonal domains) that may help to account for the origins and maintenance of some disorders. In particular, BPD reflects disturbances in romantic relationships, consistent with a role for attachment processes, and in the organization of functioning across social domains.     

Effects of metabolic control, patient education and initiation of insulin therapy on the quality of life of patients with type 2 diabetes mellitus

OBJECTIVE: The objective of this study was to evaluate the impact of initiation of insulin therapy, metabolic control and structured patient education on the diabetes-related quality of life (QoL) in insulin-treated patients with type 2 diabetes mellitus. METHODS: This prospective study was conducted with 71 consecutively recruited patients with insulin-treated diabetes at the University hospital. All patients participated an inpatient diabetes treatment and teaching program (DTTP) for conventional insulin therapy (mean age 68.9 years, HbA1c 10.1+/-1.4%, diabetes duration 11.2 years (range: 0-25.5 years), body-mass-index 28.7+/-5.7kg/m(2). Diabetes-related quality of life was assessed before and 6 months after participation in the DTTP using the standardized questionnaire of Lohr analysing the subscales: social relations, physical complaints, worries about the future, dietary restrictions, fear of hypoglycaemia, and daily struggles. RESULTS: Only patients switched on insulin therapy showed significant improvement in diabetes-related quality of life 6 months after participation in the DTTP (p=0.03), fewer physical complaints (p=0.03), fewer worries about the future (p=0.02), fewer daily struggles (p=0.01) and less fear of hypoglycaemia (p<0.001), while patients, who were already on insulin therapy showed no improvements in diabetes-related quality of life. Though, residual analysis reveals that effects on patients' QoL are mainly caused by improvements in metabolic control. CONCLUSIONS: Improvements in metabolic control have a significant effect on different diabetes-related quality of life domains in patients with diabetes mellitus. PRACTICE IMPLICATIONS: Appropriate interventions resulting in better metabolic control, such as starting on insulin therapy within a structured patient education program seem to be an effective approach to improve patients' diabetes-related quality of life.     

CONCEPTUALIZING SOCIAL INTEGRATION AMONG FORMERLY HOMELESS ADULTS WITH SEVERE MENTAL ILLNESS

The multiple dimensions of social integration among formerly homeless adults with severe mental illness have not been well‐studied. Previous studies have focused on clinical measures or narrow components of social integration. We used a multisite study of chronically homeless adults who were provided housing to (a) identify the main factors related to social integration, (b) examine the association between clinical symptoms and social integration, and (c) examine whether social integration is associated with life satisfaction. A factor analysis identified six components of social integration: housing, community participation, civic activities, religious faith, social support, and treatment support. Social integration was found to be largely independent of clinical symptoms and had only a weak association with life satisfaction. These findings suggest supported housing programs needed to focus on improving client outcomes in several domains of social integration regardless of symptoms and that additional efforts are needed to improve life satisfaction among clients.