Prospective investigations of the prodromal state of schizophrenia: review of studies.Objective: The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre-onset phase of first episode psychosis. Method: A systematic literature search was conducted and supplemented by a manual search. All relevant studies were ordered and intensively reviewed according to specified criteria. Methodological and conceptual issues are discussed. Results: Reports of 23 prospective studies were found, some describing subsamples of larger samples. Major methodological and conceptual divergences exist. Conclusion: Applied criteria detect individuals with a significantly increased risk of psychosis within the schizophrenia spectrum, but these criteria are only validated on clinical populations. The significance of differences in sample-characteristics is unclear. Most study samples are small. Results are preliminary and in need of further research before they constitute a realistic knowledge base. Methodological and conceptual issues should not be underestimated. Summations• Current research has defined new specific criteria for samples with increased risk of psychosis. The samples linked to these criteria are systematically reviewed. • Transition rates are difficult to compare because of different intake criteria and composition of sample-subgroups. • It is still uncertain whether treatment at this stage may prevent full-blown psychosis, but the persons are generally ill and in need of psychiatric/psychological help. • Conceptual issues arise from the use of the term ÔprodromalÕ. Considerations• Results of current studies are mainly preliminary and cannot yet provide general guidelines for clinical practice. • Samples are apt to be symptomatologically, phenomenologically and pathogenetically heterogeneous. • The concept of psychosis/schizophrenia is not clarified through the discussion of empirical results.• The studies are not reviewed for their statistical qualities.

The gender differences demonstrated in the study suggest gender specific treatment interventions in order to provide optimal treatment for both male and female patients.

The instruments detect individuals with an increased risk of psychosis in clinical populations, but predictive validity and measures of reliability is insufficiently evaluated. Studies including instruments from both traditions should be conducted, in order to obtain an empirical basis of hypothesized relations between instruments. Instruments elucidating phenomenological aspects of anomalies in self-experience may contribute with valuable data on the pre-onset phase of psychosis.

During recent decades, the field of treatment of schizophrenia has lacked empirical, systematic outcome studies that support psychodynamic psychotherapy as an evidence-based intervention for patients with schizophrenia. The Danish schizophrenia project (DNS) compared psychodynamic psychotherapy for psychosis with standard treatment in patients with a first-episode schizophrenia spectrum disorder. The study was designed as a prospective, comparative, longitudinal multi-site investigation of consecutively referred patients who were included during two years. The patients were treated with either manualized individual supportive psychodynamic psychotherapy (SPP) in addition to treatment as usual or with treatment as usual alone (TaU). Symptoms and functional outcomes were measured using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF). The study included 269 consecutively admitted patients, age 18-35, of whom 79% remained in the study after two years. The intervention group improved significantly on measures of both PANSS and GAF scores, with large effect sizes at two years follow-up after inclusion. Further, improvement on GAF(function) (p = 0.000) and GAF(symptom) (p = 0.010) significantly favored SPP in combination with TaU over TaU alone. In spite of limitations, this study speaks in favor of including supportive psychodynamic psychotherapy in the treatment for patients with schizophrenic first-episode psychoses.

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

Integrated treatment and supportive psychodynamic psychotherapy in addition to treatment as usual may improve outcome after 1 year of treatment for people with first-episode psychosis, compared with treatment as usual alone.

Extreme traumatization affects the individual's relation to others in several social and psychological ways. The post-traumatic experiences are characterized by helplessness, insecurity, anxiety, loss of basic trust, and fragmentation of perspectives on one's own life. Special considerations should be given to the destruction of the ability to regulate negative emotions (extreme fear, distress, anguish, anger, rage, shame) in relation to others and activate internal good and empathic object relations. Destruction of the capacity for symbolization of traumatic experience may threaten the mind with chaotic states against which the 'I' tries to defend itself and find a balanced psychic mise-en-scene. The authors emphasize three dimensions that the analyst should observe in his understanding of the traumatized mind and its conflicts. The proposed dimensions are called the body-other dimension, the subject-group dimension, and the subject-discourse dimension. All three dimensions have specific structural characteristics that are expressed in the analytic relation. Extreme trauma causes disturbances in each of these dimensions. The authors present clinical material from a traumatized refugee to illustrate the analytic work.

Disruption and loss characterise the life of the person who has undergone extreme traumatisation (torture, concentration camp, etc.), especially when he/she lives in exile. This presents new challenges both in understanding trauma and massive traumatisation and in treating it. When planning and conducting treatment, it is of special importance to take into consideration the mental survival strategies that the person has developed. These are mental capacities that aim both at developing methods of avoiding the pain of re-experiencing and at achieving solutions to the dilemmas posed by the posttraumatic phase. The latter often consists of aborted attempts at mentalisation and integration of traumatic experiences.The traumatised person will often experience the therapeutic encounter as threatening because of fear of re-experiencing and re-traumatisation, and also because having experienced atrocities disturbs or damages the capacity for developing a trusting relationship. This paper discusses the complexities of the consequences of this situation and describes a model for a psychoanalytic approach to the treatment of these patients, focusing on the disturbance of symbolisation and mentalisation caused by trauma. Treatment must address this and provide a setting where experiences that have been insufficiently symbolised (expressed in somatisation, acting, non-verbal characteristics of speech, procedural aspects of transference, etc.) can be placed in context through a process of historisation.