Pl - Plenary

Pl - 1 Thursday 14/8, 09:00-9:30
Early detection and treatment of psychosis

Merete Nordentoft, Senior Consultant, PhD, Bispebjerg Hospital, Department of Psychiatry, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark. Lone Petersen, Anne Thorup, Pia Jeppesen.

merete.nordentoft@dadlnet.dk

Background: Schizophrenia spectrum disorders generally strike during late adolescence or early adulthood and may affect all aspects of life with far-reaching implications for the individual and the family. International interest in early psychosis continues to grow rapidly in both clinical settings and in the growing research literature. OPUS is the first large randomized controlled trial of integrated treatment versus standard treatment in first episode psychosis.

Aim: The aim is to present the evidence of an association between long duration of untreated psychosis and poor prognosis, and to present the results of one-year follow-up in the Danish OPUS trial.

Methods: A total of 547 first episode patients with schizophrenia spectrum disorders were randomly assigned to either integrated treatment by a multidisciplinary psychosis team (275 patients) or treatment as usual (272 patients). The integrated treatment consisted of assertive community treatment, psycho-educational multi-family groups, social skills training and antipsychotic medication. Standard treatment offered contact with a community mental health center. Each patient was assessed comprehensively with SCAN, SAPS, SANS, Social Network Schedule and CSQ at baseline and after one year by independent researchers.

Results: At one year follow-up data from hospital records was available for 507 patients, 263 (96 percent) in integrated treatment and 244 (90 percent) in standard treatment. A total of 419 participated in follow-up interviews, 227 (83 percent) and 192 (71 percent) respectively. Patients in integrated treatment had better outcome concerning positive and negative symptoms and this was not explained by more patients receiving antipsychotic medication. Patients in integrated treatment were more satisfied with treatment. More patients in integrated treatment started or continued education and more lived independently. Fewer patients in integrated treatment had comorbid alcohol or drug abuse at one-year follow-up (16 percent versus 22 percent), and fewer had been admitted. Patients in integrated treatment used 61 (mean) bed days during the first year of follow-up, while patients in standard treatment used 81 (mean) bed days.

Conclusion: The integrated treatment improved clinical and social outcome after one year. Copenhagen and Aarhus municipalities, where the trial was conducted, have decided to implement the treatment as standard treatment.

Pl - 2 Thursday 14/8, 09:30-10:00
Neuregulin and the molecular genetics of schizophrenia

Hannes Pétursson¹, Hreinn Stefánsson², Engilbert Sigurðsson¹, Valgerður Steinþórsdóttir², Þórður Sigmundsson¹, Jón Brynjólfsson¹, Steinunn Gunnarsdóttir², Ómar Ívarsson¹, Ómar Hjaltason¹, Helgi Jónsson¹, Vala G. Guðnadóttir², Elsa Guðmundsdóttir³, Brynjólfur Ingvarsson³, Andrés Ingason², Sigmundur Sigfússon³, Hrönn Harðardóttir¹, Jeffrey R. Gulcher², Kári Stefánsson<sup>2

1</sup>Division of Psychiatry, Landspítali University Hospital, Reykjavík Iceland. ²deCode Genetics, Sturlugötu 8, 101 Reykjavík, Iceland. ³Department of Psychiatry, Akureyri Hospital, Iceland.


Seven schizophrenia susceptibility genes have been reported recently. These genes are Neuregulin 1 (NRG1), G72, D-aminoacid oxidase (DAAO), dysbindin (DTNBP1), G-protein signalling-4 (RGS4), proline dehydrogenase (PRODH) and catechol-O-methyltransferase (COMT).

Replication studies include the NRG1 at risk haplotype being found in excess in Scottish schizophrenia patients as well as in Icelandic patients. In some instances replication studies have found other at-risk haplotypes within the same gene or have failed to find a significant association. NRG 1 promotes neuronal migration and cellular differentiation as well as modulating synaptic plasticity and thus has a clear role in neurodevelopment. NRG 1 is expressed at synapses in the central nervous system and elsewhere. In common with the other genes NRG1 has an important role in the expression and activation of neurotransmitter receptors, including glutamate receptors.

A behavioural phenotype that overlaps with mouse models for schizophrenia is demonstrated by mutant mice heterozygous for either NRG 1 or its receptor ErbB4. NRG1 hypomorphs also have fewer functional NMDA receptors than wild type mice. Abnormalities of sensorimotor gating have also been reported with inactivated PRODH. With the possible exception of COMT a clear functional polymorphism has not been demonstrated. Single SNP´s are rarely found to be highly significantly associated with the risk for schizophrenia. Thus associations are presently identified by haplotypes.

Although the present findings are promising it is prudent to urge caution and further research to establish unequivocal replications. Attempts at replication may be confounded by the finding of different alleles or haplotypes. It is imperative to continue the search for other schizophrenia susceptibility genes. The study of potential endophenotypes as well as the overlap between schizophrenia and bipolar disorders may provide further clues to the pathophysiology of schizophrenia and related disorders.

Pl - 3 Thursday 14/8, 10:00-10:30
Consultation-Liaison (C-L) psychiatry: An update with clinical implications for general psychiatry

Ulrik Fredrik Malt, Professor, Rikshospitalet, Psykosomatisk avdeling, NO-0027 Oslo, Norway

u.f.malt@psykiatri.uio.no

C-L psychiatry has become a subspecialty within psychiatry in the US, but not in European countries. C-L psychiatry is important for recognition and acceptance of psychiatry among somatic colleagues and in the society as such, but requires knowledge of psychology and medicine in addition to psychiatric experience and clinical wisdom.

Psychiatric interventions may improve psychiatric symptoms in the medically ill. Prophylactic intervention may reduce the risk of developing depression in somatic treatments. However, uncritical application of psychotherapy to medically ill patients may worsen the prognosis of the somatic disorder. Nevertheless, C-L research shows that general psychiatrists often recommend psychotherapy for ideological reasons or choose treatment based on personal preference.

Ongoing studies show that temporal brain dysfunctions (PET, EEG, qEEG, ERP) may present as regular chronic psychiatric disorders (e.g. dysthymia). Psychiatrists may falsely label the patients as "treatment-resistant" or suffering from an "unstable personality disorder" requiring long-term psychotherapeutic treatment.

In particular bipolar II disorders may be referred to somatic hospitals with psychosomatic complaints only (e.g. functional dyspepsia, chronic fatigue, "burn-out"). Co-morbid anxiety may preclude correct diagnosis and treatment. Panic disorder may present as fibromyalgia.

Classic conditioning may lead to chronic and functional incapacitating somatic complaints without somatic findings and lack of ongoing psychosocial conflicts or problems. But classic conditioning may also be used to enhance the effect of somatic treatment (e.g. cancer treatment).

The lack of medical knowledge among many psychiatrists may hamper adequate diagnosis and treatment of psychiatric disorders and represent a long-term threat to psychiatry as such.

Pl - 4 Friday 15/8, 09:00-9:30
Controversies in the aetiology of schizophrenia

Robin M. Murray, Professor of Psychiatry, Box No 63, Institute of Psychiatry, De Crespigny Park, London SE5 8AF

robin.murray@iop.kcl.ac.uk

This paper will discuss whether research into schizophrenia has now reached a sufficient level of maturity to allow us to leave behind the ideological debates of the past. A model will be proposed which encompasses the importance of both biological and social factors, and integrates factors as disparate as susceptibility genes and social discrimination.

Pl - 5 Friday 15/8, 09:30-10:00
The pathogenesis of borderline pathology

John Livesley, Professor, Department of Psychiatry, University of British Columbia, 2250 Wesbrook Mall, Vancouver, BC, Canada, V6T 1W6

The evidence suggests that borderline pathology is influenced by a complex interaction of biological and psychosocial factors. Genetic and environmental factors contributing to the development of borderline personality disorder will be discussed. It will be argued that behavioral-genetic studies suggest that the traits delineating the disorder have a strong heritable component and that the covariation among these traits is influenced by genetic as opposed to environmental factors. Psychosocial factors also exert a powerful influence. Multiple forms of adversity seem to increase the risk of developing borderline personality disorder. None is necessary and sufficient to cause the condition and each form of adversity appears to account for only a relatively small amount of outcome variance. Nevertheless, environmental factors account for about 50% of the variability in borderline features. It is suggested that environmental factors primarily modulate the way genetic predispositions are expressed. Particularly important are the effects of adversity on the expression of the affective traits that form the core component of borderline pathology. Psychosocial adversity appears to amplify the expression of genetic predispositions towards anxiousness and affective lability and hinder the acquisition of affect regulating strategies and skills. This view of the etiology and pathogenesis of borderline personality disorder suggests the importance of a treatment approach using biological and psychological interventions targeted initially towards improving affective and impulse regulation, and subsequently on facilitating the acquisition of more effective interpersonal skills.

Pl - 6 Friday 15/8, 10:00-10:30

New perspectives in depression

Lars von Knorring, Professor, MD, PhD, Dept. of Neuroscience, Psychiatry University Hospital, Uppsala University, SE-751 85 Uppsala, Sweden

Although the depressive disorders have been well known since the time of Hippocrates, there are still successive changes in our view of the depressive disorders. Today it is well established that depressive disorders are the most expensive disorders to society, at least in the industrialised world. It is also clear that the prevalence is increasing and at present the lifetime risk of depressive disorders seems to be 23% in men and 45% in women. Furthermore, the age of onset is gradually decreasing and depressive disorders are now found in around 5% of teenage girls. We are also increasingly aware that depressive disorders are serious, life-threatening disorders. There is a high comorbidity between somatic and depressive disorders. The mortality is increased almost 20 times in suicides, almost 10 times in infectious disorders, almost twice in respiratory disorders, and around 15% in circulatory disorders. The complex immunological and metabolic changes occurring during depressive episodes are better elucidated.

Effective antidepressant treatments have been known for many decades. We now have effective psychotherapeutic treatments such as cognitive psychotherapy and interpersonal psychotherapy as well as effective biological treatments, including ECT, TCA, and SSRI. As a result of the more available and more effective treatments, it seems that suicide rate is decreasing. It seems likely that in the near future new treatment strategies will become available, probably including CRH blockers and substance P antagonists.

Pl 7 Saturday 16/8, 10:00-10:30
The psychology of false confessions

Gísli H. Guðjónsson, Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, England

spjtghg@iop.kcl.ac.uk

The focus of this paper is on false confessions within the context of police interviewing. There is growing evidence that false confessions, even to serious crimes such as murder, do occur on occasions. No judicial system should ignore this reality and take steps to prevent and deal satisfactorily with false confessions, whether given voluntarily for some instrumental gains (e.g. to protect a peer, to seek notoriety, inability to distinguish facts from fantasy) or coerced by police (e.g. coercive interview tactics, threat or fear of detention). There are different ways of conceptualising false confessions. Munsterberg (1908) construed false confessions as arising out of unusual circumstances, whereas Kassin and Wrightsman (1985), Ofshe and Leo (1997) and Gudjonsson (2003) argue that false confessions are associated with distinct psychological types, such as: Voluntary, Pressured-compliant, and pressured-internalised. Each type has a distinctive set of antecedents, conditions and psychological consequences. In recent years much research has been carried out into these three groups of false confessions. The research demonstrates the importance of considering a combination of custodial, situational, vulnerability, and support factors. What is clear is that false confessions occur largely in absence of mental illness. Personality factors, such as anxiety proneness, suggestibility, compliance, and on occasions antisocial personality traits, are often found to be present and of importance.

Reference
Guðjónsson GH (2003). The psychology of interrogations and confessions. A handbook. Chichester: John Wiley & Sons.

Pl - 8 Saturday 16/8, 10:30-11:00
Mental health promotion

Ville Lehtinen, Research Professor, National Research and Development Centre for Welfare and Health STAKES, Kanervatie 18, FIN-20540 TURKU, Finland

ville.lehtinen@stakes.fi

Mental health promotion uses a broad concept of mental health, including not only a negative but also a positive dimension. Mental health promotion works mainly by tackling the different components and determinants of positive mental health, which can be grouped into: 1) individual biological and psychological factors, 2) social interactions, 3) societal structures and resources, and 4) cultural values. Mental health promotion uses different entry points, operates on different levels, in different settings and with different methods of action. Increasing amount of evidence exists about the effectiveness of mental health promotion activities. Elements of successful mental health promotion programmes include: 1) appropriate theoretical base and needs/context assessment in programme development, 2) targeting appropriate determinants, using a multi-professional and multi-dimension approach and considering cultural context as its characteristics and 3) using appropriate training and supervision, manuals and programme fidelity in its implementation. Some examples of effective promotive interventions will be presented.