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Background: Alice in Wonderland syndrome (AIWS) is a neurological condition characterized by perceptual distortions, most of which are visual in nature (metamorphopsias). Over the past decade there has been a movement in contemporary figurative painting away from strict mimesis toward depicting distortions of the painting's subject, called disrupted realism. In certain cases the similarities between the distortions in those paintings and those characteristic of AIWS are so striking that we suspect that artists may have experienced distorted perceptions themselves and used them for creative inspiration., Methods: To empirically test this hypothesis we interviewed 20 painters who frequently use distortions in their work, using the SIntAD, a tailor-made, semi-structured questionnaire. We then carried out a phenomenological analysis of the perceptual phenomena reported on, and compared them with those in their paintings., Results: Of the artists interviewed, 85% reported on having experienced positive disorders of perception in general (comprising hallucinations, perceptual distortions and other perceptual phenomena), with 55% reporting on a total number of 15 metamorphopsias. Most artists had not been aware of having these distortions to their perception. Nonetheless, most did not use these specific distortions in their work, but rather different types., Conclusion: Symptoms of AIWS and other positive disorders of perception are common among contemporary painters who frequently use distortions in their figurative work, although perhaps not more common than in the general population. Artists in the disrupted-realism movement tend not to mimic their own perceptual distortions in their work, although they do feel inspired to distort their work in different ways., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Hyatt and Blom.)

The Diagnostic and Statistical Manual of Mental Disorders, abbreviated as the DSM, is one of mental health care's most commonly used classification systems. While the DSM has been successful in establishing a shared language for researching and communicating about mental distress, it has its limitations as an empirical compass. In the transformation of mental health care towards a system that is centered around shared decision-making, person-centered care, and personal recovery, the DSM is problematic as it promotes the disengagement of people with mental distress and is primarily a tool developed for professionals to communicate about patients instead of with patients. However, the mental health care system is set up in such a way that we cannot do without the DSM for the time being. In this paper, we aimed to describe the position and role the DSM may have in a mental health care system that is evolving from a medical paradigm to a more self-contained profession in which there is increased accommodation of other perspectives. First, our analysis highlights the DSM's potential as a boundary object in clinical practice, that could support a shared language between patients and professionals. Using the DSM as a conversation piece, a language accommodating diverse perspectives can be co-created. Second, we delve into why people with lived experience should be involved in co-designing spectra of distress. We propose an iterative design and test approach for designing DSM spectra of distress in co-creation with people with lived experience to prevent the development of 'average solutions' for 'ordinary people'. We conclude that transforming mental health care by reconsidering the DSM as a boundary object and conversation piece between activity systems could be a step in the right direction, shifting the power balance towards shared ownership in a participation era that fosters dialogue instead of diagnosis., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Veldmeijer, Terlouw, van Os, te Meerman, van ‘t Veer and Boonstra.)

Introduction: Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments., Methods: The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis., Results: Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations., Discussion: The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 González Moraga, Enebrink, Perrin, Sygel, Veling and Wallinius.)

Introduction: Studies have consistently demonstrated increased stress sensitivity in individuals with psychosis. Since stress sensitivity may play a role in the onset and maintenance of psychosis, this could potentially be a promising target for treatment. The current study was the first to investigate whether reactivity to and recovery from daily-life stressors in psychosis change in response to treatment, namely virtual-reality-based cognitive behavioral therapy (VR-CBT)., Methods: 116 patients were randomized to either VR-CBT or the waiting list control group (WL). Pre-treatment and post-treatment participants completed a diary ten times a day during six to ten days. Multilevel analyses were used to model the time-lagged effects of daily stressful events on negative affect (NA) and paranoia symptoms to examine reactivity and recovery., Results: There was a significant difference in NA reactivity. VR-CBT showed higher NA at post-treatment compared to pre-treatment than WL (b pre =0.14; b post =0.19 vs b pre =0.18; b post =0.14). There was a significant difference in NA recovery and paranoia recovery between the groups at lag 1: VR-CBT showed relatively lower negative affect (b pre =0.07; b post =-0.06) and paranoia (b pre = 0.08; b post =-0.10) at post-treatment compared to pre-treatment than WL (b pre =0.08; b post =0.08; b pre =0.04; b post =0.03)., Conclusion: Negative affect and paranoia recovery improved in response to treatment. Increased NA reactivity may be explained by a decrease in safety behavior in the VR-CBT group. The discrepancy between reactivity and recovery findings may be explained by the inhibitory learning theory that suggests that an original threat reaction may not erase but can be inhibited as a consequence of exposure therapy., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 van der Stouwe, Booij, Geraets, Pot-Kolder, Kuranova, van der Gaag and Veling.)

Introduction: Informal carers of people with mental health problems often have unmet support needs. Mental health recovery narratives are increasingly accessible, but their relevance to and effect on informal carers have been minimally investigated. The Narrative Experiences Online (NEON) Intervention is a first-in-field intervention that provides informal carers with access to a diverse collection of recorded mental health recovery narratives. This trial aimed to examine the feasibility and acceptability of the NEON Intervention for informal carers., Methods: This study involved a two-arm feasibility randomized controlled trial. Carers were randomly assigned to receiving versus not receiving the NEON Intervention. The feasibility aspects investigated included the acceptability of the intervention and of randomization, trial processes, engagement rates, recruitment procedures, attrition, sample size estimation, identification of candidate primary and secondary outcomes, and the feasibility of conducting a definitive trial. A qualitative process evaluation was conducted., Findings: A total of 121 carers were eligible, of whom 54 were randomized (intervention: 27, control: 27). Twelve-month follow-up data were available for 36 carers. Carers accessed a mean of 25 narratives over a 12-month period, and the intervention group, compared with the control group, reported a small effect on hope and a moderate effect on the presence of meaning in life. Five modifications were recommended to improve the user experience, applicability, and trial processes., Discussion: The NEON Intervention is feasible and acceptable. Significant refinement of the NEON Intervention and trial processes is required to personalize and ensure applicability to carers. Further feasibility testing is recommended prior to a definitive trial., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ng, Rennick-Egglestone, Onwumere, Newby, Llewellyn-Beardsley, Yeo, Ali, Pollock, Kotera, Pomberth, Gavan, van der Krieke, Robotham, Gillard, Thornicroft, Slade and the NEON Study Group.)

Background: While cardiovascular diseases is highly prevalent and an important cause of mortality in autistic adults, knowledge on their increased cardiovascular risk is limited. Hence, this study aimed to investigate psychological, behavioral, and physical factors associated with metabolic syndrome (MetS) in adults with autistic traits., Methods: In total, 17,705 adults from the Lifelines Cohort were included and categorized using Autism Spectrum Quotient-10 sum-scores. The quartiles with highest (HQ-traits-group females: n  = 2,635; males: n  = 1803) and lowest levels of autistic traits (LQ-traits-group, n  = idem) were analyzed. Using multivariable logistic regression, the associations between MetS and (self-reported and interviewed) psychological, behavioral, and physically measured factors in these stratified groups were investigated., Results: Among females, MetS was more common in the HQ-traits-group than in the LQ-traits-group (10.0% versus 7.5%, p  < 0.01), while this was not the case among males (HQ-traits-group 13.8% versus LQ-traits-group 13.1%, p  = 0.52). In both the female and male HQ-traits-group, the presence of MetS was associated with poorer self-reported health, less daily physical activity, and altered leukocyte counts., Conclusion: These findings underline the relevance of adequate cardiovascular prevention in adults with higher levels of autistic traits. Future research could gain more insight into the relationship between cardiovascular risk and autistic traits in females, and into tailored cardiovascular prevention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Warreman, Nooteboom, Leenen, Geurts, Terry, Bos, Hak, Hoek, van Rossum, Vermeiren and Ester.)

Background: Shift work is generally associated with working and sleeping out of phase with the endogenous, circadian sleep-wake cycle. This exerts detrimental effects on sleep health. The present study aimed at evaluating the presence of short and long sleep as well as sleep disorders within a broad range of shift work schedules and elucidating the role of sociodemographic factors therein., Methods: A large dataset containing information on sleep was collected through advertisement in a Belgium newspaper (De Standaard). Adult, working individuals were selected (n = 37,662) and categorized based on their work schedule (regular day, early morning, evening, night, and rotating shift). In this cross-sectional study, prevalence rates of short sleep (≤6 h), long sleep (≥9 h) and sleep disorders (screened with Holland Sleep Disorders Questionnaire), and associations between these sleep variables and sociodemographics (age, sex, education, living companion(s)) were analyzed using binominal logistic regression analyses., Results: In the total sample all sociodemographic factors affected prevalences of short, long and disordered sleep, consistent with previous studies. Compared to day workers, shift workers more frequently reported short sleep, most prominently night workers (26 vs. 50%) ( p  < 0.001). Furthermore, all sleep disorders as well as sleep disorder comorbidity were more common in shift workers, again most pronounced in night workers (all p  < 0.05). In night shift workers the level of education had the strongest associations with disturbed sleep with a two-fold higher prevalence of short and disordered sleep in low relative to academic educated groups (all p < 0.02)., Conclusion: Shift work is related not only to curtailed sleep and shift work disorder, but also to a plethora of sleep disorders, including insomnia, sleep-related breathing disorders and sleep-related movement disorders. Our findings imply that education on coping strategies may be especially important for young and/or lower educated shift workers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Boersma, Mijnster, Vantyghem, Kerkhof and Lancel.)

Tailoring interventions to the individual has been hypothesized to improve treatment efficacy. Personalization of target-specific underlying mechanisms might improve treatment effects as well as adherence. Data-driven personalization of treatment, however, is still in its infancy, especially concerning the integration of multiple sources of data-driven advice with shared decision-making. This study describes an innovative type of data-driven personalization in the context of StayFine, a guided app-based relapse prevention intervention for 13- to 21-year-olds in remission of anxiety or depressive disorders ( n = 74). Participants receive six modules, of which three are chosen from five optional modules. Optional modules are Enhancing Positive Affect, Behavioral Activation, Exposure, Sleep , and Wellness . All participants receive Psycho-Education, Cognitive Restructuring , and a Relapse Prevention Plan . The personalization approach is based on four sources: (1) prior diagnoses (diagnostic interview), (2) transdiagnostic psychological factors (online self-report questionnaires), (3) individual symptom networks (ecological momentary assessment, based on a two-week diary with six time points per day), and subsequently, (4) patient preference based on shared decision-making with a trained expert by experience. This study details and evaluates this innovative type of personalization approach, comparing the congruency of advised modules between the data-driven sources (1-3) with one another and with the chosen modules during the shared decision-making process (4). The results show that sources of data-driven personalization provide complementary advice rather than a confirmatory one. The indications of the modules Exposure and Behavioral Activation were mostly based on the diagnostic interview, Sleep on the questionnaires, and Enhancing Positive Affect on the network model. Shared decision-making showed a preference for modules improving positive concepts rather than combating negative ones, as an addition to the data-driven advice. Future studies need to test whether treatment outcomes and dropout rates are improved through personalization., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Kooiman, Robberegt, Albers, Bockting, Stikkelbroek and Nauta.)

Background: Knowledge about patient characteristics predicting treatment dropout for post-traumatic stress disorder (PTSD) is scarce, whereas more understanding about this topic may give direction to address this important issue., Method: Data were obtained from a randomized controlled trial in which a phase-based treatment condition (Eye Movement Desensitization and Reprocessing [EMDR] therapy preceded by Skills Training in Affect and Interpersonal Regulation [STAIR]; n  = 57) was compared with a direct trauma-focused treatment (EMDR therapy only; n  = 64) in people with a PTSD due to childhood abuse. All pre-treatment variables included in the trial were examined as possible predictors for dropout using machine learning techniques., Results: For the dropout prediction, a model was developed using Elastic Net Regularization. The ENR model correctly predicted dropout in 81.6% of all individuals. Males, with a low education level, suicidal thoughts, problems in emotion regulation, high levels of general psychopathology and not using benzodiazepine medication at screening proved to have higher scores on dropout., Conclusion: Our results provide directions for the development of future programs in addition to PTSD treatment or for the adaptation of current treatments, aiming to reduce treatment dropout among patients with PTSD due to childhood abuse., Competing Interests: AJ receives income from published books on EMDR therapy and training of postdoctoral professionals in this method. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bremer-Hoeve, van Vliet, van Bronswijk, Huntjens, de Jongh and van Dijk.)

Background: Emotion dysregulation (ED) is increasingly under investigation as a cross-disorder trait, and is by some considered as the core feature in mental disorders. The aims of this study were to scrutinize the overlapping and distinct characteristics of ED for internalizing, externalizing and neurodevelopmental disorders and to identify the most pertinent ED characteristics to guide clinicians in treatment choice., Methods: Information on clinical diagnosis (Attention Deficit/Hyperactivity Disorder ADHD, Autism Spectrum Disorder, Oppositional Defiant Disorder/Conduct Disorder, Anxiety and Mood Disorders), ED (measured by the CBCL-Emotion Dysregulation Index), Quality of Life (Qol, measured by the Kidscreen-27), and treatment duration (measured by Electronic Health Records) was retrieved from two large samples of toddlers (1.5-5  year old; N  = 1,544) and school aged children (6-18 year old; N  = 7,259). Frequency scores and logistic regression were used to study symptom profiles of ED, as measured with CBCL-EDI, across all disorders. Linear regression was used to determine the predictive value of ED (CBCL-EDI total score) regarding QoL and treatment duration in addition to-and in interaction with-clinical diagnosis., Results: Across disorders, equal levels of total ED were found, which predicted lower QoL and a longer treatment duration in addition to clinical diagnosis. The majority of items (11/15 and 16/18) were of equal relevance to the disorders; items that were not, largely reflected disorder specific DSM definitions (i.e., externalizing symptoms in ODD/CD and internalizing symptoms in Anxiety and Mood disorders)., Conclusion: ED is a clinically useful cross-disorder trait to predict severity of impairment as well as required treatment duration. In addition, ED is largely composed of shared features across disorders, with certain disorder specific colored elements., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bierens, Hartman, Klip, Deckers, Buitelaar and Rommelse.)

Introduction: Mild intellectual disability or borderline intellectual functioning (MID/BIF) are common in people with severe mental health problems (SMHP). Despite this, there is a lack of treatments adapted for this group of clients., Methods: This qualitative study describes the development of a new intervention, guided by the principles of action research, for people with SMHP and MID/BIF and mental health professionals to help them talk about all aspects of the process of recovery. The intervention was developed in four cycles and in close cooperation with mental health professionals, experts by experience, other experts in the field of SMHP or MID/BIF, and clients. During all cycles there was a strong focus on the content of the intervention, exercises, understandable language, and drawings for visual support., Results: This resulted in the intervention "Routes to Recovery," which covers both complaints and strengths, coping strategies, helpful (social) activities, and how to determine future steps in a recovery plan., Discussion: Routes to Recovery is a first step in helping professionals and their clients with SMHP and MID/BIF to have a conversation about personal strengths and what the client needs to recover. Future research should investigate the effects of this intervention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Berger, Bruineberg, van Ewijk, de Jong, van der Hout, van Weeghel and van der Meer.)

Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bachrach, Rijkeboer, Arntz and Huntjens.)

Background: Impaired cognitive insight and increased self-stigma have been consistently reported in individuals diagnosed with schizophrenia spectrum disorders, but little is known about its presence in individuals at ultra-high risk of developing a psychosis, although self-stigma is associated with transition.to psychosis. The current study examined whether self-stigma is already present in individuals at ultra-high risk of psychosis, and whether this is associated with impaired cognitive insight., Methods: 184 participants were recruited divided over three groups, namely individuals diagnosed with a schizophrenia spectrum disorder (SSD; n = 92, 34% females), individuals at ultra-high risk for psychosis (UHR; n = 43, 59% females) and general population controls (GPC; n = 49, 27% females). All participants completed assessments on demographic information (gender, age, education), and cognitive insight. In addition, participants with SSD and individuals at UHR completed a questionnaire on self-stigma., Results: The level of self-stigma did not differ between individuals at UHR and individuals diagnosed with SSD. Cognitive insight also did not differ significantly between the three groups, but the subscale self-reflection differed between the three groups [ F (2,184) = 4.20, p  = 0.02], with the UHR and SSD groups showing more self-reflection. Pearson's correlation analyses showed that in individuals at UHR total cognitive insight and its self-reflection subscale were significantly associated with the alienation subscale of self-stigma, and in individuals with SSD self-certainty subscale of cognitive insight was significantly associated with stereotype endorsement., Conclusion: Findings show that self-stigma was already present in the UHR phase, to a similar degree as in individuals with a diagnosis of a SSD, and is thus not dependent of previous experience of having a label of SSD. Cognitive insight in individuals at UHR of psychosis appears to be intact, but individuals at UHR showed more self-reflectiveness, and individuals at risk with high cognitive insight also experience high levels of self-stigma. Overall findings from our study suggest that pre-emptive interventions targeting self-stigma, while considering cognitive insight, are needed early on in manifestation of psychotic illness, preferably already in the UHR phase., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sportel, van Enthoven, van Donkersgoed, Kuis, van de Giessen, Lysaker, Hasson-Ohayon, de Jong, Boonstra and Pijnenborg.)

Backgrounds: Decision-making deficits have been reported as trans-diagnostic characteristics of vulnerability to suicidal behaviors, independent of co-existing psychiatric disorders. Individuals with suicidal behaviors often regret their decision to attempt suicide and may have impairments in future-oriented processing. However, it is not clear how people with suicidal dispositions use future-oriented cognition and past experience of regret to guide decision-making. Here, we examined the processes of regret anticipation and experience in subclinical youth with and without suicidal ideation during value-based decision-making., Methods: In total, 80 young adults with suicidal ideation and 79 healthy controls completed a computational counterfactual thinking task and self-reported measures of suicidal behaviors, depression, anxiety, impulsivity, rumination, hopelessness, and childhood maltreatment., Results: Individuals with suicidal ideation showed a reduced ability to anticipate regret compared to healthy controls. Specifically, suicidal ideators' experience of regret/relief was significantly different from that of healthy controls upon obtained outcomes, while their disappointment/pleasure experience was not significantly different from healthy controls., Conclusion: These findings suggest that young adults with suicidal ideation have difficulty predicting the consequences or the future value of their behavior. Individuals with suicidal ideation showed impairments in value comparison and flat affect to retrospective rewards, whereas individuals with high suicidality showed blunted affect to immediate rewards. Identifying the counterfactual decision-making characteristics of at-risk suicidal individuals may help to elucidate measurable markers of suicidal vulnerability and identify future intervention targets., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ai, Duan, Huang, Luo, Aleman and Xu.)

Background: Receiving the label of a psychotic disorder influences self-perception and may result in negative outcomes such as self-stigma and decreased self-esteem. The way the diagnosis is communicated to individuals may affect these outcomes., Aims: This study aims to explore the experiences and needs of individuals after a first episode of psychosis with regard to the way in which information about diagnosis, treatment options and prognosis is communicated with them., Design and Methods: A descriptive interpretative phenomenological approach was used. Fifteen individuals who experienced a first episode of psychosis participated in individual semi-structured open-ended interviews on their experiences and needs regarding the process of providing information about diagnosis, treatment options and prognosis. Inductive thematic analysis was used to analyze the interviews., Results: Four recurring themes where identified (1) timing (when); (2) content (what); and (3) the way information is provided (how). Individuals also reported that the provided information could elicit an emotional reaction, for which they would require specific attention, therefore the fourth theme is (4) reactions and feelings ., Conclusion: This study provides new insights into the experiences and specific information needed by individuals with a first episode of psychosis. Results suggest that individuals have different needs regarding the type of (what), how and when to receive information about diagnosis and treatment options. This requires a tailor-made process of communicating diagnosis. A guideline on when, how and what to inform, as well as providing personalized written information regarding the diagnosis and treatment options, is recommended., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Huurman, Pijnenborg, Sportel, van Rijsbergen, Hasson-Ohayon and Boonstra.)

Alexithymia is a personality trait characterized by difficulties in emotion recognition and regulation that is associated with deficits in social cognition. High alexithymia levels are considered a transdiagnostic risk factor for a range of psychiatric and medical conditions, including depression, anxiety, and autism. Hormones are known to affect social-emotional cognition and behavior in humans, including the neuropeptides oxytocin and vasopressin, the steroid hormones testosterone and estradiol, the stress hormone cortisol as well as thyroid hormones. However, few studies have investigated hormonal effects on alexithymia and on alexithymia-related impairments in emotion regulation and reactivity, stress response, and social cognition. Here, we provide a brief overview of the evidence linking alexithymia to abnormalities in hormone levels, particularly with regard to cortisol and oxytocin, for which most evidence exists, and to thyroid hormones. We address the current lack of research on the influence of sex hormones on alexithymia and alexithymia-related deficits, and lastly provide future directions for research on associations between hormonal abnormalities and deficits in emotion regulation and social cognition associated with alexithymia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Goerlich and Votinov.)

Objective: The objective of this study was to gain insight into patients' experiences of how personal recovery (PR) is facilitated or hindered in the context of an early episode psychosis setting (Soteria). We thereby aimed to contribute to the understanding of how care settings may promote or hinder the process of PR in people with (acute) psychosis., Method: This study used a qualitative method, consisting of semi-structured in-depth interviews with people who had been admitted to a Soteria house in the Netherlands. Interview transcripts were analyzed following the Grounded Theory approach., Results: Five themes emerged from the data illustrating how Soteria facilitated or impeded PR. The experience of togetherness in contact with staff and peers, feeling at home, and being active facilitated PR, while the emphasis put on medication by staff was experienced as hindering, and attention to spirituality was missed., Conclusion: In addition to the literature that identified factors associated with PR in psychosis, the current study gives a sense of how this can be put into practice. By offering treatment within a normalizing, holding environment, with emphasis on equality, close contact, optimism, active structured days, open-mindedness toward spirituality, and the role of medication, PR can be facilitated without detracting from guideline-based treatment aimed at symptomatic recovery. Similarities with existing concepts are discussed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Leendertse, Hirzalla, van den Berg, Castelein and Mulder.)

Introduction: The descriptive classification Attention-Deficit/Hyperactivity Disorder (ADHD) is often mistaken for a disease entity that explains the causes of inattentive and hyperactive behaviors, rather than merely describing the existence of such behaviors. The present study examines discourse on ADHD to analyze how authors passively and actively contribute to reification-a fallacy in which a concept is represented as a thing existing on its own., Methods: Critical Discourse Analysis and Qualitative Content Analysis of academic textbooks, scientific articles, websites and videos were used to analyze how ADHD is reified., Results: The analyses reveal four ways in which inattentive and restless behaviors are presented as an entity by means of the ADHD classification: language choice, logical fallacies, genetic reductionism, and textual silence. First, language choice, such as medical jargon and metaphors aid in representing ADHD as a disease entity. Second, several logical fallacies do the same, including the relatively unknown "ecological fallacy" that refers to the erroneous belief that average group findings, such as average brain size of groups of those with an ADHD classification, can be applied on an individual level. Third, genetic reductionism is often achieved by overstating the results of twin studies and being silent about the disappointing molecular genetic research. Such textual silence is the last identified mechanism of reification and includes instances in which societal factors that affect the ADHD construct are often omitted from texts, thereby obscuring the extent to which ADHD is a limited heuristic., Discussion: It is essential that discourse communities do not repeat these four ways of reifying behavior and social relations into an alleged entity with the acronym ADHD. The errors and habits of writing may be epistemologically violent by influencing how laypeople and professionals see children and ultimately how children may come to see themselves in a negative way. Beyond that, if the institutional world shaped to help children is based on misguided assumptions, it may cause them harm and help perpetuate the misguided narrative. To counter the dominant, reifying and medicalizing view, guidelines such as the recently published "Dutch ADHD Psychoeducation Guidelines" might be helpful., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 te Meerman, Freedman and Batstra.)

Background: The incubus phenomenon is a paroxysmal sleep-related disorder characterized by the visuotactile sensation of a person or entity exerting pressure on one's thorax during episodes of sleep paralysis and (apparent) wakefulness. This terrifying phenomenon is relatively unknown even though a previous meta-analysis indicated a lifetime prevalence of 0.11 for individuals in the general population and of 0.41 for selected at-risk groups, including people diagnosed with schizophrenia and students. Since the studies reviewed did not always make a strict distinction between the incubus phenomenon and isolated sleep paralysis, we carried out a cross-sectional study in a contemporary patient and student sample to attain current, more detailed data on the incubus phenomenon., Materials and Methods: In a cross-sectional design, we used the Waterloo Unusual Sleep Experience Questionnaire (WUSEQ) to screen patients with severe psychiatric disorders and university undergraduates to establish and compare prevalence rates, frequencies of occurrence, and risk factors for the incubus phenomenon., Results: Having interviewed 749 people, comprising 606 students and 143 patients with a schizophrenia spectrum or related disorder who had been acutely admitted to a secluded nursing ward, we computed a reported lifetime prevalence of 0.12 and 0.09, respectively, which rates were not statistically different. In both groups, the phenomenon was more common in people with a non-Western European background. Risk factors noted for the students were the use of psychotropic medication and the lifetime presence of an anxiety disorder, eating disorder, or sleeping disorder. We found no associations with age or gender in either group., Conclusion: The 0.09 and 0.12 lifetime prevalence rates we recorded for the incubus phenomenon in students and psychiatric inpatients is substantially lower than the 0.41 found in an earlier meta-analysis. We tentatively attribute this difference to an overgeneralization in previous studies but also discuss alternative explanations. The elevated prevalence among non-Western European participants may well be due to the fact that the topic continues to be part of the cultural and religious heritage of many non-Western countries., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Molendijk, Bouachmir, Montagne, Bouwman and Blom.)

Background: Recognition that the loss of a loved one may result in prolonged grief disorder (PGD) has gained broad attention recently. PGD may disturb daily functioning to such a degree that mental health treatment is required. Because PGD symptoms often resemble symptoms of common mental disorders (CMD) such as anxiety, depressive, and post-traumatic stress disorder, clinicians may not consider a PGD diagnosis. Moreover, cultural varieties in expression of PGD may complicate recognition. This study explores the prevalence of PGD among both natives and refugees with anxiety, depressive, or trauma- and/or stressor-related disorders as well as clinicians' awareness and knowledge of PGD symptoms. In addition, a psychoeducation module on PGD symptoms is developed through patient expert collaboration., Methods: Prevalence of PGD symptoms is investigated among 50 participants who are referred to outpatient clinics for anxiety, depression, or post-traumatic stress, using the Traumatic Grief Inventory-Self Report Plus (TGI-SR+) and the Bereavement and Grief-Cultural Formulation Interview (BG-CFI). Clinicians will be interviewed on knowledge (gaps) with respect to PGD symptoms. Finally, focus groups with patient experts are held to develop a psychoeducation module tailored to the patients' needs, norms and values., Results: This study will show prevalence of PGD among patients who are referred for anxiety, depression, and post-traumatic stress, awareness and knowledge of clinicians on PGD symptoms, and will offer patient expert informed psychoeducation., Discussion: Research on prevalence and recognition of PGD is vital. Study results of the prevalence of PGD will be compared to previous studies. Recognition of PGD as distinct disorder from CMDs requires clinicians' awareness of symptoms related to the loss of a loved one. Thereby, clinicians need to take cultural aspects related to death, bereavement and mourning into consideration., Ethics and Dissemination: The study protocol will be carried out in accordance with relevant guidelines and regulations. Exploratory research to assess the prevalence of PGD in patients suffering from CMDs will facilitate adequate diagnosis by increasing clinician's awareness of PGD symptoms. Tailored PGD psychoeducation, co-created by culturally diverse patient experts and clinicians will be made publicly available., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Groen, Menninga, Cath and Smid.)

The acute response after a terror attack may have a crucial impact on the physical and psychological wellbeing of the victims. Preparedness of the professionals involved in the acute response is a key element to ensure effective interventions, and can be improved through trainings. Today in Europe there is a recognized lack of inter-professional and international trainings, which are important, among others, to respond to the needs and the rights of victims affected by a terrorist attack in another country than their home country. In this paper we report the perspectives of an expert panel composed by different categories of professionals on the possible role of interprofessional trainings provided remotely. The experts discussed the pertinence of remote trainings for professionals involved in the acute response of a terror attack, and highlighted their Strengths, Weaknesses, Opportunities and Threats (SWOT analysis). We concluded that, while remote trainings cannot replace in-person trainings, they may be useful to share knowledge about the role and the organization of the different categories of professionals, thus potentially improving response coordination, and to easily share good practices across professionals and countries., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Askenazy, Fernandez, Altan, Battista, Dückers, Gindt, Nachon, Ivankovic, Porcar-Becker, Prieto, Robert, Stene, Thummler and Manera.)

Scientific attempts to identify biomarkers to reliably diagnose mental disorders have thus far been unsuccessful. This has inspired the Research Domain Criteria (RDoC) approach which decomposes mental disorders into behavioral, emotional, and cognitive domains. This perspective article argues that the search for biomarkers in psychiatry presupposes that the present mental health categories reflect certain (neuro-) biological features, that is, that these categories are reified as biological states or processes. I present two arguments to show that this assumption is very unlikely: First, the heterogeneity (both within and between subjects) of mental disorders is grossly underestimated, which is particularly salient for an example like Attention Deficit/Hyperactivity Disorder (ADHD). Second, even the search for the biological basis of psychologically more basic categories (cognitive and emotional processes) than the symptom descriptions commonly used in mental disorder classifications has thus far been inconclusive. While philosophers have discussed this as the problem of mind-body-reductionism for ages, Turkheimer presented a theoretical framework comparing weak and strong biologism which is more useful for empirical research. This perspective article concludes that mental disorders are brain disorders in the sense of weak , but not strong biologism. This has important implications for psychiatric research: The search for reliable biomarkers for mental disorder categories we know is unlikely to ever be successful. This implies that biology is not the suitable taxonomic basis for psychiatry, but also psychology at large., Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Schleim.)

Tourette syndrome (TS) is characterized by multiple motor and vocal tics, and high-comorbidity rates with other neuropsychiatric disorders. Obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), autism spectrum disorders (ASDs), major depressive disorder (MDD), and anxiety disorders (AXDs) are among the most prevalent TS comorbidities. To date, studies on TS brain structure and function have been limited in size with efforts mostly fragmented. This leads to low-statistical power, discordant results due to differences in approaches, and hinders the ability to stratify patients according to clinical parameters and investigate comorbidity patterns. Here, we present the scientific premise, perspectives, and key goals that have motivated the establishment of the Enhancing Neuroimaging Genetics through Meta-Analysis for TS (ENIGMA-TS) working group. The ENIGMA-TS working group is an international collaborative effort bringing together a large network of investigators who aim to understand brain structure and function in TS and dissect the underlying neurobiology that leads to observed comorbidity patterns and clinical heterogeneity. Previously collected TS neuroimaging data will be analyzed jointly and integrated with TS genomic data, as well as equivalently large and already existing studies of highly comorbid OCD, ADHD, ASD, MDD, and AXD. Our work highlights the power of collaborative efforts and transdiagnostic approaches, and points to the existence of different TS subtypes. ENIGMA-TS will offer large-scale, high-powered studies that will lead to important insights toward understanding brain structure and function and genetic effects in TS and related disorders, and the identification of biomarkers that could help inform improved clinical practice., Competing Interests: Authors IN and SR were employed by the company Forschungszentrum Jülich GmbH. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Paschou, Jin, Müller-Vahl, Möller, Rizzo, Hoekstra, Roessner, Mol Debes, Worbe, Hartmann, Mir, Cath, Neuner, Eichele, Zhang, Lewandowska, Munchau, Verrel, Musil, Silk, Hanlon, Bihun, Brandt, Dietrich, Forde, Ganos, Greene, Chu, Grothe, Hershey, Janik, Koller, Martin-Rodriguez, Müller, Palmucci, Prato, Ramkiran, Saia, Szejko, Torrecuso, Tumer, Uhlmann, Veselinovic, Wolańczyk, Zouki, Jain, Topaloudi, Kaka, Yang, Drineas, Thomopoulos, White, Veltman, Schmaal, Stein, Buitelaar, Franke, van den Heuvel, Jahanshad, Thompson and Black.)

Background: Previous research has provided insight into the grief of suicide survivors, but little is known about grief following physician-assisted dying (PAD), and no prior study specifically focused on grief following PAD due to a mental disorder. The current study aims to increase insight into experiences preceding PAD or suicide of a loved one due to a mental disorder and their impact on mental health symptoms., Methods: We performed a survey study and in-depth interviews with 27 bereaved life partners. The deceased had been in treatment for mental disorders and had died by PAD ( n = 12) or suicide ( n = 15). Interviews explored grief experiences and experiences with mental health care. In the survey, we assessed self-reported symptoms of grief, post-traumatic stress, anxiety, depression, quality of life, and impairments in social, and occupational functioning., Results: All participants reported generally low levels of mental health symptoms. Longer time since death and death by PAD were associated with lower grief intensity. Interviews showed various degrees of expectedness of the partners ' death, and a varying impact of being present at the death on bereaved partners., Conclusion: Expectedness of the death of the partner, absence of suffering of the partner at the time of dying, and presence of physician support may in part explain the protective effects of PAD against severe grief reactions. Physicians considering their position regarding their personal involvement in PAD due to a mental disorder could take grief reactions of the bereaved partner into account., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Snijdewind, de Keijser, Casteelen, Boelen and Smid.)

Background: The loss of a significant other can lead to variety of responses, including prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. The aim of this study was to replicate and extend previous research that indicated that three subgroups of bereaved individuals can be distinguished based one similar post-loss symptom profiles using latent class analysis (LCA). The second aim was to examine whether sociodemographic and loss-related characteristics as well as the extent of meaning making were related to classes with more pervasive psychopathology., Methods: Telephone-based interviews with 433 Dutch and German speaking persons who had lost a significant other at last 6 months earlier were conducted. Self-rated PGD, PTSD, and depression symptoms were assessed. LCA was conducted and correlates of class-membership were examined using the 3step approach., Results: The LCA resulted in three distinct classes: a no symptoms class (47%), a moderate PGD, low depression/PTSD class (32%), and a high PGD, moderate depression/PTSD class (21%). A multivariate analysis indicated that female gender, a shorter time since loss, an unexpected loss and less meaning made to a loss were significantly associated with membership to the moderate PGD, low depression/PTSD and high PGD, moderate depression/PTSD class compared to membership to the no symptom class. Losing a child or spouse, a shorter time since loss, and having made less meaning to the loss further distinguished between the high PGD, moderate depression/PTSD symptom class and the moderate PGD, low depression/PTSD class., Discussion: We found that the majority of individuals coped well in response to their loss since the no symptom class was the largest class. Post-loss symptoms could be categorized into classes marked by different intensity of symptoms, rather than qualitatively different symptom patterns. The findings indicate that perceiving the loss as more unexpected, finding less meaning in the loss, and loss-related factors, such as the recentness of a loss and the loss of a partner or child, were related to class membership more consistently than sociodemographic factors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Heeke, Franzen, Hofmann, Knaevelsrud and Lenferink.)

Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Alzheimer's disease (AD) is a global public health priority as with aging populations, its prevalence is expected to rise even further in the future. The brain and gut are in close communication through immunological, nervous and hormonal routes, and therefore, probiotics are examined as an option to influence AD hallmarks, such as plaques, tangles, and low grade inflammation. This study aimed to provide an overview of the available animal evidence on the effect of different probiotics on gut microbiota composition, short chain fatty acids (SCFAs), inflammatory markers, Amyloid-β (Aβ), and cognitive functioning in AD animal models. A systematic literature search was performed in PubMed, SCOPUS, and APA PsychInfo. Articles were included up to May 2021. Inclusion criteria included a controlled animal study on probiotic supplementation and at least one of the abovementioned outcome variables. Of the eighteen studies, most were conducted in AD male mice models ( n = 9). Probiotics of the genera Lactobacillus and Bifidobacterium were used most frequently. Probiotic administration increased species richness and/or bacterial richness in the gut microbiota, increased SCFAs levels, reduced inflammatory markers, and improved cognitive functioning in AD models in multiple studies. The effect of probiotic administration on Aβ remains ambiguous. B. longum (NK46), C. butyricum , and the mixture SLAB51 are the most promising probiotics, as positive improvements were found on almost all outcomes. The results of this animal review underline the potential of probiotic therapy as a treatment option in AD., Competing Interests: SH was employee of Winclove Probiotics. Winclove produces, markets and investigates probiotics. HH and Winclove receive collective research grants. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 de Rijke, Doting, van Hemert, De Deyn, van Munster, Harmsen and Sommer.)

The death of a child is a devastating experience for most parents. Consequently, bereaved parents are at risk to develop physical and mental health problems, including prolonged grief disorder. Nevertheless, there is a lack of evaluated psychosocial interventions for bereaved parents. The primary aim of this study was to examine the feasibility of the My Grief app for bereaved parents. The secondary aim was to evaluate the potential reduction of symptoms of prolonged grief, depression and post-traumatic stress, and cognitive-behavioral processes proposed to prolong grief reactions. The study was a mixed-method open trial design, using pre- and post-intervention surveys and post-intervention interviews. Thirteen parents had access to the app for 4 weeks, eight parents participated in interviews and 10 parents answered the follow-up survey. The study provided evidence for the app's feasibility and acceptability, with participants reporting satisfaction with the app and stating that they would recommend it to parents in similar situations. According to the participants, the app was easy to use, the content gave a feeling of not being alone or weird in how one grieves, and the app gave a valuable overview of information, knowledge and further support. In addition, all parents expressed that an app like My Grief is needed and would be particularly useful to access early in the grieving process. Significant reductions of prolonged grief symptoms ( d within = 0.86) and grief-related rumination ( d within = 0.72), loss avoidance ( d within = 0.95) and negative cognitions ( d within = 1.36) from pre- to post-assessment were found. In conclusion, the app appears acceptable and feasible to use and will be evaluated in a larger randomized controlled trial (Trial registration number: NCT04552717, https://clinicaltrials.gov/ct2/show/NCT04552717)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Eklund, Eisma, Boelen, Arnberg and Sveen.)

Background: To contain the spread of COVID-19, governmental measures were implemented in many countries. Initial evidence suggests that women and men experience increased anger and aggression during COVID-19 lockdowns. Not surprisingly, media reports and initial empirical evidence highlight an increased risk for domestic violence (DV) during the pandemic. Nonetheless, a systematic review of studies utilizing participants' reports of potential changes in DV prevalence and severity during the pandemic as compared to pre-pandemic times is needed., Objective: To examine empirical, peer-reviewed studies, pertaining to the potential change in prevalence and severity of different types of DV during the COVID-19 pandemic, as reported by study participants., Data Sources: Electronic EMBASE, MEDLINE, PsycINFO, and CINAHL searches were conducted for the period between 2020 and January 5, 2022. References of eligible studies were integrated by using a snowballing technique., Study Selection: A total of 22 primary, empirical, peer-reviewed studies published in English or German were included., Results: Of the 22 studies, 19 were cross-sectional whereas 3 included both pre-pandemic and during pandemic assessments. Data synthesis indicates that severity of all types of DV as well as the prevalence of psychological/emotional and sexual DV increased for a significant number of victims in the general population during the pandemic. Evidence for changes in prevalence regarding economic/financial, physical, and overall DV remains inconclusive. There was considerable between-study variation in reported prevalence depending on region, sample size, assessment time, and measure., Conclusions: Data synthesis partly supports the previously documented increase in DV. Governmental measures should consider the availability of easily accessible, anonymous resources. Awareness and knowledge regarding DV need to be distributed to improve resources and clinical interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Thiel, Büechl, Rehberg, Mojahed, Daniels, Schellong and Garthus-Niegel.)

Objective: This paper used meta-regression to analyze the heterogenous factors contributing to the prevalence rate of mental health symptoms of the general and frontline healthcare workers (HCWs) in China under the COVID-19 crisis., Method: We systematically searched PubMed, Embase, Web of Science, and Medrxiv and pooled data using random-effects meta-analyses to estimate the prevalence rates, and ran meta-regression to tease out the key sources of the heterogeneity., Results: The meta-regression results uncovered several predictors of the heterogeneity in prevalence rates among published studies, including severity (e.g., above severe vs. above moderate, p < 0.01; above moderate vs. above mild, p < 0.01), type of mental symptoms (PTSD vs. anxiety, p = 0.04), population (frontline vs. general HCWs, p < 0.01), sampling location (Wuhan vs. Non-Wuhan, p = 0.04), and study quality ( p = 0.04)., Conclusion: The meta-regression findings provide evidence on the factors contributing to the prevalence rate of mental health symptoms of the general and frontline healthcare workers (HCWs) to guide future research and evidence-based medicine in several specific directions., Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=220592, identifier: CRD42020220592., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chen, Chen, Zhang, Dong, Li, Dong, Ye, Tong, Zhao, Cao, Li and Zhang.)

Background: There are numerous observations of reward sensitivity being associated with different psychiatric disorders. Nonetheless, most studies investigating this relationship have been cross-sectional. Additionally, current knowledge is fragmentary as studies often investigate only one disorder at a time. The present study addresses these gaps by investigating whether reward sensitivity at age 13 predicts the course of nine psychopathology domains (attention and hyperactivity, autism spectrum, reactive aggression, proactive aggression, mood, anxiety, smoking, alcohol use, and cannabis use) over a 14-year follow-up period., Methods: We used dimensional outcomes on 2,523 individuals over five measurement waves between ages 13 and 26 of the Dutch Tracking Adolescents' Individual Lives Survey (TRAILS). Reward sensitivity was measured with the Behavioral Activation System (BAS) scale. The longitudinal associations between reward sensitivity and psychopathology were examined using growth curve analysis within a multilevel framework., Results: Reward sensitivity at age 13 was associated with changes in psychopathology over time. Reward sensitivity had a stable main effect on the future course of reactive and proactive aggression problems and anxiety problems. The effect of reward sensitivity increased over time for alcohol and cannabis use. Post-hoc analyses showed that reward sensitivity also had a stable effect on attention problems and hyperactivity and smoking when based on the fun-seeking subscale for both domains and when changing the informant who reported on attention problems and hyperactivity. No evidence was found for a longitudinal association between reward sensitivity and autism spectrum problems and mood problems., Conclusion: The current study provides evidence for the long-lasting effects of reward sensitivity on the course of different domains of psychopathology., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Cardoso Melo, Groen and Hartman.)

Background: In non-randomized studies (NRSs) where a continuous outcome variable (e.g., depressive symptoms) is assessed at baseline and follow-up, it is common to observe imbalance of the baseline values between the treatment/exposure group and control group. This may bias the study and consequently a meta-analysis (MA) estimate. These estimates may differ across statistical methods used to deal with this issue. Analysis of individual participant data (IPD) allows standardization of methods across studies. We aimed to identify methods used in published IPD-MAs of NRSs for continuous outcomes, and to compare different methods to account for baseline values of outcome variables in IPD-MA of NRSs using two empirical examples from the Thyroid Studies Collaboration (TSC)., Methods: For the first aim we systematically searched in MEDLINE, EMBASE, and Cochrane from inception to February 2021 to identify published IPD-MAs of NRSs that adjusted for baseline outcome measures in the analysis of continuous outcomes. For the second aim, we applied analysis of covariance (ANCOVA), change score, propensity score and the naïve approach (ignores the baseline outcome data) in IPD-MA from NRSs on the association between subclinical hyperthyroidism and depressive symptoms and renal function. We estimated the study and meta-analytic mean difference (MD) and relative standard error (SE). We used both fixed- and random-effects MA., Results: Ten of 18 (56%) of the included studies used the change score method, seven (39%) studies used ANCOVA and one the propensity score (5%). The study estimates were similar across the methods in studies in which groups were balanced at baseline with regard to outcome variables but differed in studies with baseline imbalance. In our empirical examples, ANCOVA and change score showed study results on the same direction, not the propensity score. In our applications, ANCOVA provided more precise estimates, both at study and meta-analytical level, in comparison to other methods. Heterogeneity was higher when change score was used as outcome, moderate for ANCOVA and null with the propensity score., Conclusion: ANCOVA provided the most precise estimates at both study and meta-analytic level and thus seems preferable in the meta-analysis of IPD from non-randomized studies. For the studies that were well-balanced between groups, change score, and ANCOVA performed similarly., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Syrogiannouli, Wildisen, Meuwese, Bauer, Cappola, Gussekloo, den Elzen, Trompet, Westendorp, Jukema, Ferrucci, Ceresini, Åsvold, Chaker, Peeters, Imaizumi, Ohishi, Vaes, Völzke, Sgarbi, Walsh, Dullaart, Bakker, Iacoviello, Rodondi and Del Giovane.)

Introduction: Treatment resistance and disengagement from mental health services are major obstacles in the treatment of dual diagnosis patients with Severe Mental Illness. The patients in this study were admitted to a long-term involuntary treatment facility., Aim of the Study: To study which patient experiences and perceptions are related to the outcome measures Subjective Quality of Life (SQOL) and Treatment Satisfaction (TS) during the long-term involuntary treatment., Methods: Patients were invited for an interview by an independent researcher, which included self-report questionnaires. The structured interviews included self-assessing Helping Alliance, Insight, Attitude toward involuntary admission, Perceived coercion and Perceived benefit were studied as determinants of SQOL and TS. The relationship between the determinants and the outcomes were analyzed by linear regression analysis., Results: Patient reported outcomes from dual diagnosis patients in a long-term treatment facility, showed that most of the patients, in spite of the involuntary character of the treatment, were satisfied with the treatment. With respect to the determinants of SQOL and TS the perceptions that "My opinion is taken into account" and "Perceived benefits of the treatment" are strong predictors of both the outcomes., Conclusions: The current study shows that the most important aspects for treatment satisfaction and quality of life of dual-diagnosis patients admitted involuntary to long-term treatment, are being listened to (being taken seriously) and experiencing improvements during treatment. These qualities reflect the goals of Shared Decision Making and Perceived Procedural Justice in treatment. The study also corroborates earlier findings that even when treated involuntarily, patients might not hold particular negative views regarding their treatment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Van Kranenburg, Diekman, Van den Brink, Mulder, Pijnenborg and Mulder.)

Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions-particularly first choice non-pharmacological therapies-and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lancel, van Marle, Van Veen and van Schagen.)

Introduction: Social functioning is often impaired in the ultra-high-risk (UHR) phase of psychosis. There is some evidence that empathy is also impaired in this phase and that these impairments may underlie difficulties in social functioning. The main aim of this study was to investigate whether cognitive and affective empathy are lower in people in the UHR phase of psychosis in comparison to healthy controls, and whether possible impairments have the same magnitude as in people with schizophrenia. A second aim was to examine whether there is a relationship between empathy and social functioning in individuals in the UHR phase. Method: Forty-three individuals at UHR for psychosis, 92 people with a schizophrenia spectrum disorder, and 49 persons without a psychiatric disorder completed the Interpersonal Reactivity Index (IRI), Questionnaire of Cognitive and Affective Empathy (QCAE), and Faux Pas as instruments to measure empathy. The Time Use survey was used to measure social functioning. MAN(C)OVA was used to analyse differences between groups on empathy and social functioning, and correlations were calculated between empathy measures and social functioning for each group. Results: The UHR group presented significantly lower levels of self-reported cognitive empathy than the healthy controls, but not compared to patients with SSD, while performance-based cognitive empathy was unimpaired in the UHR group. On the affective measures, we found that people with UHR and patients with SSD had significantly higher levels of self-reported distress in interpersonal settings compared to healthy controls. In the UHR group, perspective-taking was negatively associated with time spent on structured social activities. In the SSD group, we found that structured social activities were positively associated with perspective-taking and negatively associated with personal distress in interactions with others. Lastly, in people without mental illness, social activities were positively associated with performance-based perspective-taking. Conclusion: Impairments in subjective cognitive empathy appear to be present in the UHR phase, suggesting that difficulties in interpreting the thoughts and feelings of others precede the onset of psychotic disorders. This can inform future interventions in the UHR phase., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kuis, van de Giessen, de Jong, Sportel, Boonstra, van Donkersgoed, Lysaker, Hasson-Ohayon and Pijnenborg.)

Background: Tactile and somatic hallucinations are distressing phenomena that have hardly been researched. The few studies that have been published focus on their occurrence in neurodegenerative disorders and substance use, and, surprisingly, not on schizophrenia spectrum disorders. Objective: To fill this gap in our knowledge, we sought to explore the phenomenological characteristics of tactile and somatic hallucinations in a group of psychotic Muslim patients. Since many Muslims attribute such experiences to jinn (invisible spirits) and jinn are often perceived in multiple sensory modalities, we not only charted the involvement of the tactile and somatic modalities but also their interrelatedness with hallucinations in other sensory modalities. Methods: We performed a cross-sectional study using a semi-structured interview and dedicated questionnaire. Results: Of the 42 Muslim inpatients mostly diagnosed with a schizophrenia spectrum disorder, 62% reported to suffer from tactile and/or somatic hallucinations. Their phenomenological characteristics varied, with 96% being multimodal in nature and 38% taking the form of full-blown entity/jinn encounters. In comparison to other entity experiences, the involvement of the tactile and somatic modalities was exceptionally high, as was the level of ensuing distress. Regarding the order of recruitment of the various sensory modalities, we suggest the involvement of an underlying stochastic process. Conclusion: Muslim patients with severe psychosis can have tactile and somatic hallucinations, of which a large number are multimodal or full-blown entity/jinn encounters, which are almost invariably appreciated as harrowing. On the basis of our findings we make recommendations for further research and clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lim and Blom.)

We describe a case of an adolescent male with Niemann-Pick Type C (NP-C), a neurodegenerative lysosomal lipid storage disorder, who presented with recurrent catatonia which required repeated treatment with electroconvulsive therapy (ECT). During the ECT-course, seizure threshold increased substantially, leading to questions about the influence of NP-C on neuronal excitability. In this exemplary ECT-patient, NP-C was diagnosed not until after the first ECT-course when initial psychopharmacology for catatonia had failed and antipsychotics and benzodiazepines showed significant side-effects . Clinicians should be aware of NP-C in patients referred for ECT, especially in the case of treatment resistance, neurological symptoms and intolerance of psychopharmacological drugs. As was shown in our NP-C patient, ECT can be repeatedly effective for catatonic features. In the literature, effectiveness of ECT in patients with NP-C has sparsely been reported. This case demonstrates that detection of NP-C is beneficial for patients because more optimal treatment with ECT can be provided earlier without further exposure to side-effects., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 van Verseveld, Koens, de Koning, Derikx and van Waarde.)

Background: Yoga may pose a promising complementary therapy in the multimodal treatment of in-patients with schizophrenia spectrum disorders (SSD). However, to date, no studies have qualitatively examined in-patients' with SSD experiences of Yoga as well as their perceptions of its limitations and benefits as a treatment component. This qualitative study aimed to explore for the first time the mechanisms and processes of Yoga-based Group Intervention (YoGI) for in-patients with SSD in Germany by asking for their subjective experiences. Findings could serve as a preliminary basis for developing an effective and evidence-based YoGI manual tailored to this patient group. Materials and Methods: In total, 25 semi-structured interviews were conducted directly after YoGI, for which responses were either noted down by hand or audio-recorded. The interview guide was pilot-tested and consisted of 14 questions to explore the personal articulated experiences of participation in YoGI from in-patients with SSD. Positive, negative, depressive, and anxiety symptoms were assessed during a diagnostic interview and through questionnaires. The interview data was transcribed, coded by two independent researchers, and analysed using an inductive thematic approach. The research team collaboratively discussed emerging categories to reduce redundancy and form meaningful themes and subthemes. Results: The analysis revealed seven main themes. YoGI was perceived as feasible and focusing on individual adaptation, captured by the theme inclusivity . Nevertheless, participants encountered challenges ; thus, physical limitations need to be considered. While practising together, participants experienced interconnectedness and developed a mindful stance as they accepted their limitations and adapted exercises with self-compassion. Patients described that following the flow of the asanas required physical persistence, which ultimately led many participants to experience confidence and relaxation . YoGI affected symptom representation as heightened awareness led participants to notice impeding as well as improved symptoms. Conclusion: YoGI showed various promising effects on in-patients with SSD. Future research should examine to what extent these effects can be sustained and how the mindful approach during YoGI can be transferred to areas outside the Yoga class. Furthermore, a randomised controlled trial could investigate the effectiveness of a manualised YoGI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Schulze, Hahn, Hahne, Bergmann, Fuchs, Mähler, Zierhut, Ta, Pijnenborg and Böge.)

Background: The COVID-19 lockdown increases psychological problems in children and adolescents from the general population. Here we investigate the mental and social health during the COVID-19 lockdown in children and adolescents with pre-existing mental or somatic problems. Methods: We included participants (8-18 years) from a psychiatric ( N = 249) and pediatric ( N = 90) sample, and compared them to a general population sample ( N = 844). Measures were assessed during the first lockdown (April-May 2020) in the Netherlands. Main outcome measures were Patient-Reported Outcomes Measurement Information System (PROMIS®) domains: Global Health, Peer Relationships, Anxiety, Depressive Symptoms, Anger, and Sleep-Related Impairment, as reported by children and youth. Additionally, socio-demographic variables, COVID-19-related questions, changes in atmosphere at home from a parent and child perspective, and children's experiences of lockdown regulations were reported by parents. Results: On all measures except Global Health, the pediatric sample reported least problems. The psychiatric sample reported significantly more problems than the general population sample on all measures except for Anxiety and Peer Relationships. Having a COVID-19 affected friend/relative and a COVID-19 related change in parental work situation negatively moderated outcome, but not in the samples with pre-existing problems. All parents reported significant decreases in atmosphere at home, as did children from the general population. Conclusion: We observed significant differences in mental and social health between three child and adolescent samples during the COVID-19 pandemic lockdown and identified COVID-19-related factors influencing mental and social health., Competing Interests: JB has served as a member of the advisory board of Medice, Roche, Servier, Angelini and has received speaker fee from Takeda and Medice. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Zijlmans, Teela, van Ewijk, Klip, van der Mheen, Ruisch, Luijten, van Muilekom, Oostrom, Buitelaar, Hoekstra, Lindauer, Popma, Staal, Vermeiren, van Oers, Haverman and Polderman.)

Objective: The purpose of this study was to compare the prevalence of MetS and the associated sociodemographic, clinical, and pharmacotherapeutic characteristics of patients with schizophrenia in three psychiatric hospitals in the West Siberian region. Methods: Patients with a clinical diagnosis of schizophrenia (ICD-10: F20) and an age between 18 and 60 years were included in the study after giving informed consent. Metabolic syndrome was diagnosed according to the International Diabetes Federation criteria. This research was carried out at three Western Siberian psychiatric hospitals in Kemerovo, Tomsk, and Omsk. The study population included respectively 94, 131, and 91 inpatients with schizophrenia. We carried out schizophrenia symptoms assessment by PANSS, antipsychotic therapy evaluation, anthropometry, and biochemical analysis. Statistical Analysis included the Shapiro-Wilk test, non-parametric Kruskal-Wallis H -test for independent samples, Mann-Whitney U -test for independent samples, the chi-square test, stepwise multiple regression analyses. The level of significance was p < 0.05. Results: The metabolic syndrome prevalence was higher among patients in Tomsk (36.6%), compared with Kemerovo (20.2%, p = 0.008) or Omsk (18.7%, p = 0.004), mainly due to the high prevalence of abdominal obesity, while men from Tomsk were more susceptible to this condition than men from other regions ( p < 0.05). Patients from Omsk had the highest severity schizophrenia symptoms according to PANSS, and patients from Tomsk had the lowest severity of positive symptoms according to PANSS. Patients from Tomsk had the minimum duration of antipsychotic therapy compared with the patient from Kemerovo ( p = 0.017) and from Omsk ( p = 0.000019), but most patients from Tomsk received second-generation atypical antipsychotics, while patients from Omsk received mainly conventional antipsychotics ( p = 0.0001). Multiple regression analysis showed that metabolic syndrome associated with schizophrenia duration and body mass index, although the association was not so strong (adjusted R 2 = 0.2435, p The study illustrates that in different psychiatric hospitals within the same region, the prevalence of metabolic syndrome in patients with schizophrenia can vary significantly, which dictates the need to look for opportunities to minimize the risk of its occurrence, taking into account the experience of each hospital.Discussion: The study illustrates that in different psychiatric hospitals within the same region, the prevalence of metabolic syndrome in patients with schizophrenia can vary significantly, which dictates the need to look for opportunities to minimize the risk of its occurrence, taking into account the experience of each hospital., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kornetova, Kornetov, Mednova, Goncharova, Gerasimova, Pozhidaev, Boiko, Semke, Loonen, Bokhan and Ivanova.)

Of the perceptual distortions characteristic of Alice in Wonderland syndrome, substantial alterations in the immediate experience of time are probably the least known and the most fascinating. We reviewed original case reports to examine the phenomenology and associated pathology of these time distortions in this syndrome. A systematic search in PubMed, Ovid Medline, and the historical literature yielded 59 publications that described 168 people experiencing time distortions, including 84 detailed individual case reports. We distinguished five different types of time distortion. The most common category comprises slow-motion and quick-motion phenomena. In 39% of all cases, time distortions were unimodal in nature, while in 61% there was additional involvement of the visual (49%), kinaesthetic (18%), and auditory modalities (14%). In all, 40% of all time distortions described were bimodal in nature and 19% trimodal, with 1% involving four modalities. Underlying neurological mechanisms are varied and may be triggered by intoxications, infectious diseases, metabolic disorders, CNS lesions, paroxysmal neurological disorders, and psychiatric disorders. Bizarre sensations of time alteration-such as time going backwards or moving in circles-were mostly associated with psychosis. Pathophysiologically, mainly occipital areas appear to be involved, although the temporal network is widely disseminated, with separate component timing mechanisms not always functioning synchronously, thus occasionally creating temporal mismatches within and across sensory modalities (desynchronization). Based on our findings, we propose a classification of time distortions and formulate implications for research and clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer DC declared a past co-authorship with several of the authors JDB, FW to the handling editor., (Copyright © 2021 Blom, Nanuashvili and Waters.)

Background: Digital technologies have the potential to provide objective and precise tools to detect depression-related symptoms. Deployment of digital technologies in clinical research can enable collection of large volumes of clinically relevant data that may not be captured using conventional psychometric questionnaires and patient-reported outcomes. Rigorous methodology studies to develop novel digital endpoints in depression are warranted. Objective: We conducted an exploratory, cross-sectional study to evaluate several digital technologies in subjects with major depressive disorder (MDD) and persistent depressive disorder (PDD), and healthy controls. The study aimed at assessing utility and accuracy of the digital technologies as potential diagnostic tools for unipolar depression, as well as correlating digital biomarkers to clinically validated psychometric questionnaires in depression. Methods: A cross-sectional, non-interventional study of 20 participants with unipolar depression (MDD and PDD/dysthymia) and 20 healthy controls was conducted at the Centre for Human Drug Research (CHDR), the Netherlands. Eligible participants attended three in-clinic visits (days 1, 7, and 14), at which they underwent a series of assessments, including conventional clinical psychometric questionnaires and digital technologies. Between the visits, there was at-home collection of data through mobile applications. In all, seven digital technologies were evaluated in this study. Three technologies were administered via mobile applications: an interactive tool for the self-assessment of mood, and a cognitive test; a passive behavioral monitor to assess social interactions and global mobility; and a platform to perform voice recordings and obtain vocal biomarkers. Four technologies were evaluated in the clinic: a neuropsychological test battery; an eye motor tracking system; a standard high-density electroencephalogram (EEG)-based technology to analyze the brain network activity during cognitive testing; and a task quantifying bias in emotion perception. Results: Our data analysis was organized by technology - to better understand individual features of various technologies. In many cases, we obtained simple, parsimonious models that have reasonably high diagnostic accuracy and potential to predict standard clinical outcome in depression. Conclusion: This study generated many useful insights for future methodology studies of digital technologies and proof-of-concept clinical trials in depression and possibly other indications., Competing Interests: OS, JC, KH, LG, VD, FA, JP, VV, AD, BG-M, KB, MD, and J-HC were employed by Novartis. FC was employed by Cambridge Cognition. JA was employed by Neurotrack Technologies, Inc. ZP, GI, and OL were employed by ElMindA, Ltd. DJ was employed by Sonde Health, Inc. AZ, RZ, KR, ZZ, and GJ were employed by CHDR. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sverdlov, Curcic, Hannesdottir, Gou, De Luca, Ambrosetti, Zhang, Praestgaard, Vallejo, Dolman, Gomez-Mancilla, Biliouris, Deurinck, Cormack, Anderson, Bott, Peremen, Issachar, Laufer, Joachim, Jagesar, Jongs, Kas, Zhuparris, Zuiker, Recourt, Zuilhof, Cha and Jacobs.)

Long-term admissions in psychiatric facilities often result in a gradual erosion of the identity of people diagnosed with severe mental illnesses (SMIs) into merely "patient." Moreover, experiences of loss often reduced people's sense of purpose. Although regaining a multidimensional identity and a sense of purpose are essential for personal recovery, few interventions specifically address this, while at the same time take people's often considerable cognitive and communicative disabilities into consideration. This study describes the development process of a new intervention through user-centered design (UCD). UCD is an iterative process in which a product (in this case, an intervention) is developed in close cooperation with future users, such that the final product matches their needs. The design process included three phases: an analysis, design, and evaluation phase. In the analysis phase, the "problem" was defined, users' needs were identified, and design criteria were established. In the design phase, the collected information served as input to create a testable prototype using a process of design and redesign, in close collaboration with service users and other stakeholders. This resulted in an intervention entitled "This is Me" (TiM) in which service users, together with a self-chosen teammate, actively engage in new experiences on which they are prompted to reflect. Finally, in the evaluation phase, TiM was implemented and evaluated in a real-life setting. In a small feasibility pilot, we found indications that some people indeed demonstrated increased reflection on their identity during the intervention. Furthermore, TiM seemed to benefit the relationship between the service users and the mental health professionals with whom they underwent the experiences. The pilot also revealed some aspects of the (implementation of) TiM that can be improved. Overall, we conclude that UCD is a useful method for the development of a new psychosocial intervention. The method additionally increased our knowledge about necessary factors in targeting personal recovery for people with complex mental health needs. Moreover, we conclude that TiM is a promising tool for supporting people with SMI in redeveloping a multidimensional identity and a renewed sense of purpose., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 van der Meer, Jonker, Wadman, Wunderink, van Weeghel, Pijnenborg and van Setten.)

The Yale Global Tic Severity Scale (YGTSS) is a clinician-rated instrument considered as the gold standard for assessing tics in patients with Tourette's Syndrome and other tic disorders. Previous psychometric investigations of the YGTSS exhibit different limitations such as small sample sizes and insufficient methods. To overcome these shortcomings, we used a subsample of the large-scale "European Multicentre Tics in Children Study" (EMTICS) including 706 children and adolescents with a chronic tic disorder and investigated convergent, discriminant and factorial validity, as well as internal consistency of the YGTSS. Our results confirm acceptable convergent and good to very good discriminant validity, respectively, indicated by a sufficiently high correlation of the YGTSS total tic score with the Clinical Global Impression Scale for tics ( r = 0.65) and only low to medium correlations with clinical severity ratings of attention deficit/hyperactivity symptoms ( s = 0.65) and only low to medium correlations with clinical severity ratings of attention deficit/hyperactivity symptoms ( r s = 0.27). Internal consistency was found to be acceptable (Ω = 0.58 for YGTSS total tic score). A confirmatory factor analysis supports the concept of the two factors "motor tics" and "phonic tics," but still demonstrated just a marginal model fit (root mean square error of approximation = 0.09 [0.08; 0.10], comparative fit index = 0.90, and Tucker Lewis index = 0.87). A subsequent analysis of local misspecifications revealed correlated measurement errors, suggesting opportunities for improvement regarding the item wording. In conclusion, our results indicate acceptable psychometric quality of the YGTSS. However, taking the wide use and importance of the YGTSS into account, our results suggest the need for further investigations and improvements of the YGTSS. In addition, our results show limitations of the global severity score as a sum score indicating that the separate use of the total tic score and the impairment rating is more beneficial.r s = 27) as well as internalizing symptoms ( r s = 0.27). Internal consistency was found to be acceptable (Ω = 0.58 for YGTSS total tic score). A confirmatory factor analysis supports the concept of the two factors "motor tics" and "phonic tics," but still demonstrated just a marginal model fit (root mean square error of approximation = 0.09 [0.08; 0.10], comparative fit index = 0.90, and Tucker Lewis index = 0.87). A subsequent analysis of local misspecifications revealed correlated measurement errors, suggesting opportunities for improvement regarding the item wording. In conclusion, our results indicate acceptable psychometric quality of the YGTSS. However, taking the wide use and importance of the YGTSS into account, our results suggest the need for further investigations and improvements of the YGTSS. In addition, our results show limitations of the global severity score as a sum score indicating that the separate use of the total tic score and the impairment rating is more beneficial., Competing Interests: TJH and VT have received funding from the Guys and St Thomas' NHS Foundation Trust. IH has received research funding or support from the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. PM has received grants from the Instituto de Salud Carlos III (PI10/01674, PI13/01461), the Consejería de Economía, Innovación, Ciencia y Empresa de la Junta de Andalucía (CVI-02526, CTS-7685), the Consejería de Salud y Bienestar Social de la Junta de Andalucía. KM-V has received financial or material research support from the EU (FP7-PEOPLE-2012-ITN No. 316978), the German Research Foundation (DFG: GZ MU 1527/3-1), the German Ministry of Education and Research (BMBF: 01KG1421), the National Institute of Mental Health (NIMH), the Tourette Gesellschaft Deutschland e.V., the Else-Kröner-Fresenius-Stiftung, and Abide Therapeutics, Almirall Hermal GmbH, GW pharmaceuticals, Lundbeck, Syneos Health, and Therapix Biosciences Ltd. She has received consultant's honoraria from Abide Therapeutics, Allmiral, Boehringer Ingelheim International GmbH, Bionorica Ethics GmbH, CannaMedical Pharma GmbH, Canopy Grouth, Columbia Care, CTC Communications Corp., Eurox Deutschland GmbH, Global Praxis Group Limited, Lundbeck, Resalo Vertrieb GmbH, Sanity Group, STADAPHARM GmbH, Synendos Therapeutics AG, and Tilray. She was a consultant or advisory board member for Abide Therapeutics, The Academy of Medical Cannabis Limited, Alirio, Aphria Deutschland GmbH, CannaMedical Pharma GmbH, Bionorica Ethics GmbH, CannaXan GmbH, Canopy Growth, Columbia Care, CTC Communications Corp., Leafly Deutschland GmbH, Lundbeck, Nuvelution TS Pharma Inc., Resalo Vertrieb GmbH, Sanity Group, Syqe Medical Ltd., Therapix Biosciences Ltd., Tilray, and Wayland Group. She has received speaker's fees from Aphria Deutschland GmbH, Cogitando GmbH, Emalex, Eurox Deutschland GmbH, Ever pharma GmbH, PR Berater, Spectrum Therapeutics GmbH, Tilray, and Wayland Group. She has received royalties from Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin, Elsevier, and Kohlhammer. She served as a Guest editor for Frontiers in Neurology on the research topic “The neurobiology and genetics of Gilles de la Tourette syndrome: new avenues through large-scale collaborative projects,” and is Associate editor for “Cannabis and Cannabinoid Research,” Editorial Board Member for “Medical Cannabis and Cannabinoids” and “MDPI-Reports,” and scientific board member for “Zeitschrift für Allgemeinmedizin.” AM has received research funding or support from the Possehl-Stiftung (Lübeck, Germany), the Margot und Jürgen Wessel Stiftung (Lübeck, Germany), the Tourette Syndrome Association (Germany), Interessenverband Tourette Syndrom (Germany), CHDI, Damp-Stiftung; Deutsche Forschungsgemeinschaft (DFG): projects 1692/3-1, 4-1, SFB 936, and FOR 2698 (project numbers 396914663, 396577296, 396474989), Innovationsausschuss of the Gemeinsamer Bundesausschuss: Translate NAMSE (structural support for the Lübeck Center for Rare Diseases); European Reference Network—Rare Neurological Diseases (ERN—RND). SW has received in the last 5 years royalties from Thieme Hogrefe, Kohlhammer, Springer, Beltz. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel, Unicentia, Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/. AS has received research funding or support from University College London, National Institute of Health (NIHR), National Institute for Health Research ULCH Biomedical Research Centre, the International Parkinson and Movement Disorder Society (IPMDS), the European Commission, Parkinson's UK, GE Healthcare and the Economic and Social Research Council. Honoraria for consultancy from Biogen, Abbvie, Roche, Bial, GE Healthcare; and license fee payments from the University College London for the MSA-QoL, PSP-QoL, and PQolCarers. Royalties from Oxford University Press. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Haas, Jakubovski, Fremer, Dietrich, Hoekstra, Jäger, Müller-Vahl and the EMTICS Collaborative Group.)

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores ( r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope ( r = 0.56, 95%CI 0.48-0.63), meaning in life ( r = 0.48, 95%CI 0.38-0.58) and empowerment ( r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness ( r = 0.34, 95%CI 0.43-0.65) and identity ( r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Leendertse, Wierdsma, van den Berg, Ruissen, Slade, Castelein and Mulder.)

Background: Most of our knowledge about the etiology, course, treatment, and outcome of schizophrenia spectrum and other psychotic disorders stems from Western countries. Data from populations living in other geographical areas and low- and middle-income countries, with different genomes (ethnicity) and exposomes (e.g., culture and social support, drugs of abuse, religion), will add to our knowledge of this complex disorder. Methods: The Azeri Acute phase/Recent onset psychosis Survey (ARAS) has been initiated to study the course of the disorder in patients with recent-onset psychosis using validated diagnostic tools and a comprehensive outcome monitoring system, aiming to reveal indicators for understanding the risk and resilience factors and for choosing the best-personalized treatment strategy. All participants will be evaluated for clinical signs and symptoms as well as risk and resilience factors and will be followed up for 1, 3, and 5 years for outcomes in several domains. A hierarchical cluster method will be applied to identify the number of clusters for each outcome. Defined models will be applied to assess the predictive value of cognition on symptomatic and functional outcomes at follow-up. Discussion: The ARAS cohort will yield significant academic- (research and education) and care-related achievements. ARAS data and experience will have value both in being a useful model for other parts of this region and in an expansion of the currently available knowledge., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Farhang, Ghaemmaghami, Shafiee-Kandjani, Noorazar, Veling, Malek, Somi, Bruggeman and Alizadeh.)

Associations between psychotic experiences and suicidal ideation are not yet fully understood, and the potential role of depressive symptoms in this relationship remains unclear. The current study examined relationships between depressive symptoms (DS), psychotic experiences (PE) and suicidal ideation (SI) using two complementary approaches on cross-sectional data from a community sample of adolescents aged 13-19 years ( N = 1,591). First, we investigated the association between the three domains using mediation analysis, showing that depressive symptoms partly mediate the relationship between psychotic experiences and suicidal ideation. Second, we looked at associations between the three domains at item level using network analysis. Specific associations between symptoms of the three domains were found, indicating depressive symptoms of sadness, avolition, pessimism, and self-criticalness/worthlessness as the most central symptoms in the network. Suicidal ideation was associated with the depressive symptoms pessimism and worthlessness, to social anxiety, and to perceptual anomalies. Our results show that the mediating effect of depressive symptoms between psychotic experiences and suicidal ideation may be due to associations between specific aspects of SI, depressive symptoms and psychotic experiences. These findings can contribute to the planning of health services and programs aimed at the timely detection of psychopathology and suicidal risk in young people., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Núñez, Monjes, Campos and Wigman.)