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Background Visual experiences such as hallucinations are commonly reported by people with psychosis, psychological trauma and dissociative states, although questions remain about their similarities and differences. For diagnostic and therapeutic purposes, clinical research must better delineate and compare the characteristics of these experiences in post-traumatic stress disorder (PTSD) and in schizophrenia. Aims To compare visual phenomena and dissociation in participants with a primary psychotic illness and those with a trauma diagnosis. Method A quantitative group design study comparing visual phenomena in three participant groups who also have a history of hearing voices: schizophrenia and no trauma history (n = 19), PTSD with dissociation (n = 17) and comorbid schizophrenia and PTSD (n = 20). Validated clinical measures included the North-East Visual Hallucination Interview, PTSD Symptoms Scale Interview, Clinician Administered Dissociative States Scale, Psychotic Symptoms Rating Scales and Positive and Negative Syndrome Scale. Results There was a remarkable similarity in visual experiences, including rates of complex visual hallucinations, between the three diagnostic groups. There were no significant differences in the severity or components of distress surrounding the visual experiences. Dissociation predicted visual hallucination severity for the comorbid schizophrenia and PTSD group, but not for PTSD or schizophrenia alone. Conclusions Visual experiences in PTSD can include visual hallucinations that are indistinguishable from those experienced in schizophrenia. Multimodal hallucinations are frequently observed in both schizophrenia and PTSD. A model for visual hallucinations in PTSD is suggested, following two separate neurobiological pathways based on distinct responses to trauma.

Objective: To increase awareness of practising clinicians and researchers to the phenomenological distinctions between visual hallucinations and trauma-based, dissociative, visual re-experiencing phenomena seen in psychiatric disease. Conclusions: The experience of visual hallucinations is not exclusive to psychotic disorders in psychiatry. Different forms of experiences that resemble visual hallucinations may occur in patients with a trauma background and may potentially affect diagnosis. Given the paucity of literature around the subject, it is imperative that further research aims to characterise the distinction between visual hallucinations in psychosis and visual phenomena associated with trauma.

In response to the COVID-19 pandemic, our early psychosis program rapidly transitioned to telepsychiatry. This study examined the change in health service utilization and experiences of young people and clinicians in response to the implementation of telepsychiatry.Mixed methodology and triangulation of evidence drawn from health service databases and survey data. Using a retrospective observational design, health service data from pre- (Time 1) and post-(Time 2) telepsychiatry periods were compared. Surveys were also conducted with representation from clinicians and young people.The number of appointments increased between Time 1 and 2, although this was accompanied by a near-doubling in missed appointments (8% to 13%). Young people had mixed views about telepsychiatry. While convenience was a frequently cited benefit, clients reported technological issues, isolation and lack of human connection. A preference for face-to-face appointments was linked to younger age and anxiety when using telepsychiatry. Clinicians reported improved workplace satisfaction and efficiency but noted some limitations in the use of telepsychiatry including difficulty interviewing and managing unwell clients remotely and called for greater skill development.The introduction of telepsychiatry in response to COVID-19 was associated with an increase in service activity; however, there was an increase missed appointments by young people. Although clinicians and clients reported positive experiences, telepsychiatry was not completely endorsed as a replacement for face-to-face interactions.

The recent renaissance of psychedelic science has reignited interest in the similarity of drug-induced experiences to those more commonly observed in psychiatric contexts such as the schizophrenia-spectrum. This report from a multidisciplinary working group of the International Consortium on Hallucinations Research (ICHR) addresses this issue, putting special emphasis on hallucinatory experiences. We review evidence collected at different scales of understanding, from pharmacology to brain-imaging, phenomenology and anthropology, highlighting similarities and differences between hallucinations under psychedelics and in the schizophrenia-spectrum disorders. Finally, we attempt to integrate these findings using computational approaches and conclude with recommendations for future research.

People with psychosis benefit enormously from Cognitive Behavioural Therapy for Insomnia (CBTI), although some variability exists in treatment outcomes. While recent efforts have focused on profiling sleep at treatment initiation, an alternative methodological approach involves using treatment response as a starting point to better understand what constitutes an effective treatment. This study used Grade of Membership analysis (GoM) to estimate the occurrence of unique treatment outcomes and associated patient characteristics. Outcome measures included changes in sleep (self-reported latency, efficiency, duration, quality), functional outcomes (daytime dysfunction, negative mood, need for sleep medication) and treatment goal, collected in 50 individuals with a psychotic disorder and insomnia who underwent CBT-I treatment. Three distinct profiles were identified: (1) Strong responders, who met their treatment goals and showed broad improvements in both sleep and functional domains; (2) Partial responders, who showed sleep improvements (particularly in total sleep time), without noticeable gains in function, and who were predominantly female; and (3) Non-responders who showed little treatment response and failed to meet their treatment goals. This group was also more likely to have greater psychopathology (high levels of negative mood and psychotic symptoms, and antipsychotic medication dosage). These findings suggest that (i) CBT-I can serve to improve sleep and daytime function (although sleep can improve independently from function), (ii) client-elicited treatment goals are a key predictor of CBT-I response, (iii) other important variables associated with treatment response include sleep profile, clinical acuity, and sex.

Weight gain remains a major problem in young people with psychosis treated with antipsychotic medication. Aripiprazole is now available in monthly long-acting injection (LAI) and daily oral tablet formulation, but information is lacking about differences in weight gain between the two formulations. We monitored for up to 24 months the weight changes associated with oral or LAI-administered aripiprazole and in a group who not prescribed any antipsychotic medication.Participants included 109 young people with early psychosis (n = 30 Oral, 41 LAI, 38 Nil antipsychotic) with a treatment completion median time of 15 months. Weight (kilogram) and body mass index (BMI) were recorded at 3 monthly intervals. Multilevel modelling analyses assessed the contribution of time and group on weight change.Participants taking nil antipsychotics did not gain weight over time, while the two aripiprazole groups gained a combined average of 7.1 kg (SD = 5.0) or 1.9 BMI (SD = 0.4). An examination of formulation effects showed a significantly greater rate of change over time in the Oral group with a weight increase of approximately 11.0 kg (SD = 8.2) or 3.5 BMI (SD = 0.7, compared to the LAI group with a gain of 3.7 kg (SD = 2.1) or 0.8 BMI (SD = 0.1) in the LAI group. These differences could not be explained by demographic or clinical characteristics, medication dosage, or baseline weight.While aripiprazole is generally considered relatively benign in terms of weight, it still poses a significant risk especially for people with early psychosis. However the current study suggests that the risk may be lower in those treated with LAI than with Oral formulation, consolidating the clinical utility of LAI.

Objective: Aripiprazole is often prescribed to young people, although there remain unanswered questions about its effects on weight gain. This study undertook a meta-analysis of weight gain occurring in young people with early psychosis who were prescribed aripiprazole. Method: A systematic search was conducted for studies reporting on aripiprazole and weight change in young people with a psychotic disorder. A meta-analysis integrated the data into an estimate of effect size. Results: Eleven studies met the inclusion criteria amounting to 886 participants (mean age 18 years). The results showed significant weight gain averaging 2.7 kg. These increases were associated with a longer duration of exposure to aripiprazole but not a higher dosage. Conclusions: The results highlight the importance of regular patient monitoring and the early implementation of interventions to manage antipsychotic-related weight gain.

Hallucinations are one of the most interesting and least understood of all human experiences. This commentary addresses the ideas which most influenced my thinking in the past 20 years and what I believe to be the most currently promising area of enquiry. Interest in hallucinations reaches far back into antiquity and across cultures. The similarity of hallucinations in mental illness with the perceptual experiences reported by individuals who not mentally unwell has long been recognized. Early scientific research on hallucinogen drugs such as lysergic acid diethylamide (LSD) was criticized and then withdrawn, but its recent revival offers new opportunities to examine the mechanism and 'process' of hallucinating. Many psychedelic compounds can elicit intense and realistic hallucinations. The study of hallucinogens conducted in carefully controlled and supervised settings and with individuals who are not mentally unwell opens exciting new possibilities. For example, it may be possible to study the temporal shifts in perceptual awareness, decode what influences the contents, affect, meaning, and appraisals of hallucinations and guide novel psychotherapy techniques and drug therapy.

Few studies have compared the content and appraisal of hallucinatory experiences (HE) by people with psychosis and those without. This study compared the characteristics of HE, and their appraisals, in individuals with psychotic disorder, non-psychotic mental disorder and no disorder in the general population. Participants (n = 253) aged between 30-33 years who reported HE were recruited from a birth cohort and assessed for lifetime diagnoses of mental disorders. They were allocated to groups based on their diagnosis and their HE were rated to assess their form, content and associated appraisals. Compared to those with no mental disorder, participants with a psychotic disorder had almost twelve times the odds of appraising their HE as distressing and dangerous and nine times the odds of experiencing recurrent HE. Those with a non-psychotic disorder had more than twice the odds of recurrent HE compared to those with no disorder. Overall, HE showed more similarities than differences across the diagnostic groups. Negative appraisals of HE and their recurrence differentiated clinical from non-clinical populations. Screening for HE and assessment of their associated appraisals is essential in those seeking care for mental health difficulties. Interventions aimed at modifying maladaptive appraisals can assist in reducing hallucination related distress.

Drug studies are powerful models to investigate the neuropharmacological mechanisms underlying temporal processing in humans. This study administered dexamphetamine to 24 healthy volunteers to investigate time perception at different time scales, along with contributions from working memory. Healthy volunteers were administered 0.45 mg/kg dexamphetamine or placebo in a double-blind, crossover, placebo-controlled design. Time perception was assessed using three experimental tasks: a time-discrimination task, which asked participants to determine whether a comparison interval (1200 ± 0, 50, 100, 150, 200 ms) was shorter or longer than a standard interval (1200 ms); a retrospective time estimation task, which required participants to verbally estimate time intervals (10, 30, 60, 90 and 120 s) retrospectively; and a prospective time-production task, where participants were required to prospectively monitor the passing of time (10, 30, 60, 90 and 120 s). Working memory was assessed with the backwards digit span. On the discrimination task, there was a change in the proportion of long-to-short responses and reaction times in the dexamphetamine condition (but no association with working memory), consistent with an increase in the speed of an internal pacemaker, and an overestimation of durations in the timing of shorter intervals. There was an interaction between dexamphetamine, working memory, and performance on the estimation and production tasks, whereby increasing digit span scores were associated with decreasing interval estimates and increased produced intervals in the placebo condition, but were associated with increased interval estimates and decreased produced intervals after dexamphetamine administration. These findings indicate that the dexamphetamine-induced increase in the speed of the internal pacemaker was modulated by the basal working memory capacity of each participant. These findings in healthy humans have important implications for the role of dopamine, and its contributions to timing deficits, in models of psychiatric disorders.

Objective: Effective implementation of mobile applications into the mainstream of mental health care cannot be imposed without acknowledging consumers’ perspectives. This study investigated the willingness of mental health consumers and clinical staff to adopt new technology in their treatment.Method: A total of 74 mental health consumers and 116 clinical staff were recruited for the study. Survey data for consumers were collected using hard copies and for staff using the REDCap data management platform.Results: Both consumers and clinical staff reported positive attitudes towards the use of mobile applications in mental health care, emphasising their validity, ease of use and cost. Consumers were more likely to use apps supporting relaxation and time management than those targeting complex problems (alcohol, smoking, hearing voices). However, about half of consumers expressed concerns regarding privacy, and about 40% of them felt uncomfortable about providing personal information to clinicians. T...

Targeted, highly accessible early intervention for youths with emerging and complex psychiatric presentations is increasingly needed. The Youth Community Assessment and Treatment Team (YCATT) multidisciplinary service was established to provide intensive intervention for youths in Perth, Australia.The authors conducted a retrospective evaluation to examine YCATT's impact on emergency department (ED) visits, psychiatric inpatient admissions, and provision of care for youths in the transition period between adolescent and adult psychiatric services. Demographic, clinical, and service utilization data for all referrals over the pilot period (2016-2017) were collected and analyzed with descriptive statistics.During the pilot period, 308 referrals were accepted. All referred youths had a trauma history and presented with acute or complex conditions, and most (66%) were between 16 and 18 years old. The admission rate to a psychiatric inpatient unit was7%. Of 61 youths specifically referred to YCATT as an alternative to psychiatric admission, 90% were successfully diverted from psychiatric or ED admission. After discharge from YCATT, youths had improved scores on the Health of the Nations Outcome Scale and 10-item Kessler Psychological Distress Scale.These findings suggest that YCATT is an accessible and effective service for the population of transition-age youths. It appears that YCATT, in collaboration with other community services, contributed to diverting psychiatric inpatient admissions, facilitated outpatient treatment, and enabled continuity of care for vulnerable youths. The results underscore the need for more accessible, individualized treatment approaches for youths who transition to adulthood.

Within the broad field of human perception lies the category of stimulus-independent perceptions, which draws together experiences such as hallucinations, mental imagery and dreams. Traditional divisions between medical and psychological sciences have contributed to these experiences being investigated separately. This review aims to examine their similarities and differences at the levels of phenomenology and underlying brain function and thus reassemble them within a common framework. Using Edmund Parish's historical work as a guiding tool and the latest research findings in the cognitive, clinical and computational sciences, we consider how different perspectives may be reconciled and help generate novel hypotheses for future research. This article is part of the theme issue ‘Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation’.

Objective: Ketamine is a potential rapid-acting treatment for depression. Studies have suggested that the side effects are minimal and temporary, but the psychotic symptom side effects have yet to be fully examined. This study investigated whether ketamine infusion in the treatment of mood disorders is associated with increases in positive symptoms and whether these symptom effects endure over time. Methods: A systematic review and meta-analysis of studies of ketamine in the treatment of depression. Embase and Medline databases were searched for studies including (a) participants with major affective disorders, (b) 0.4 or 0.5 mg intravenously administered ketamine, (c) measurement of positive symptoms using BPRS+, and (d) a within-subject repeated-measures design with participants serving as their own baseline. Results: Seventeen studies met the inclusion criteria, comprising 458 participants. The meta-analyses examined symptom change occurring within the first 4 h, after 1 day, and after 3 days. Results showed significant BPRS+ increases within the first 30–60 min in 72% of studies, followed by a return to baseline levels. Conclusion: Peak symptom change occurred within the first hour post infusion. There are limited data to determine if ketamine is safe in the longer term, but there were no indications that psychotic symptoms re-occurred after the first hour and in the days following administration.

Objective: Coronavirus (COVID-19) has led to high levels of psychological distress in the community. This study aimed to examine whether emergency departments (EDs) also recorded a rise in mental health presentations. Method: Changes in the number, and type, of mental health presentations to Western Australia EDs were examined between January and May 2020, and compared to 2019. Results: Data showed an unexpected decrease in the number of mental health presentations, compared to 2019, which was temporally coincident with the rise in local COVID-19 cases. Presentations for anxiety and panic symptoms, and social and behavioural issues, increased by 11.1% and 6.5%, respectively, but suicidal and self-harm behaviours decreased by 26%. Conclusion: A rise in local COVID-19 cases was associated with a decrease in mental health presentations to EDs. This has important implications for the planning and provision of healthcare services in the current pandemic.

Hallucinations can occur in different sensory modalities within an individual, both simultaneously and serially in time. Historically, they have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Yet, hallucinatory experiences that occur in two or more sensory systems - multimodal hallucinations (MMHs) - are more prevalent than previously thought, and may have greater adverse impact than unimodal ones, but they remain relatively under-researched. Why people experience multi- modal hallucinations, what the implications for the person are, and how this could impact how such experiences are treated when distressing remain under-studied questions. Here, we review the available literature on MMHs and discuss some key concepts in the field, namely a) the definition and categorisation of both serial and simultaneous MMHs, b) which assessment tools are available and how they can be improved, and c) the explanatory power that current hallucination theories might have for MMHs. Overall, we suggest that current models need to be updated or developed in order to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and clinical practice, highlighting the potential clinical impact of MMHs, the need for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena (such as delirium), as well as the need for service-user involvement in the validation of classification systems of MMHs.

This study investigated sleep subtypes in schizophrenia, and their response to Cognitive Behavioural Therapy for Insomnia (CBT-I) treatment. Sleep profiling was conducted using latent class analysis on baseline Pittsburgh Sleep Quality Index data (N = 74 outpatients with schizophrenia who were poor sleepers, 52% male, mean age = 41.4 years). Of these, 40 took part in CBT-I treatment. Analyses revealed three sleep subtypes based on total sleep time (TST), sleep efficiency (SE), and sleep onset latency (SOL) parameters: Cluster 1 ('classic severe insomnia', 44.6%), Cluster 2 ('insomnia with normal sleep duration', 37.8%), and Cluster 3 ('insomnia with hypersomnia', 17.6%). Gains analysis of pre- and post-treatment data from CBT-I participants revealed improvements in sleep and psychopathology in all three clusters, although there were some group differences in the areas and magnitude of improvement. Cluster 1 showed the greatest benefits with longer TST and improved SE. Cluster 2 showed a comparatively blunted treatment response although TST moved closer to recommended sleep guidelines. Cluster 3 showed significant reductions in TST. Altogether, this is the first demonstration of different sleep profiles in schizophrenia and their influence on treatment response to CBT-I. It also supports the notion that therapies should be tailored to the person and their insomnia presentation.

Background Multiple services are often needed to address the needs of young people with complex emotional or behavioural needs. The Youth Wraparound model of service aims to provide all health and supportive services from one coordinating agency. While this has been researched overseas, there are currently few examples of this described in the Australian psychiatric context. Aim To document the implementation and evaluation of a Youth Wraparound service which was provided to a young person with exceptionally complex and challenging needs for 6 months. A single-case study design is presented with an evaluation of the clinical outcome and economic costs. Methods We present a description of the service context, principles of the model of care, implementation process, and an evaluation of service utilization data from health and child protection services and mental health records. A single-case longitudinal design compared service utilization data obtained up to 3 years prior to treatment with data collected one and a half years since treatment commenced. Results There were significant reductions in the number of admissions to emergency departments, mental health wards and secure units, and improvements in mental health and well-being. Yearly average time in institutional settings reduced from 69% to 7%. Cost savings in health utilization were estimated at $2 326 790. Conclusions The Youth Wraparound model has the potential to offer improved clinical outcomes, significant cost savings over time, improved coordination between care providers, and an alternative to detention or incarceration.

Aim Aboriginal young people are more likely to experience mental health issues and to access mental health services than other young Australians, yet there are few culturally informed mental health programs and services available. This study describes and documents the effectiveness of the culturally sensitive model within YouthLink, a state-wide mental health service program in Western Australia for young people aged 13 to 24 years of age. Methods A mixed-method design including a descriptive approach reporting on the YouthLink framework and an empirical research design where 40 Aboriginal clients completed client feedback monitoring measures between 2014 and 2016. Results The YouthLink culturally informed conceptual framework adheres to best practice principles relevant to work with Indigenous people, family and communities. Aboriginal young people indicated improvement across the treatment period as shown by within-group differences between the first and last session scores on feedback measures. Therapeutic alliance (together with lower baseline acuity and female gender) also contributed significantly to positive treatment outcomes. Conclusions Through a strong role of Aboriginal practitioners, relationships with Aboriginal communities, and greater service flexibility that embraces cultural meaning and knowledge, YouthLink has sought to enhance its response to the needs of Aboriginal youth.

Hallucinations occur in the context of many disorders. When experienced as distressing, they are a likely cause of presentation to emergency departments. Knowledge about the rates, diagnoses, and associated costs of hallucinations in emergency departments however is currently lacking. In this study, we analysed patients' presenting complaints in Western Australia's Emergency Department Data Collection dataset during a two year period (n = 1,798,754). Visits to emergency departments because of distressing hallucinations were more common than previously assumed. Hallucinations (auditory, visual, undifferentiated modality) accounted for 1.8% of all mental health-related presentations and 0.09% of all general health presentations (84.7 per 100,000 persons). Psychotic disorders accounted for a third of all presentations, and hallucinations without a clear medical or psychiatric cause represented 17% of the sample. Hallucination presentations had significantly prolonged lengths of stay compared to other mental health presentations (15 vs 7.5h, p < 0.001) and were linked to frequent re-admissions (average of 7.4 visits per year). Cost estimates revealed that hallucinations were in the top-10 most costly mental health complaint, and twice as costly to treat as delusions. Altogether, the service utilisation and care needs of people with distressing hallucinations outside of mental health services appear much larger than usually estimated.

Individuals with passivity (first-rank) symptoms report that their actions, thoughts and sensations are influenced or controlled by an external (non-self) agent. Passivity symptoms are closely linked to schizophrenia and related disorders yet they remain poorly understood. One dominant framework posits a role for deficits in the sense of agency. An important question is whether deficits in self-agency can be differentiated from other-agency in schizophrenia and passivity symptoms. This study aimed to evaluate self- and other-agency in 51 people with schizophrenia (n=20 current, 10 past, 21 no history of passivity symptoms), and 48 healthy controls. Participants completed the projected hand illusion (PHI) with active and passive movements, as well as immediate and delayed visual feedback. Experiences of agency and loss of agency over the participant's hand and the image ('the other hand') were assessed with a self-report questionnaire. Those with passivity symptoms (current and past) reported less difference in agency between active and passive movements on items assessing agency over their own hand (but not agency over the other hand). Relative to the healthy controls, the current and never groups continued to experience the illusion with delayed visual feedback suggesting impaired timing mechanisms regardless of symptom profile. These findings are consistent with a reduced contribution of proprioceptive predictive cues to agency judgements specific to self representations in people with passivity symptoms, and a subsequent reliance on external visual cues in these judgements. Altogether, these findings emphasise the multifactorial nature of agency and the contribution of multiple impairments to passivity symptoms.

Hallucinated voices are common across psychiatric and non-clinical groups. The predominant cognitive theory about the impact of voices posits that beliefs about voice power (‘Omnipotence’) and voice intent (‘Malevolence’/‘Benevolence’) play a key role in determining emotional and behavioral reactions. The revised Beliefs about Voices Questionnaire (BAVQ-R) was designed to assess these constructs, together with two styles of responding (Engagement and Resistance). The BAVQ-R is widely used in clinical and research settings, yet it has not received validation of its constructs and factor structure. This study examined the factor structure of the BAVQ-R by combining datasets from five study centers, comprising 450 participants (belief constructs) and 269 participants (response styles), and using confirmatory and exploratory factor analysis. Findings failed to support a three factor belief model, instead showing a two-factor structure (‘Persecutory beliefs’ combining Omnipotence and Malevolence constructs, and a Benevolent construct). Emotional and behavioral items did not separate. Overall, results showed that (i) a two-factor model of beliefs (Persecutory and Benevolent beliefs) provides a better fit to the data than a three-factor model, and (ii) emotional and behavioral modes of responding items should not be separated. Theoretical implications of this finding are discussed in relation to the research and therapy., Highlights • The BAVQ-R was designed to measure beliefs about voices and reactions to voices. • Despite widespread use, the factor structure of the BAVQ-R has not been established. • A two-factor model of beliefs (Persecutory and Benevolent) provided the best fit. • A two-factor model of reactions (Engagement and Resistance) provided the best fit.

BackgroundVisual hallucinations (VH) are common symptoms in schizophrenia and other psychoses. An understanding of their cross-sectional and longitudinal patterns of association with auditory hallucinations (AH) is essential for developing accurate models of hallucinatory phenomena.ObjectiveThis study presents the most comprehensive examination of the association between VH and AH, and its change over time, in 1303 individuals with first-episode psychosis (FEP) and 469 individuals with chronic schizophrenia.MethodThe samples included data from the WHO multicentre study on the Determinants of Outcome of Severe Mental Disorders and the Western Australian Family Study of Schizophrenia (WAFSS). Standardized assessment of symptoms and functioning were used to examine the clinical profile and symptom co-occurrence of hallucinations over time.ResultsVH were approximately half as frequent as AH, almost always co-occurred with AH, and tended to be linked to a more severe psychopathological profile. AH and VH at baseline also predicted higher disability, risk of relapse and duration of psychosis after 1 and 2 years, especially when occurring in combination.ConclusionsThe findings point to three hallucination ‘subtypes’ with different symptom profile. The VH + AH combination signals greater psychopathology and a less favourable prognosis, than hallucinations occurring in isolation, and no hallucinations. This conclusion points to one common mechanism for all hallucinations, which can separate into distinct pathways and modalities. For a more complete clinical picture, clinicians should carefully probe for both auditory and VHs in presenting patients.

Background Although previous studies reported a link between sleep dysfunction and psychotic symptoms, more detailed information is needed to translate this association into clinical practice. This study investigates the impact of different aspects of sleep quality on prevalence, type and severity of psychotic-like experiences, in a large general population sample. In doing so, we distinguish between hallucinations in the auditory (AH) and visual (VH) domains and delusions, to arrive at a more comprehensive understanding of the detrimental effects of impaired sleep. Methods An online survey was used to gather information on self-reported psychotic-like experiences and sleep quality in a sample of 10.301 Dutch participants (median age 32 yrs; 68.9% females). The Questionnaire for Psychotic Experiences (QPE) was used to assess aspects of AH and VH. A subset of the participants also filled-out a second part of the QPE regarding occurrence of delusion. Furthermore, a measure of general sleep quality was derived based on seven sleep domains as assessed using the Pittsburgh Sleep Quality Index (PSQI). Binomial logistic regression was used to investigate the effects of the seven sleep domains on the likelihood that participants had experienced hallucinations in the preceding week, using 3324 participants with and a random subsample of 3391 participants without such experiences. The same analysis was performed on the data regarding delusions, using 438 participants with and a random subsample of 445 participants without delusions in the past week. Reported odds ratios (OR) reflect the increment in likelihood of occurrence of hallucinations and delusions. To further assess whether impaired sleep affects the level of distress caused by hallucinations, participants were divided into ‘good’ and ‘poor’ sleepers using a cut-off score of 5 points on the total PSQI score. Chi-square tests were then used to compare the two groups on occurrence of distressing vs non-distressing AH and VH. Results Impaired sleep showed to entail significant predictors of the prevalence of hallucinations. Specifically, sleeping less than 5 hours a night (OR 1.88), having sleep disturbances more than 3 times a week (OR 5.81), the use of sleep medication more than 2 times a week (OR 1.61) and decreased daytime functioning more than 3 times a week (OR 1.87) increased the odds to experience hallucinations, as compared to participants without these sleep difficulties. Furthermore, experiencing sleep disturbances more than 2 times a week (OR 9.24) and decreased daytime functioning more than 2 times a week (OR 5.53) also strongly increased the odds to experience delusions. Subjective sleep quality, sleep latency, and sleep efficiency were not significant predictors for the prevalence of hallucinations or delusions. Importantly, sleep impairment also affected the experienced distress as caused by hallucinations. A larger proportion of the poor sleepers than of the good sleepers experienced distressing AH (p < .001) and reported that the AH had a negative impact on their functioning (p < .001). Likewise, a larger proportion of the poor sleepers than of the good sleepers reported distressing VH (p < .001) and reported a negative impact of VH on their functioning (p < .001). Discussion Sleep impairments were associated with increased prevalence of psychotic-like experiences, and with more severe distress as caused by hallucinations. Sleep restoration should be explored as a first line intervention for people suffering from psychotic-like experiences. In case of delusions, such interventions should be directed at decreasing the number of nightly disturbances, while for individuals suffering from hallucinations additional focus should be put on increasing the achieved hours of sleep.

Questions: What perceptions do physiotherapists have about their role in managing the physical health of people with severe and persistent mental illness (SPMI)? What are the barriers to treating physical health conditions in this clinical population, and what enablers may improve access to physiotherapy services? Design: Mixed-methods research design combining focus groups, interviews and an online survey. Participants: Eighty-eight Australian registered physiotherapists: 31 in the focus groups and interviews (mean age 32 years, 68% female) and 57 in the survey (mean age 38 years, 86% female). Methods: Focus groups and interviews explored participants' understanding of mental illness; their role in managing the physical health of people with SPMI; and the barriers and enablers to service delivery. Key themes were derived using an inductive approach. The survey was used to determine physiotherapists' attitudes and knowledge regarding mental illness; perceived role of physiotherapy in mental health; and need for professional development in the mental health area. Participant characteristics and survey information were analysed using descriptive statistics. Results: Qualitative and quantitative results were confirmatory. Participants indicated that physiotherapists can play a role in the management of physical health conditions in people with SPMI. Participants also stated that such treatment was part of their job, given the extensive evidence that physiotherapy interventions are effective for the comorbidities that are common among people with SPMI. Barriers included: limited education about and confidence in how to manage people with SPMI; health system structure; and stigmatisation of people with SPMI. Conclusion: Physiotherapists are ideally poised to become leaders in managing the physical health of people with SPMI. To improve the physical health in this important yet overlooked population, it is recommended that: physiotherapists take up general mental health training opportunities; undergraduate physiotherapy education increases content in this clinical area; physiotherapy-specific professional development opportunities are developed further; and health system barriers are addressed. Key words: Physiotherapy, Physical therapy, Severe mental illness, Mental health, Physical activity

That trauma can play a significant role in the onset and maintenance of voice-hearing is one of the most striking and important developments in the recent study of psychosis. Yet the finding that trauma increases the risk for hallucination and for psychosis is quite different from the claim that trauma is necessary for either to occur. Trauma is often but not always associated with voice-hearing in populations with psychosis; voice-hearing is sometimes associated with willful training and cultivation in nonclinical populations. This article uses ethnographic data among other data to explore the possibility of multiple pathways to voice-hearing for clinical and nonclinical individuals whose voices are not due to known etiological factors such as drugs, sensory deprivation, epilepsy, and so forth. We suggest that trauma sometimes plays a major role in hallucinations, sometimes a minor role, and sometimes no role at all. Our work also finds seemingly distinct phenomenological patterns for voice-hearing, which may reflect the different salience of trauma for those who hear voices. publishedVersion

Hallucinations constitute one of the 5 symptom domains of psychotic disorders in DSM-5, suggesting diagnostic significance for that group of disorders. Although specific featural properties of hallucinations (negative voices, talking in the third person, and location in external space) are no longer highlighted in DSM, there is likely a residual assumption that hallucinations in schizophrenia can be identified based on these candidate features. We investigated whether certain featural properties of hallucinations are specifically indicative of schizophrenia by conducting a systematic review of studies showing direct comparisons of the featural and clinical characteristics of (auditory and visual) hallucinations among 2 or more population groups (one of which included schizophrenia). A total of 43 articles were reviewed, which included hallucinations in 4 major groups (nonclinical groups, drug- and alcohol-related conditions, medical and neurological conditions, and psychiatric disorders). The results showed that no single hallucination feature or characteristic uniquely indicated a diagnosis of schizophrenia, with the sole exception of an age of onset in late adolescence. Among the 21 features of hallucinations in schizophrenia considered here, 95% were shared with other psychiatric disorders, 85% with medical/neurological conditions, 66% with drugs and alcohol conditions, and 52% with the nonclinical groups. Additional differences rendered the nonclinical groups somewhat distinctive from clinical disorders. Overall, when considering hallucinations, it is inadvisable to give weight to the presence of any featural properties alone in making a schizophrenia diagnosis. It is more important to focus instead on the co-occurrence of other symptoms and the value of hallucinations as an indicator of vulnerability.

Individuals with schizophrenia, particularly those with passivity symptoms, often feel that their actions and thoughts are controlled by an external agent. Recent evidence has elucidated the role of body representations in the aetiology of passivity symptoms, yet one representation - body structural description - has not yet been examined. Additionally, body image has rarely been examined outside of bodily illusions (e.g., rubber hand experiments) and external validation is required.Body structural description was assessed with an in-between task and a matching body parts by location task, and body image with a questionnaire examining body distortion experiences (containing subscales assessing boundary loss, depersonalisation and body size distortions). Individuals with schizophrenia (20 with current, 12 with past and 21 with no history of passivity symptoms) and 48 healthy controls participated in the study.People with schizophrenia (as a group) made more errors on the in-between task, but not on the matching body parts by location task. Individuals with current passivity symptoms reported greater distortions on all subscales relative to the other clinical samples, except for experiences of boundary loss which were common to both passivity symptom groups.The results indicate that body structural description may be altered in schizophrenia generally and body image alterations are worsened in passivity symptoms, and these alterations likely contribute to the emergence of passivity symptoms.

In recent years, there has been increasing interest in the potential for alterations to the brain's resting-state networks (RSNs) to explain various kinds of psychopathology. RSNs provide an intriguing new explanatory framework for hallucinations, which can occur in different modalities and population groups, but which remain poorly understood. This collaboration from the International Consortium on Hallucination Research (ICHR) reports on the evidence linking resting-state alterations to auditory hallucinations (AH) and provides a critical appraisal of the methodological approaches used in this area. In the report, we describe findings from resting connectivity fMRI in AH (in schizophrenia and nonclinical individuals) and compare them with findings from neurophysiological research, structural MRI, and research on visual hallucinations (VH). In AH, various studies show resting connectivity differences in left-hemisphere auditory and language regions, as well as atypical interaction of the default mode network and RSNs linked to cognitive control and salience. As the latter are also evident in studies of VH, this points to a domain-general mechanism for hallucinations alongside modality-specific changes to RSNs in different sensory regions. However, we also observed high methodological heterogeneity in the current literature, affecting the ability to make clear comparisons between studies. To address this, we provide some methodological recommendations and options for future research on the resting state and hallucinations.

Objective We examined the academic performance at age 12 years of children of mothers diagnosed with schizophrenia or other severe mental illness using a large whole-population birth cohort born in Western Australia. We investigated the association between academic performance and the subsequent development of psychotic illness. Method The sample comprised 3169 children of mothers with severe mental illness (schizophrenia, bipolar disorder, unipolar major depression, delusional disorder or other psychoses; ICD-9 codes 295–298), and 88 353 children of comparison mothers without known psychiatric morbidity. Academic performance of children was indexed on a mandatory state-wide test of reading, spelling, writing and numeracy. Results A larger proportion of children (43.1%) of mothers with severe mental illness performed below the acceptable standard than the reference group (30.3%; children of mothers with no known severe mental illness). After adjusting for covariates, children of mothers with any severe mental illness were more likely than the reference group to perform below-benchmark on all domains except reading. For all children, poor spelling was associated with the later development of psychosis, but particularly for those at familial risk for severe mental illness (hazard ratio [HR] = 1.81; 95% CI for HR = 1.21, 2.72). Conclusions Children of mothers with a severe mental illness are at increased risk for sub-standard academic achievement at age 12 years, placing these children at disadvantage for the transition to secondary school. For children with familial risk for severe mental illness, very poor spelling skills at age 12 years may be an indicator of risk for later psychotic disorder.

This article reports on the Third Biennial Meeting of the International Consortium on Hallucinations Research, held in Melbourne, Australia, in October 2015. Following a public conference in which research findings were considered in relation to subjective experience and practice, 9 multidisciplinary working groups examined key current issues in progressing the conceptualization and research of hallucinations. Work group topics included: multicenter validation of the transdiagnostic and multimodal Questionnaire for Psychotic Experiences; development of an improved outcome measure for psychological therapies; the relationship between inhibition and hallucinations across multiple levels of explanation; hallucinations in relation to sleep phenomena; emotion and hallucinations; multiple interactions between the experience of self and hallucinations; interactions between language, auditory and memory networks; resting state networks including the default mode; and analyses arising from functional magnetic resonance imaging (fMRI) data-sharing. Major themes in hallucinations research identified during the meeting included (1) progression beyond the auditory verbal modality in schizophrenia to consider hallucinations across modalities and different populations; (2) development of new measures; (3) the central role of multisite collaboration through shared data collection and data pooling; (4) study of time-based and interactive models of hallucination; and (5) the need to increase the accessibility and availability of "real-life" interventions for people with persisting and distressing hallucinations.

Auditory hallucinations (AH) are often considered a sign of a psychotic disorder. This is promoted by the DSM-5 category of Other Specified Schizophrenia Spectrum And Other Psychotic Disorder (OSSSOPD), the diagnostic criteria for which are fulfilled with the sole presence of persistent AH, in the absence of any other psychotic symptoms. And yet, persistent AH are not synonymous with having a psychotic disorder, and should therefore not be uncritically treated as such. Many people who seek treatment for persistent AH have no other psychotic symptoms, have preserved reality-testing capacities, and will never develop a schizophrenia spectrum disorder. Instead, hallucinations may be the result of many different causes, including borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders or brain lesions, and they may even occur outside the context of any demonstrable pathology. In such cases, the usage of the DSM-5 diagnosis of OSSSOPD would be incorrect, and it may prompt unwarranted treatment with antipsychotic medication. We therefore argue that a DSM-5 diagnosis of Schizophrenia Spectrum Disorder (or any other type of psychotic disorder) characterized by AH should require at least one more symptom listed under the A-criterion (i.e. delusions, disorganized speech, disorganized or catatonic behavior or negative symptoms). Adhering to these more stringent criteria may help to distinguish between individuals with persistent AH which are part of a psychotic disorder, for whom antipsychotic medication may be helpful, and individuals with AH in the absence of such a disorder who may benefit from other approaches (e.g. different pharmacological interventions, improving coping style, trauma-related therapy).

Little is known about the presence of parasomnias such as nightmare disorder, sleep paralysis, REM sleep behavior disorder (RBD), and sleep-related eating disorders (SRED) in people with mental illness. A predominant view suggests that psychotropic medications might be contributing to parasomnias. This article summarizes knowledge regarding the relationships between psychiatric disorders and parasomnias, and possible confounds. A systematic search of the literature in the past 10 years identified 19 articles. There were significantly elevated rates of parasomnias in psychiatric disorders (average prevalence of nightmares was 38.9%, sleep paralysis 22.3%, SRED 9.9%, sleepwalking 8.5%, and RBD 3.8%). Medication usage was only one of many risk factors (other sleep disorders, medical comorbidities, and substance abuse) which were associated with parasomnias. A strong association exists between mental illness and parasomnias which is not fully explained by medications. Prospective longitudinal studies are needed to develop a better understanding of the unique and shared variance from multiple risk factors.

Questions How do mental health professionals perceive the role of physiotherapists in the care of people with severe and persistent mental illness, and what factors do they perceive as influencing access to physiotherapy services? How do people with severe and persistent mental illness understand the potential role of physiotherapy in their healthcare, and what factors do they perceive as influencing access to physiotherapy services? Design Qualitative study. Participants Twenty-four mental health professionals and 35 people with severe and persistent mental illness. Methods Interview schedules were developed to explore participants' understanding of physiotherapy, as well as barriers and enablers to service access. Focus groups and interviews were conducted for each group of participants. Transcripts were analysed using an inductive approach to derive key themes. Results Both the mental health professionals and the people with severe and persistent mental illness expressed a limited understanding of the role and relevance of physiotherapy for physical health in mental healthcare. Common barriers to service access were cost, transport and lack of motivation. Likewise, enablers of reduced cost, provision of transport and education about physiotherapy to improve their understanding were identified. The health system structure and perceived lack of mental health knowledge by physiotherapists influenced referrals from mental health professionals. Consequently, education in mental health for physiotherapists and integration of the service within mental health were identified as potential enablers to physiotherapy access. Conclusion Limited understanding about physiotherapy and its relevance to physical health in mental healthcare among mental health professionals and people with severe and persistent mental illness was found to be a key factor influencing service access. Limited physiotherapy presence and advocacy within mental health were also highlighted. There is a need for greater understanding about physiotherapy among stakeholders, and for physiotherapists to be well equipped with skills and knowledge in mental health to facilitate greater involvement. [Lee S, Waters F, Briffa K, Fary RE (2017) Limited interface between physiotherapy primary care and people with severe mental illness: a qualitative study. Journal of Physiotherapy 63: 168–174]