Impaired Sense of Agency and Associated Confidence in Psychosis

The Sense of Agency (SoA), our sensation of control over our actions, is a fundamental mechanism for delineating the Self from the environment and others. SoA arises from implicit processing of sensorimotor signals as well as explicit higher-level judgments. Psychosis patients suffer from difficulties in the sense of control over their actions and accurate demarcation of the Self. Moreover, it is unclear if they have metacognitive insight into their aberrant abilities. In this pre-registered study, we examined SoA and its associated confidence judgments using an embodied virtual reality paradigm in psychosis patients and controls. Our results show that psychosis patients not only have a severely reduced ability for discriminating their actions but they also do not show proper metacognitive insight into this deficit. Furthermore, an exploratory analysis revealed that the SoA capacities allow for high levels of accuracy in clinical classification of psychosis. These results indicate that SoA and its metacognition are core aspects of the psychotic state and provide possible venues for understanding the underlying mechanisms of psychosis, that may be leveraged for novel clinical purposes.

Dissociachotic: Seeing the Nonpsychosis We Share

The potential for growth within a relationship between individuals experiencing “psychotic” and “nonpsychotic” realities in based in acceptance of a shared human vulnerability. Through the human-to-human relationship, acceptance of the mutual experience of ontological insecurity and fear of nihilation can facilitate the emergence of a “nonpsychotic” reality. Interconnectedness, that occurs through the process of growth within a loving, nongoal–orientated relationship, leads to a negation of the need for an altered state to exist to defend the threat of nihilation in the person experiencing “psychosis,” and the person in a “nonpsychotic” state to resist the attempt to change the legitimate reality the other person is experiencing. The ensuing changes to the liminal space occupied by a person said to be in a “psychotic” state, when being together in a coexisting same experience, can lead to mutual growth and the evaporation of the so labelled “psychotic” state. This demonstrates the “psychotic” experience is more consistent with a dissociative response to threat in relationship and could be reframed as a “Dissociachotic”—a form of dissociation that has been mislabelled as a unique condition of “psychosis” due to its specific representation of creating safety for a person experiencing threat in relationship.

Corticosteroid-induced psychosis: Case report and review of the literature

IntroductionSteroid psychosis still presents many unsettled clinical aspects. Despite several reviews and case reports are available, modes of onset and recovery need a more accurate description. We will focus on a 53-year-old woman who was hospitalized against her will because of her agitated psychotic state. Her symptoms were indicative of an acute psychotic disorder resulting from the use of corticosteroids. We considered it important to report this case because corticosteroids have been widely prescribed since about 1950 to treat a broad spectrum of somatic illnesses and to emphasize the relevance of the dose of steroids in this case.ObjectivesWe describe a case of substance-induced psychotic disorder resulting from corticosteroids administration and we review the scientific literature about this topic.AimsTo obtain more information about the incidence of steroid-induced psychotic symptoms, the relation between the type of steroids, its dose and the clinical presentation, the most important risk factors and how to prevent psychotic episodes during steroids-treatment.MethodsAfter discussing the case, we studied the literature systematically using official medical browsers.ResultsVery little reliable evidence has been available relating to steroid-induced psychosis.ConclusionsThere is much to learn about adverse psychiatric reactions to corticosteroid treatment. It should be improved awareness of the limited available knowledge and to stimulate research aimed at improved methods of prevention, recognition and treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Crisis Dialogue for Acute Psychotic State and Ethical Difficulties: What Do You Do When Trials Are Interrupted Because Clinicians Find the Intervention Too Effective?

Clinical studies carry with them a paradox: The more obviously efficient an intervention is, the more ethical problems its trials pose. This article discusses the ethical problem of breached equipoise principle because of the perceived effectiveness of a nonblindable verbal technique, crisis dialogue (CD). CD is designed to help establish a therapeutic relationship with persons in a suspected psychotic state. In a pilot randomized controlled study in Yverdon, Switzerland (usual treatment vs. usual treatment + CD), after inclusion of 30 patients, clinicians expressed a consensual opinion that CD was effective in most cases. Following their opinion, the joint clinical and research team decided that the study had to be discontinued and that CD should be tried with all patients for ethical reasons. This poses an ethical problem with potential far-reaching consequences: In this interrupted study, differences between groups in terms of clinical outcome (Brief Psychiatric Rating Scale, Clinical Global Impression), therapeutic alliance (Working Alliance Inventory, Difficult Doctor–Patient Relationship Questionnaire), and patient satisfaction were consistent in favoring CD, but these differences did not reach statistical significance in most measurements. The early interruption of the study because of perceived effectiveness of the intervention can be seen as unethical as well because chances were high that a larger sample would have shown more conclusive results, allowing for faster introduction of CD in various clinical settings with corresponding improvement of patient care.