OBJECTIVE: The clinical hallmark of schizophrenia is psychosis. The objective of this overview is to link the neurobiology (brain), the phenomenological experience (mind), and pharmacological aspects of psychosis-in-schizophrenia into a unitary framework. METHOD: Current ideas regarding the neurobiology and phenomenology of psychosis and schizophrenia, the role of dopamine, and the mechanism of action of antipsychotic medication were integrated to develop this framework. RESULTS: A central role of dopamine is to mediate the “salience” of environmental events and internal representations. It is proposed that a dysregulated, hyperdopaminergic state, at a “brain” level of description and analysis, leads to an aberrant assignment of salience to the elements of one’s experience, at a “mind” level. Delusions are a cognitive effort by the patient to make sense of these aberrantly salient experiences, whereas hallucinations reflect a direct experience of the aberrant salience of internal representations. Antipsyc...

Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology in schizophrenia.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/j.2051-5545.2011.tb00014.x

Physical illness in patients with severe mental disorders.I. Prevalence, impact of medications and disparities in health care

/pdf/practice-guideline-for-the-treatment-of-patients-with-major-ofberaz3o1.pdf

PRACTICE GUIDELINE FOR THE Treatment of Patients With Major Depressive Disorder

The concept of insight into psychosis has received scant attention in the psychiatric literature. Drawing on sources such as phenomenology, clinical research and experimental psychology, it is proposed that insight is not an 'all-or-none' phenomenon but is composed of three distinct, overlapping dimensions, namely, the recognition that one has a mental illness, compliance with treatment, and the ability to relabel unusual mental events (delusions and hallucinations) as pathological. A scheme is proposed to standardise the assessment of insights to assist further research.

Insight and Psychosis

Although the subject has been debated and examined for more than 3 decades, it is still not clear whether all psychotherapies are equally efficacious. The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments. Each major type of treatment had been examined in at least 5 randomized comparative trials. There was no indication that 1 of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective supportive treatment (which was somewhat less efficacious than the other treatments; d = -0.13). The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression.

/pdf/psychotherapy-for-depression-in-adults-a-meta-analysis-of-1xbb03yuyv.pdf

Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies.

A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients

A total of 7.2% of the patients in a private psychiatric hospital were placed in seclusion during a one-year study. These 63 patients had a more frequent diagnosis of schizophrenia and manic-depressive illness, manic type, than a comparison group. Significant intergroup differences in age and length of hospitalization became insignificant when the seclusion patients under 20 were excluded. Although seclusion was often used to protect patients, others, and property, the most frequent reason was to maintain a therapeutic environment. This study pointed toward a staff tendency to see the "problem" of the patient's behavior as being solved by seclusion rather than viewing seclusion as an intensive care environment in which the patient's behavior and treatment could be morec arefully monitored.

Seclusion: uses and complications.

• A group of 19 acute, medication-free schizophrenic patients was studied, using average-evoked responses (AERs) to four intensities of light. Comparison with age- and sex-matched normal controls and patients with bipolar affective disorders showed that schizophrenics had smaller AER amplitudes and either no increase or an actual decrease in amplitude with increasing stimulus intensity. Normal subjects and schizophrenic patients were discriminated with 71% accuracy using AER variables; normals, patients with bipolar disorders, and schizophrenic patients with 64% accuracy. Patients who evidenced this AER "reducing" pattern to a noticeable extent early in hospitalization showed greater improvement and tended to have relatively good premorbid histories.

https://jamanetwork.com/journals/psych/articlepdf/491430/archpsyc_32_10_003.pdf

Schizophrenia and stimulus intensity control.

The experiences of acutely psychotic patients during research procedures reveal important characteristics of the process of recovery from delusional thought. Changes in the patients' perceptions and interpretations of testing experiences parallel changes in their clinical status and are used to demonstrate the continuum between delusional and nondelusional thinking. Three specific phases are defined: the delusional, double-awareness, and nondelusional phases. The interaction between this regular sequence of changes and the patients' participation in research is examined with particular reference to the process of recovery from delusions.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=PSYCH&articleId=491066&pdfFileName=archpsyc_30_1_015.pdf

Michael H. Sacks

Papers

A comparative trial of psychotherapy and pharmacotherapy for “pure” dysthymic patients

Seclusion: uses and complications.

Schizophrenia and stimulus intensity control.

Recovery From Delusions: Three Phases Documented by Patient's Interpretation of Research Procedures

Seroprevalence of HIV and Risk Factors for AIDS in Psychiatric Inpatients