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Introduction: The psychic structure of people with psychosis has been the subject of theoretical and qualitative considerations. However, it has not been sufficiently studied quantitatively. Therefore, the aim of this study was to explore the structural abilities of people diagnosed with schizophrenia and schizoaffective psychosis using the Levels of Structural Integration Axis of the Operationalized Psychodynamic Diagnosis System (OPD-2-LSIA). The study aimed to determine possible associations between the OPD-2-LSIA and central parameters of illness. Additionally, possible structural differences between people diagnosed with schizophrenia and schizoaffective psychosis were tested. Methods: This cross-sectional study included 129 outpatients with schizophrenia or schizoaffective disorders. Measures of structural integration, symptom load, severity of illness, cognition, and social functioning were obtained. Descriptive statistics were used to analyze the overall structural level and the structural dimensions. Correlation coefficients were computed to measure the associations between OPD-2-LSIA and variables regarding the severity of illness and psychosocial functioning. Regression models were used to measure the influence of illness-related variables on OPD-2-LSIA, and the influence of OPD-2-LSIA on psychosocial functioning. Participants diagnosed with schizophrenia and schizoaffective disorders were examined with regard to possible group differences. Results: The results of the OPD-2-LSIA showed that the overall structural level was between 'moderate to low' and 'low level of structural integration'. Significant correlations were found between OPD-2-LSIA and psychotic symptoms (but not depressive symptoms), as well as between OPD-2-LSIA and psychosocial functioning. It was found that variables related to severity of illness had a significant impact on OPD-2-LSIA, with psychotic, but not depressive symptoms being significant predictors. OPD-2-LSIA was found to predict psychosocial functioning beyond symptoms and cognition. No significant differences were found between participants with schizophrenia and schizoaffective psychosis. There was also no correlation found between OPD-2-LSIA and depressive symptomatology (except for the subdimension Internal communication). Discussion: Contrary to theoretical assumptions, the results of the study show a heterogenous picture of the psychic structure of people with psychosis. The associations between OPD-2-LSIA and severity of illness, particularly psychotic symptomatology, as well as the influence of OPD-2-LSIA on psychosocial functioning, are discussed.

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Current approaches to the treatment of non-affective psychosis include elements of mentalization-based treatment and the potential in enhancing mentalizing capacity in this patient group has been widely emphasized. This article presents the "psychotic identity dilemma", a concept by Stavros Mentzos, and a therapeutic approach considering this concept as a valuable complementary addition to these treatments. The idea of a dilemma between closeness and distance, which in itself cannot be represented mentally at first, helps to respond to specific needs of patients with psychotic disorders by placing the treatment focus on fundamental interpersonal processes. Following this train of thought, this article attempts to shed light on the importance of the "real relationship" between therapist and patient as well as the exploration of the "here and now", especially at the beginning of psychotherapeutic treatment. Two treatment modes are suggested, one characterized by the experience of interpersonality within the therapeutic relationship and a second one characterized by the reflection of interpersonal phenomena. These modes are framed by Stavros Mentzos' concept of an identity dilemma. We describe how mentalizing first needs to be addressed implicitly in a tolerable, exemplary relationship in which closeness and distance are regulated based on the therapist's countertransference, then explicitly. A series of interventions are described, which allow for moments of shared attention, promote intentionality and contingency and, later in the course of therapy, help to integrate experiences into narratives.

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Synthetic metacognition is a heterogeneous construct related to psychotic disorders. One important tool to assess this construct is the Metacognition Assessment Scale - Abbreviated (MAS-A). In this study, we investigated the latent structure as well as the interrater reliability and convergent and incremental validity of the MAS-A in a sample of patients with non-affective psychosis. Analyses indicated that the scale might be one-dimensional. Interrater reliability of the MAS-A total score was good. In terms of convergent validity, correlational analyses showed significant associations of MAS-A metacognition with the Operationalized Psychodynamic Diagnosis Level of Structural Integration Axis (OPD-LSIA) and the Levels of Emotional Awareness Scale (LEAS). In terms of construct validity, a significant association was observed between MAS-A metacognition and a short version of the International Classification of Functioning, Disability and Health (MINI-ICF), which persisted after self-report measures of impairments in structural capacities (Structure Questionnaire of Operationalized Psychodynamic Diagnosis [OPD-SQS]) and mentalizing abilities (Mentalization Questionnaire [MZQ]) were included as covariates, but not after symptom dimensions were included. There was a significant correlation with the current living situation, but not with other external criteria like diagnosis or duration of illness. Future studies should explore alternative outcomes and replicate results in longitudinal designs.

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The ability to mentalize (i.e., to form representations of mental states and processes of oneself and others) is often impaired in people with schizophrenia spectrum disorders. Emotional awareness (EA) represents one aspect of affective mentalizing and can be assessed with the Levels of Emotional Awareness Scale (LEAS), but findings regarding individuals with schizophrenia spectrum disorders are inconsistent. The present study aimed at examining the usability and convergent validity of the LEAS in a sample of N = 130 stabilized outpatients with schizophrenia or schizoaffective disorders. An adequacy rating was added to the conventional LEAS rating to account for distortions of content due to, for example, delusional thinking. Scores of the patient group were compared with those of a matched healthy control sample. Correlation with symptom clusters, a self-report measure of EA, a measure of synthetic metacognition (MAS-A-G), and an expert rating capturing EA from the psychodynamic perspective of psychic structure (OPD-LSIA) were examined. Regarding self-related emotional awareness, patients did not score lower than controls neither in terms of conventional LEAS nor in terms of adequacy. Regarding other-related emotional awareness, however, patients showed a reduced level of adequacy compared to controls whereas no such difference was found for conventional LEAS scores. Higher conventional LEAS scores were associated with fewer negative symptoms, and higher structural integration of self-perceptions measured by the OPD-LSIA. Higher adequacy of responses correlated with fewer symptoms of disorganization as well as excitement, higher scores of self-reflection on the MAS-A-G as well as self- and object-perception and internal and external communication as measured by the subscales of the OPD-LSIA. Findings suggest that the LEAS might not be sensitive enough to detect differences between mildly symptomatic patients with schizophrenia or schizoaffective disorders and healthy controls. However, LEAS ratings are still suitable to track intraindividual changes in EA over time. Observing the adequacy of patients' responses when using the LEAS may be a promising way to increase diagnostical utility and to identify patterns of formal and content-related alterations of mentalizing in this patient group. Methodological indications for future studies are discussed.

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Synthetic metacognition is defined by integrative and contextualizing processes of discrete reflexive moments. These processes are supposed to be needed to meet intrapsychic as well as interpersonal challenges and to meaningfully include psychotic experience in a personal life narrative. A substantial body of evidence has linked this phenomenon to psychosocial functioning and treatment options were developed. The concept of synthetic metacognition, measured with the Metacognition Assessment Scale-Abbreviated (MAS-A), rises hope to bridge gaps between therapeutic orientations and shares valuable parallels to modern psychodynamic constructs, especially the 'levels of structural integration' of the Operationalized Psychodynamic Diagnosis (OPD-2). As theoretical distinctions remain, aim of this study was to compare the predictive value of both constructs with regard to psychosocial functioning of patients with non-affective psychoses, measured with the International Classification of Functioning, Disability and Health (MINI-ICF-APP). It was further explored if levels of structural integration (OPD-LSIA) would mediate the impact of metacognition (MAS-A) on function (MINI-ICF-APP). Expert ratings of synthetic metacognition (MAS-A), the OPD-2 'levels of structural integration' axis (OPD-LSIA), psychosocial functioning (MINI-ICF-APP) and assessments of general cognition and symptoms were applied to 100 individuals with non-affective psychoses. Whereas both, MAS-A and OPD-LSIA, significantly predicted MINI-ICF-APP beyond cognition and symptoms, OPD-LSIA explained a higher share of variance and mediated the impact of MAS-A on MINI-ICF-APP. Levels of structural integration, including the quality of internalized object representations and unconscious interpersonal schemas, might therefore be considered as valuable predictors of social functioning and as one therapeutic focus in patients with non-affective psychoses. Structural integration might go beyond and form the base of a person's actual reflexive and metacognitive capabilities. Psychotherapeutic procedures specific for psychoses may promote and challenge a patient's metacognitive capacities, but should equally take the need for maturing structural skills into account. Modern psychodynamic approaches to psychosis are shortly presented, providing concepts and techniques for the implicit regulation of interpersonal experience and aiming at structural integration in this patient group.

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Primary aim of this study was to determine the extent and type of self-reported interpersonal problems in patients with non-affective psychoses and their impact on psychosocial functioning. Furthermore, we aimed to explore potential links with the psychodynamic construct of Stavros Mentzos' "psychotic dilemma", which describes an insufferable inner tension caused by an individual's struggle of being torn between "self-oriented" and "object-oriented" tendencies. In a cross-sectional study among 129 patients with non-affective psychoses, measures of cognition, symptom load and social functioning as well as a tentative, psychodynamic assessment of Mentzos' "dilemma" were obtained during a clinical research visit. Self-report data on interpersonal problems were gathered using the Inventory of Interpersonal Problems (IIP-64D) and compared with a German representative standard sample. Second, IIP-64D scores were compared between groups with or without Mentzos' "dilemma". Hierarchical regression analyses were performed to test for the impact of interpersonal problems on psychosocial functioning, while controlling for cognitive deficits and psychopathology. Results showed that IIP-64D scores differed significantly from healthy controls, except for "self-centred" and "intrusive" interpersonal styles. Participants with a potential "psychotic dilemma" scored significantly higher on the subscales: "domineering", "self-centred", "cold", and "socially avoidant" than the group without a "psychotic dilemma". The total amount of interpersonal problems, and particularly high scores on the IIP-64D "socially avoidant" subscale, predicted psychosocial dysfunction, whereas a "cold" interpersonal style had an opposite effect. In conclusion, specific interpersonal problems may predict psychotherapeutic outcome measures like psychosocial functioning and are partly compatible with the psychodynamic construct of Stavros Mentzos' "psychotic dilemma".

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OBJECTIVES: To obtain data and hypotheses regarding the amelioration of risk estimation and preventive psychotherapy in patients in a prodromal state of schizophrenia by using OPD. METHODS: 20 participants with a prodromal condition--6 subjects far from psychosis and 14 close to psychosis--along with 10 patients with paranoid schizophrenia as reference group were examined using the first four OPD axes. RESULTS: Both groups differed considerably in all four axes. Compared to the schizophrenic participants, prodromal probands appear to have more favourable preconditions for therapy. Moreover, they experienced the interaction partners, including the investigator, as less aversive and induced less distanced behaviour in the investigator. Conflicts of self-esteem were prominent in both prodromal subgroups. However, patients farther from psychosis showed less conflicts of autonomy versus dependence and displayed a higher integration in structures such as "defence" and "attachment" when compared to participants closer to psychosis. CONCLUSIONS: Particularly the differences between the prodromal subgroups suggest that application of the OPD may positively complement previous approaches of early detection, prevention,and psychotherapy for prodromal conditions. The hypotheses obtained should be tested in longitudinal studies with larger sample sizes.

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Schizophrenia is mostly a progressive psychiatric illness. Although cognitive changes in chronic schizophrenia have been investigated, little is known about the consequences of a single psychotic episode on memory mechanisms and formation. We investigated changes in hippocampal long-term potentiation (LTP) and spatial memory in a rat model of an acute psychotic episode. Application of NMDA receptor antagonists, such as MK801 (dizolcilpine) in rats, have been shown to give rise to an acute and short-lasting behavioral state, which mirrors many symptoms of schizophrenia. Furthermore, NMDA antagonist-intake in humans elicits symptoms of schizophrenia such as hallucinations, delusions, and affective blunting. We therefore treated animals with a single systemic injection of MK801 (5 mg/kg). Increased stereotypy, locomotion, and ataxia were evident immediately after MK801-treatment, with effects disappearing within 24 h. MK801-treatment caused a disruption of prepulse inhibition of the acoustic startle reflex, 1 day but not 7 or 28 days after treatment. These effects were consistent with the occurrence of an acute psychotic episode. LTP was profoundly impaired in freely moving rats 7 days after MK801 application. Four weeks after treatment, a slight recovery of LTP was seen, however marked deficits in long-term spatial memory were evident. These data suggest that treatment with MK801 to generate an acute psychotic episode in rats, gives rise to grave disturbances in synaptic plasticity and is associated with lasting impairments with the ability to form spatial memory.

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We analysed acute and long-term effects of the N-methyl-d-aspartate receptor antagonist MK-801 on long-term heterosynaptic population spike depression (LTHPSD) evoked by high-frequency stimulation of the direct cortical input in female rat hippocampal slices to understand disturbances in cognitive functions associated with an acute phencyclidine-induced psychosis. High-frequency stimulation (HFS) of the direct cortical input (dCI) to cornu ammonis area 1 (CA1) induced homosynaptic long-term potentiation (LTP) while simultaneously evoking LTHPSD at the Schaffer collateral input. Animals treated with a single intraperitoneal application of MK-801 (5 mg/kg body weight) showed severe behavioural alterations for 24 h, although histological examination of CA1 did not reveal any morphological changes. However, after application of MK-801, homosynaptic LTP of the dCI was suppressed for up to 7 days and recovered within 4 weeks. Likewise, LTHPSD in response to HFS of the dCI to CA1 was abolished for at least 1 week post-treatment, with partial recovery occurring after 4 weeks. Homosynaptic LTP, induced by HFS of Schaffer collaterals, was also disturbed for at least 24 h, with recovery after 7 days. Remarkably, bath application of MK-801 (50 microM) converted LTHPSD, induced by dCI HFS, into persistent heterosynaptic long-term enhancement of stratum radiatum-evoked responses. The acute effects of MK-801 on synaptic plasticity seen in this study may contribute to the observed severe behavioural alterations and long-term effects and may explain some of the long-lasting symptoms remaining after an acute psychotic episode in humans.

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The entorhinal cortex (EC) innervates area CA1 and the subiculum directly via the portion of the perforant path, which originates from EC layer III cells referred to as direct cortical input (dCI), and indirectly via the trisynaptic loop through the dentate gyrus and area CA3. The dCI is of great importance as it mediates positional information for activation of place cells that is not prevented after interrupting information flow from area CA3 to CA1. In this study, we investigated the effects of low-frequency stimulation of the dCI on homo- and heterosynaptic plasticity in area CA1 and tested for the contribution of NMDA, GABA(A), GABA(B), kainate and group I mGlu receptors. We demonstrate that 1 Hz stimulation of the dCI induces homosynaptic long-term depression (LTD) and that 1 Hz stimulation of the dCI induces a long-lasting augmentation of stratum radiatum-induced population spikes in area CA1 (heterosynaptic long-term potentiation). Additionally we show that homosynaptic effects depend on activation of GABA(B) and kainate receptors, whereas the heterosynaptic effects are GABA(A) and mGlu receptor dependent.

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OBJECTIVE: In animals, nicotine, the primary psychoactive constituent of tobacco smoke, reduces neurogenesis and increases cell loss in both hippocampus and cortex. Accordingly, tobacco smoking has been linked to reduced performance on cognitive paradigms requiring attention and working memory in humans. However, few prior studies have tested for evidence of structural brain alterations in human tobacco smokers. In this study, proton magnetic resonance spectroscopy was used to assess the effects of chronic smoking on neuronal integrity of the hippocampus and anterior cingulate cortex (ACC). METHODS: Absolute concentrations of N-acetylaspartate, total choline (tCho), and total creatine were measured in the left hippocampus and ACC in 13 chronic tobacco smokers and 13 nonsmokers matched for age, sex, and education. RESULTS: The N-acetylaspartate concentration was significantly reduced in smokers relative to nonsmokers in the left hippocampus but not in the ACC. There were no group differences in the tCho and total creatine concentrations in either voxel. However, ACC tCho concentration was positively correlated with magnitude of lifetime exposure to tobacco smoke (pack-years). CONCLUSION: The results are consistent with prior observations of hippocampal neuronal damage in rodents receiving nicotine and working memory deficits in human tobacco smokers. The positive relationship between tCho and lifetime tobacco exposure suggests that a component of tobacco smoke, presumably nicotine, may increase cortical membrane turnover or modify cell density. Together, these results add to growing evidence that nicotine exerts neurotoxic effects in human brain, although an a priori nature of the findings cannot be ruled out.

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OBJECTIVE: Chronic smoking and nicotine exposure are accompanied by impaired cognitive task performance, modulated cerebral activity in brain imaging studies, and neuritic damage in experimental animals. The profile of the described dysfunctions matches frontal lobe circuits which also play a role in reward processing and reinforcement behavior. However, it is largely unknown if cerebral dysfunctions are reversible or persist during long term abstinence. MATERIALS AND METHODS: Cortical activation during auditory target processing (oddball task, P300 component) was recorded with 32-channel EEG in 247 healthy subjects consisting of 84 smokers, 53 former smokers (mean time of abstinence 11.9 years), and 110 never smokers. RESULTS: Both current smokers and former smokers exhibited significantly diminished P300 amplitudes (Cz, Pz) relative to never smokers. Neuroelectric source analysis (low resolution brain electromagnetic tomography) revealed a hypoactivation of the anterior cingulate, orbitofrontal, and prefrontal cortex in smokers compared to never smokers. A similar profile of hypoactivation was observed in former smokers. CONCLUSION: For the first time, evidence is provided that dysfunctional activation of frontal lobe networks in smokers is also present in long term abstainers.

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