T248. PSYCHOPATHOLOGY IN F2X.X-UNAFFECTED CO-TWINS AS A VULNERABILITY INDICATOR OF PSYCHOSIS

Abstract Background Studies have shown that the risk of developing schizophrenia is associated with an increased risk of most other psychiatric disorders1 and that the familial transmission of risk extends across diagnostic categories.2 In twin studies, unaffected twins may not be completely free of symptomatology even when they do not fulfill diagnostic criteria for a psychiatric illness, but this has not been systematically tested in a twin design. The aim of the study was to investigate subtle psychopathology in unaffected co-twins from proband twin pairs, where one twin had a schizophrenia spectrum disorder diagnosis (ICD-10: F2x.x), and compare the level of psychopathology of F2x.x-unaffected co-twins to that of healthy twins. Methods We conducted a multimodal, cross-sectional combined clinical and register-based nation-wide twin study, by including twin pairs where one or both twins had a diagnosis in the schizophrenia spectrum (identified by linking The Danish Twin Register and the Danish Psychiatric Central Research Register). A group of age-and gender matched healthy twin pairs were included. All subjects underwent ratings of psychopathology with Positive and Negative Syndrome Scale (PANSS), Comprehensive Assessment of At Risk Mental State (CAARMS), and Clinical Global Impression (CGI). The current level of functioning was estimated with Global Assessment of Function (GAF). Results A total of 219 twins were included; i.e. proband twins (n=65), F2x.x-unaffected co-twins (n=56) and healthy twins n=98). For unaffected co-twins, the mean PANSS total score was 38 (SD 12.6), the CGI score was 1.7 (SD 1.1) and the GAF score was 74 (SD 13.3), which were all significantly higher than in healthy twins (all p<0.02), who had a mean PANSS total score of 32 (SD 5.7), a CGI score of 1 (SD 0.3) and a GAF score of 85 (SD 7.3). For CAARMS, the following items were significantly more severe in the unaffected co-twins compared to healthy twins: anxiety (p=0,021), OCD (p=0.008), stress tolerance (p=0.001), aggression (p=0.01), inappropriate affect (p=0.03), social isolation (p=0.01), and impaired role-function (p=0.001). Discussion These preliminary results indicate a subtle but significant level of psychopathology in unaffected co-twins of probands affected with a schizophrenia spectrum disorder compared to healthy twins, measured by PANSS and CGI. Results from CAARMS indicate specific areas of interest, clustered around emotional and behavioral symptoms like anxiety, stress intolerance, social isolation, inappropriate affect/aggression and impaired role-function. This may suggest subtle symptomatology in the f2x.x-unaffected co-twins, which may contribute to the significantly lower level of function in the co-twins compared to healthy twins. The heritability of these measures of psychopathology will be examined using Structural Equation Modelling on the whole cohort of probands, unaffected co-twins and healthy twins. References 1. Mortensen PB, Pedersen MG, Pedersen CB. Psychiatric family history and schizophrenia risk in Denmark: which mental disorders are relevant? Psychol Med 2010; 40: 201–10. 2. Rasic D, Hajek T, Alda M, Uher R. Risk of mental illness in offspring of parents with schizophrenia, bipolar disorder, and major depressive disorder: a meta-analysis of family high-risk studies. Schizophr Bull 2014; 40: 28–38.

1. Staff's experience of using interactive methods will be analyzed through focus-groups; four group interviews with 5 people in each group. (Assisting nurses and nurses working full-time, who have been educated in interactive conflict-handling and worked according to the method for at least one year). 2. Intervention study. The staff at the psychiatric departments of four different hospitals will receive training in interactive conflict handling, and after the course, supervision. The purpose is to compare the number of aggressive events before and after the intervention.
The instruments that will be used for measurement of the effect are the Staff Observation Aggression Scale -revised (primary outcome), the Social Dysfunction Aggression Scale and the Clinical Global Impression -Severity Scale. We will also document the type of care (voluntary or compulsory), the number of psychiatric hospital beds, the number of inpatient patients, the number of staff employed, if the patient was affected by alcohol or illegal drugs and several other variables. Diagnoses will be retrieved from patient records.
3. Evaluation of implementation. The purpose is to analyze the implementation of the intervention at four hospitals. Group interviews will be conducted and the data will be analyzed qualitatively by using Normal Process Theory (NPT) as a framework. NPT is an action research perspective that focuses on what actors actually do and discerns between, implementation, embedding integration as different levels of change.
Results: Data collection for the first sub-study will be completed in June 2018 and results from the second and third are anticipated to be available by March 2019 and December 2019, respectively. Discussion: Possible methodological problems are that data from focusgroups may not be possible to generalize. However, qualitative data may capture experiences that shed light on the psychological working-mechanisms of the intervention. The intervention study is expected to generate rich data, where essential variables are controlled for, for example organizational features, distribution of diagnoses and severity of symptoms. However, in a complex organization, it may not be possible to control for all variables that might explain variations in outcome. Background: Apathy and amotivation are considered as the core features of negative symptoms in patients with schizophrenia spectrum disorders. It's well know that schizophrenia patients often lack insight into their symptoms. Insight bias affects self-representation, social functioning and social outcomes, reduces effects of psychosocial treatment and rehabilitation. Objective: To research key aspects of insight into apathy depending on diagnostic categories in patients with schizophrenia spectrum disorders. The aim of the study was to analyze correlations of insight into apathy/ amotivation with clinical symptoms, compliance with treatment and social cognition.
Methods: 103 patients with schizophrenia and schizophrenia spectrum disorders were recruited to participate in the study. Only patients in stabilized state that met criteria of PANSS total score ≤ 80 points were included. Demographic data was collected along with the clinical description on prevailing symptoms during acute phase. Discrepancy score for Apathy Evaluation Scale clinical (AES-C) and self-rated (AES-S) versions was used to assess insight into amotivation syndrome. Hinting Task, Ekman-60 and RAD-15 were used to assess social cognition and BACS was used for neurocognition. Results: Overall, moderate positive correlations between AES-C and PANSS amotivation subscale N2 and N4 items, N6 item with total PANSS negative subscale were revealed. No significant correlations with G16 item were registered. AES-C/AES-S discrepancy ratio also modestly correlated with paranoid schizophrenia (r=0,29) and prevailing delusional symptoms during acute phase (r=0,33) of manifest psychoses, age of onset (r=0,28) and inpatient only treatment intake (r=0,27). It was negatively correlated with number of hospital admissions (r=-0,43). It is worth noting that we found no correlation between AES discrepancy ratio and social cognition and neurocognition. Discussion: Patients with prevailing paranoid symptoms not only lack insight into positive symptoms, but tend to underestimate their negative symptoms such as motivation and apathy. Clinically this can be described by overestimated strengths, overstated expectations, exaggerated hopes, mistakenly overrated beliefs. These phenomena often biases the recovery process and need to be addressed during motivational enhancement therapy. Patients with more difference between the results in AES-C and AES-S are less critical to their conditions and less committed to therapy while being more paranoid in their beliefs. It is also harder to identify problems and targets for these patients as they often see no reasons for treatment at all. Probably with some of these patients indirect methods (metacognitive training) would be preferable rather than psychoeducation-based approaches when choosing psychological therapies. Interestingly no relationship of insight and social cognition was revealed. That needs further investigation as motivation is often considered to be a mediator for neurocognitive and social cognitive functions while there is still little works on the role of insight in relation to social cognition. In twin studies, unaffected twins may not be completely free of symptomatology even when they do not fulfill diagnostic criteria for a psychiatric illness, but this has not been systematically tested in a twin design. The aim of the study was to investigate subtle psychopathology in unaffected co-twins from proband twin pairs, where one twin had a schizophrenia spectrum disorder diagnosis (ICD-10: F2x.x), and compare the level of psychopathology of F2x.x-unaffected co-twins to that of healthy twins. Methods: We conducted a multimodal, cross-sectional combined clinical and register-based nation-wide twin study, by including twin pairs where one or both twins had a diagnosis in the schizophrenia spectrum (identified by linking The Danish Twin Register and the Danish Psychiatric Central Research Register). A group of age-and gender matched healthy twin pairs were included. All subjects underwent ratings of psychopathology with Positive and Negative Syndrome Scale (PANSS), Comprehensive Assessment of At Risk Mental State (CAARMS), and Clinical Global Impression (CGI). The current level of functioning was estimated with Global Assessment of Function (GAF).
Results: A total of 219 twins were included; i.e. proband twins (n=65), F2x.x-unaffected co-twins (n=56) and healthy twins n=98). For unaffected co-twins, the mean PANSS total score was 38 (SD 12.6), the CGI score was 1.7 (SD 1.1) and the GAF score was 74 (SD 13.3), which were all significantly higher than in healthy twins (all p<0.02), who had a mean PANSS total score of 32 (SD 5.7), a CGI score of 1 (SD 0.3) and a GAF score of 85 (SD 7.3). For CAARMS, the following items were significantly more severe in the unaffected co-twins compared to healthy twins: anxiety (p=0,021), OCD (p=0.008), stress tolerance (p=0.001), aggression (p=0.01), inappropriate affect (p=0.03), social isolation (p=0.01), and impaired role-function (p=0.001). Discussion: These preliminary results indicate a subtle but significant level of psychopathology in unaffected co-twins of probands affected with a schizophrenia spectrum disorder compared to healthy twins, measured by PANSS and CGI. Results from CAARMS indicate specific areas of interest, clustered around emotional and behavioral symptoms like anxiety, stress intolerance, social isolation, inappropriate affect/aggression and impaired role-function. This may suggest subtle symptomatology in the f2x.x-unaffected co-twins, which may contribute to the significantly lower level of function in the cotwins compared to healthy twins. The heritability of these measures of psychopathology will be examined using Structural Equation Modelling on the whole cohort of probands, unaffected co-twins and healthy twins. The recommendations made in the guidelines have resulted in some controversy -most notably about the use of depot antipsychotics, and antipsychotic medication discontinuation after recovery from first episode psychosis. As with most CPGs, there is no mechanism for ongoing updating of treatment recommendations in response to new evidence, so regular revisions of CPGs will be needed. Discussion: The Guidelines provide a comprehensive summary of the evidence for interventions to treat schizophrenia and related disorders, set out a recommended standard of care to be adopted by clinicians in Australia and New Zealand, and create a benchmark against which individual practice and services can be compared. The debate generated by the publication of the guidelines has highlighted the gap between the recommended standard of care and existing practice, especially as it relates to the physical care and psycho-social interventions offered to people with these conditions.