Disorganized Thinking Research Articles

Retraction to: S117. DOES ADDING AUTOMATED ANALYSIS OF SPEECH COHESION TO DIMENSIONALIZED R-PAS COGNITIVE CODES IMPROVE OUR ABILITY TO ASSESS DISORGANIZED THINKING?

Abstract Background Research is increasingly pointing toward the need for a dimensional, rather than categorical, conceptualization of psychopathology. This is particularly true within the literature on psychosis and related disorders. Taking a dimensional approach to conceptualizing psychosis requires deconstructing its components in assessment. The Rorschach Performance Assessment System (R-PAS) contains meta-analytically supported scales with international norms that are used to categorically rate signs of disordered thinking and perceptions in individuals’ responses to the Rorschach inkblots. Recently, a new dimensionalized set of scales called the Scales of Problematic Communication and Thinking (SPCT) have been developed for R-PAS with three main components: Disturbed and Confusing Communication, Illogical Verbal Justification, and Incongruous Perceptual Combinations. Research also suggests that linguistic measures of speech cohesion can be used to successfully predict conversion to psychosis in clinical high-risk patients and may be more related to stable neurocognitive deficits than clinical measures of disorganized speech. Coh-Metrix, an automated speech analysis software, provides over 100 specific measures of linguistic cohesion, such as connectivity, syntax simplicity, and referential cohesion. The purpose of this presentation is twofold: (a) to report recent findings showing the SPCT provides incremental validity over the traditional R-PAS measure of disordered thinking in predicting clinician ratings of disorganized thinking on the PANSS and (b) to determine if Coh-Metrix measures of linguistic cohesion provide incremental validity to SPCT ratings in predicting these PANSS ratings. Methods R-PAS protocols from a maximum-security inpatient forensic hospital (N = 91) aged 19 to 80 years (M=40) and predominantly male (89%) were coded for thinking and perceptual disturbances using the R-PAS traditional measure of disordered thinking and the 6-point dimensional SPCT measure. The patients’ primary clinician provided PANSS ratings. Protocols will be coded for speech cohesion using 15 indices from the automated speech analysis software Coh-Metrix, which were chosen based on a literature review. Results Interrater reliability was excellent for the SPCT ratings (ICC = 0.97) and good for the PANSS clinician ratings (ICC = 0.71). In a previous study, SPCT ratings showed significant associations with the clinician ratings of disorganized thinking on the PANSS (r = 0.42, p < 0.01, N = 90); hierarchical regression analyses demonstrated incremental validity over the traditional R-PAS measure of disordered thinking (ΔR = 0.28, p < 0.01). Using hierarchical regression analyses, the Coh-Metrix indices of cohesion are predicted to provide incremental validity to the SPCT ratings. Discussion The SPCT shows promise as a reliable and valid dimensionalized measure for assessing the continuum of clear thinking to psychosis-level disturbances. The measures of linguistic cohesion provided by Coh-Metrix have the potential to offer clinicians a quick, efficient, and objective method for assessing disorganized thinking. The R-PAS international norms are currently being coded for SPCT and, if Coh-Metrix measures provide incremental validity, will be coded for these measures as well. Using these measures in combination with SPCT ratings can provide clinicians with a clearer understanding of this significant component of psychosis.

COVID-19 testing and patients in mental health facilities.

COVID-19 testing and patients in mental health facilities.

Pharmacological Treatments for Delirium in Critically Ill Adults

What effects do pharmacological treatments for delirium have on the duration of delirium in critically ill adults?Delirium is one of the most common behavioral manifestations of acute brain dysfunction in patients in intensive care units (ICUs), affecting up to 80% of those who are critically ill.1 Delirium is characterized by inattention, altered consciousness, and disorganized thinking, and it is associated with various serious adverse outcomes including hospital and ICU mortality, longer duration of mechanical ventilator support, prolonged ICU and hospital stays, and long-term cognitive impairment.2 For this reason, nurses must appropriately manage delirium to minimize adverse outcomes.Treatment options include both pharmacological and nonpharmacological interventions, although serious illness often requires a pharmacological treatment. The effectiveness of such regimens vary and are not standardized internationally.2 The most common pharmacological interventions are antipsychotic medications, yet published evidence provides mixed support for their use. A Cochrane systematic review by Burry et al3 compared the 6 main types of medications and assessed their impact on delirium in critically ill patients.This summary describes the review by Burry et al,3 which included data from 14 randomized controlled trials with a combined total of 1844 participants. The review explored 1 primary outcome: Duration of delirium (ie, the time from when delirium was identified until it resolved) measured in days.The randomized controlled trials evaluated by Burry et al3 compared various medications with placebo:The review also evaluated various secondary outcomes:Burry et al3 independently assessed the risk of bias in each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing and discussing the data together.The authors used medians and means with 95% CIs as measures of treatment effects among various comparisons and outcomes. They used the internationally approved Grades of Recommendation, Assessment, Development and Evaluation approach to determine the quality of evidence for each outcome. This approach assigns a level of high, moderate, low, or very low regarding the confidence of an outcome or conclusion: (1) high, which indicates that further research is very unlikely to change the confidence in the conclusion; (2) moderate, which means that further research is likely to have an important impact on the confidence in the conclusion and may change it; (3) low, which indicates that further research is very likely to have an important impact on the confidence in the conclusion and is likely to change it; and (4) very low, which means the conclusion is uncertain.4When each drug class was directly compared with a placebo, only the α2-adrenergic agonist dexmedetomidine reduced the duration of delirium; the cholinesterase inhibitor rivastigmine prolonged the duration. Both of these results are based on findings from a single small study. The other drugs, when compared with placebo, did not change delirium duration. In addition, the results did not indicate that any drug reduced the duration of coma, the length of stay, or mortality, nor did the drugs improve long-term cognitive outcomes. Some results did show that dexmedetomidine shortened the duration of mechanical ventilation.The following points provide additional detail about the main results of this systematic review.Delirium continues to be a challenge in the critical care setting, and health care teams continue to use pharmacological interventions to treat it. The main outcomes explored in the systematic review by Burry et al3 suggest that the α2-adrenergic agonist dexmedetomidine may help shorten the duration of both delirium and mechanical ventilation, but those results are based on the findings of only a single small study. No other pharmacological intervention—including antipsychotics, the medication most commonly prescribed for treating delirium—had any effect on delirium duration or on any of the secondary outcomes.One key result was that the cholinesterase inhibitor rivastigmine was associated with harm and a longer stay in the ICU; as such, clinicians should advocate against and carefully consider its use for treating delirium in patients in the ICU. One study showed advantages to using dexmedetomidine to treat delirium in such patients, but additional evidence is needed to fully support this. Health care teams should evaluate the options and make the most appropriate clinical decision on the basis of the best available evidence. The results of ongoing studies such as the international work from the group Del-COrS (Development of core outcome sets for effectiveness trials of interventions to prevent and/or treat delirium) may provide further insight into and guidance regarding delirium management.5Advocating for the best evidence-based treatment is an important part of our role as nurses caring for critically ill patients. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is appropriate for our particular patient.

Understanding the Breadth and Depth of C-L Psychiatry: Assessing and Managing Delirium

Understanding the Breadth and Depth of C-L Psychiatry: Assessing and Managing Delirium

Outcome of Older Patients with Acute Neuropsychological Symptoms Not Fulfilling Criteria of Delirium.

Although delirium is often investigated, little is known about the outcomes of patients having acute neuropsychological changes at a single time point without fulfilling the criteria of full delirium. Our aim was to determine point prevalence, predictors, and long-term outcomes of delirium and acute neuropsychological changes in patients aged 60 years and older across different departments of a university hospital with general inpatient care. Prospective observational study. University hospital excluding psychiatric wards. At baseline, 669 patients were assessed, and follow-ups occurred at months 6, 12, 18, and 36. Measurements were obtained using the Confusion Assessment Method (CAM), comprehensive geriatric assessment, health-related quality of life, functional state (month 6), and mortality rates (months 6, 12, 18, and 36). Subjects were classified into (1) patients with delirium according to the CAM, (2) patients with only two positive CAM items (2-CAM state), and (3) patients without delirium. Delirium was present in 10.8% and the 2-CAM state in an additional 12.7% of patients. Highest prevalence of delirium was observed in medical and surgical intensive care units and neurosurgical wards. Cognitive restrictions, restricted mobility, electrolyte imbalance, the number of medications per day, any fixations, and the presence of a urinary catheter predicted the presence of delirium and 2-CAM-state. The mean Karnofsky Performance Score and EuroQol-5D were comparable between delirium and the 2-CAM state after 6 months. The 6-, 12-, 18-, and 36-month mortality rates of patients with delirium and the 2-CAM state were comparable. The nurses' evaluation of distinct patients showed high specificity (89%) but low sensitivity (53%) for the detection of delirium in wide-awake patients. Patients with an acute change or fluctuation in mental status or inattention with one additional CAM symptom (ie, disorganized thinking or an altered level of consciousness) have a similar risk for a lower quality of life and death as patients with delirium. J Am Geriatr Soc 68:1469-1475, 2020.

Cortical thickness and formal thought disorder in schizophrenia: An ultra high-field network-based morphometry study

BackgroundPersistent formal thought disorder (FTD) is a core feature of schizophrenia. Recent cognitive and neuroimaging studies indicate a distinct mechanistic pathway underlying the persistent positive FTD (pFTD or disorganized thinking), though its structural determinants are still elusive. Using network-based cortical thickness estimates from ultra-high field 7-Tesla Magnetic Resonance Imaging (7T MRI), we investigated the structural correlates of pFTD. MethodsWe obtained speech samples and 7T MRI anatomical scans from medicated clinically stable patients with schizophrenia (n = 19) and healthy controls (n = 20). Network-based morphometry was used to estimate the mean cortical thickness of 17 functional networks covering the entire cortical surface from each subject. We also quantified the vertexwise variability of thickness within each network to quantify the spatial coherence of the 17 networks, estimated patients vs. controls differences, and related the thickness of the affected networks to the severity of pFTD. ResultsPatients had reduced thickness of the frontoparietal and default mode networks, and reduced spatial coherence affecting the salience and the frontoparietal control network. A higher burden of positive FTD related to reduced frontoparietal thickness and reduced spatial coherence of the salience network. The presence of positive FTD, but not its severity, related to the reduced thickness of the language network comprising of the superior temporal cortex. ConclusionsThese results suggest that cortical thickness of both cognitive control and language networks underlie the positive FTD in schizophrenia. The structural integrity of cognitive control networks is a critical determinant of the expressed severity of persistent FTD in schizophrenia.

Linguistic determinants of formal thought disorder in first episode psychosis.

Thought disorder is a core feature of schizophrenia but assessment of disordered thinking is challenging, which may contribute to the paucity of mechanistic understanding of disorganization in early psychosis. We studied the use of linguistic connectives in relation to clinically quantified dimensions of thought disorder using automated speech analysis in untreated, first episode psychosis (FEPs) and healthy controls (HCs). 39 treatment-naïve, actively psychotic FEPs and 23 group matched HCs were recruited. Three one-minute speech samples were induced in response to photographs from the Thematic Apperception Test and speech was analysed using COH-METRIX software. Five connectives variables from the Coh-Metrix software were reduced using principle component analysis, resulting in two linguistic connectives factors. Thought disorder was assessed using the Thought Language Index (TLI) and the PANSS-8. Connective factors predicted disorganization, but not impoverishment suggesting aberrant use of connectives is specific to positive thought disorder. An independent t test comparing low and high disorganization FEPs showed higher load of acausal temporal connectives in high disorganization FEPs compared to low disorganization FEPs (mean [SD] in high vs low disorganization FEPs = 0.64 (1.1) vs -0.37 (1.02); t = 2.91, P = .006). Acausal-temporal connectives were not correlated with severity of symptoms or cognition suggesting connective use is a specific index of disorganized thinking rather than overall illness status. Clinical assessment of disorganization in psychosis is likely linked to the aberrant use of connectives resulting in an intuitive sense of incoherence. In early psychosis, thought disorder may be reliably quantifiable using automated syntax analysis.

Cognitive functioning in adolescents with schizophrenia treated with paliperidone extended-release: 6-Month exploratory analysis from an open-label, single-arm safety study

ObjectiveTo assess cognitive functioning in adolescents (12–17 years old) with schizophrenia during open-label treatment with paliperidone extended-release (pali ER). MethodsIn this exploratory analysis, adolescents treated with pali ER (oral, flexibly dosed, 1.5–12 mg/day) underwent cognitive assessments at baseline and month 6 using a battery of cognitive tests validated in adolescents. Correlation analysis was used to explore the relationship between cognitive assessments and clinical symptoms (Positive and Negative Syndrome Scales [PANSS] and factors) and functionality (Children Global Assessment Scale [CGAS]) at baseline and at 6 months. ResultsA total of 324 of 393 patients had evaluable neurocognitive data. Changes in cognition function tests from baseline to endpoint were generally small to modest, with improvement noted for most cognitive domains (motor speed, attention/working memory, verbal learning and memory, social cognition, speed of processing, executive functioning). No improvement was noted for visual learning and memory. At baseline, there were modest negative correlations between disorganized thoughts and most cognitive domains; these correlations persisted at 6 months. Other significant negative correlations at 6 months were between speed of processing and PANSS total score, positive symptoms, negative symptoms and uncontrolled hostility (p < 0.05). At 6 months, higher CGAS scores (improved functioning) positively correlated with speed of processing and executive functioning, especially among pali ER responders. ConclusionsIn this large sample of adolescents with schizophrenia, frank cognitive deficits across multiple domains were observed. Treatment with pali ER over 6 months did not worsen neurocognitive functioning and was possibly associated with positive improvement in certain domains.

Is cognitive behavioural therapy effective for individuals experiencing thought disorder?

Various clinical guidelines recommend cognitive behavioural therapy (CBT) to treat psychosis without reference to patients’ thought disorder. However, there is a risk that disorganized thinking hampers CBT. We tested the prediction that thought disorder would interfere with the effectiveness of CBT for hallucinations and delusions, compared to treatment as usual and supportive counselling, in secondary data from two large, single blind randomised controlled trials. We fitted latent growth curve models separately for the development of frequency and distress of symptoms. CBT was significantly more successful than counselling in reducing delusional frequency in the short term and hallucinatory distress at any point, even in those with relatively high thought disorder. We found little evidence that clinicians should restrict CBT in this subgroup of patients. Nevertheless, the findings highlight the importance of effective initial treatment of thought disorder in maximising the benefit of CBT for psychosis, particularly for reducing distress from hallucinations.

A symptom combination predicting treatment-resistant schizophrenia – A strategy for real-world clinical practice

Early identification of symptoms that can predict treatment-resistant schizophrenia (TRS) could help clinicians to avoid delays in clozapine therapy. This study aims to investigate symptom patterns that could predict TRS using a discovery/replication study design. First, we followed a cohort of inpatients with schizophrenia (n = 164) in which the most discriminative items at baseline of the Positive and Negative Syndrome Scale (PANSS) were determined using logistic regression with TRS status as an outcome. Using Receiver Operating Characteristic (ROC) curves, we tested the prediction performance of multiple combinations of the identified items. The same items' combination was tested in an independent replication sample of (n = 207) outpatients with schizophrenia. In the discovery sample, the best combination to predict TRS at the discharge was the sum of three baseline PANSS items – conceptual disorganization (P2), difficulty in abstract thinking (N5), and unusual thought content (G9). The P2 + N5 + G9 model yielded an area under the curve (AUC) of 0.881, a sensitivity of 77.8%, and a specificity of 83.3%. In the outpatient sample, the model P2 + N5 + G9 predictive accuracy for TRS was only in the range of “acceptable” with an AUC of 0.756 and sensitivity of 72.3% and a specificity of 74.4%. Overall, the P2 + N5 + G9 model corresponds to the construct of formal thought disorder composed of disorganized thinking, concrete thinking, and bizarre-idiosyncratic thinking. Pronounced levels of these symptoms are easily identifiable in clinical practice and may be a feasible strategy in TRS. Replicating in first-episode cohorts is desirable to understand the likely clinical utility.

Comorbid of Obsessive Compulsive Disorder and Schizophrenia: A Case Report

Abstract&#x0D; Introduction&#x0D; Schizophrenia was a chronic mental disorder that marked by abnormal social and impairment in reality testing ability. A person diagnosed with schizophrenia may experience amount of symptoms including hallucinations, delusions, and disorganized thinking, bizzare speech and behaviour. Obsessive compulsive disorder are well known as a comorbid of schizophrenia. Comorbid OCD will affect treatment of schizophrenia and others mental disorder.&#x0D; Case Presentation&#x0D; A 14-year-old student Muslim boy from a rural household in Central Java, Indonesia who had 8 years of formal education and live with his parent was brought to emergency department of mental hospital by his parents who reported a one year history of excessive washing of his body, soaking his body for hours in bathtub and sleep in bathroom. The patient first fell in January 2019; over a six-month period he became progressively deteriorated, lost interest in his hobby, stopped going to school and reduced his food intake. After one week treatment of venlafaxine and risperidone, He became more cooperative and interactive to the examiner. At that time, the patient reported delusional beliefs about contamination, paranoid delusion and there were several indications of formal thought disorder, including derailment, neologisms, concrete thinking, circumstantiality, and illogicality. An intelligence test revealed average intelligence (IQ=100). The total score of the Brief Psychiatric Rating Scale (BPRS) 3 dropped from 42 to 24, the score on the Yates-Brown Obsessive Compulsive Symptoms (YBOCS)4 scale dropped from 24 to 18, and the score on the Global Assessment of Functioning scale (GAF)5 increased from 25 to 55. After discharge the patient adhered to his medication regimen and at three months after discharge his clinical improvement persisted; he was able to maintain is his personal hygiene and take care of his daily needs, but he remained socially isolated and was unable to return to school.&#x0D; &#x0D; Conclusion&#x0D; Obsessive compulsive disorder and schizophrenia could happen together in one individual. The treatment should consider underlying condition and cognitive function, especially if patient in productive age.

Deconstructing Poststroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage.

Poststroke delirium may be underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurologic deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in patients with intracerebral hemorrhage. Prospective observational cohort study. Neurocritical Care and Stroke Units at a university hospital. Consecutive patients with intracerebral hemorrhage from February 2018 to May 2018. None. An attending neurointensivist performed 257 total daily assessments for delirium on 60 patients (mean age 68.0 [SD 18.4], 62% male, median intracerebral hemorrhage score 1.5 [interquartile range 1-2], delirium prevalence 57% [n = 34]). Each assessment included the Confusion Assessment Method for the ICU, Intensive Care Delirium Screening Checklist, a focused bedside cognitive examination, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria, then compared performance of the Confusion Assessment Method for the ICU and Intensive Care Delirium Screening Checklist against reference-standard expert diagnosis. Symptom fluctuation (61% of all assessments), psychomotor changes (46%), sleep-wake disturbances (46%), and impaired arousal (37%) had the highest prevalence and were never rated "unable to assess," while inattention (36%), disorientation (27%), and disorganized thinking (18%) were also common but were often rated 'unable to assess' (32%, 43%, and 44% of assessments, respectively), most frequently due to aphasia (32% of patients). Including nonverbal assessments of attention decreased the frequency of 'unable to assess' ratings to 11%. Since the Intensive Care Delirium Screening Checklist may be positive without the presence of symptoms that require verbal assessment, it was more accurate (sensitivity = 77%, specificity = 97%, area under the receiver operating characteristic curve, 0.87) than the Confusion Assessment Method for the ICU (sensitivity = 41%, specificity = 88%, area under the receiver operating characteristic curve, 0.64). Delirium is common after intracerebral hemorrhage, but severe neurologic deficits may confound its assessment and lead to underdiagnosis. The Intensive Care Delirium Screening Checklist's inclusion of nonverbal features may make it more accurate than the Confusion Assessment Method for the ICU in patients with neurologic deficits, but novel tools designed for such patients may be warranted.

Evaluating the Sustained Attention Response Task to Quantify Cognitive Fluctuations in Dementia With Lewy Bodies.

Cognitive fluctuations (CFs) are a core diagnostic feature of dementia with Lewy bodies (DLB). Detection of CF is still mostly based on subjective reports from the patient or informant; more quantitative measures are likely to improve the accuracy for the diagnosis of DLB. The purpose of the current study is to test whether performance on the Sustained Attention Response Task (SART) could distinguish those patients with DLB with and without CF. Twenty-four patients with DLB were tested on the SART and performance was related to scores on the Clinical Assessment of Fluctuations (CAFs) and One Day Fluctuation Assessment Scale (ODFAS). The number of "misses" made was a significant predictor of their fluctuation severity, attentional performance, disorganized thinking, and language production ratings on the ODFAS. However, measures on the SART did not correlate with measures on the CAF scale. In conclusion, these findings suggest that SART is a feasible measure of sustained attention in this population and has clinical and diagnostic relevance to the measurement of CF, particularly those aspects measured by the ODFAS.

Cholinergic Medication for Antipsychotic‐Induced Tardive Dyskinesia

Antipsychotic medication is prescribed for use for mental health disorders such as schizophrenia to manage symptoms like hallucinations, delusions and disorganised thinking, and the prevention of r...

The “fluid mask” of Antonin Artaud: effects of corporeal hyperreflexivity on schizophrenic subjects

The aim of this paper is to frame schizophrenia as a paradigm for the identification of the bodily roots of self. In order to do that, we will deepen the knowledge of a central figure of twentieth-century theatre: the schizophrenic playwright, actor and poet Antonin Artaud. However, we will not focus on his notorious conceptualization of theatre, but rather on the interpretation that an influential psychiatrist – namely, Louis Sass – gave to some excerpts of his early writings, such as The Umbilicus of Limbo, The Nerve Meter and Fragments of a Journal in Hell, which all date back to 1925. The reason why such collections of poems and disorganized thoughts are particularly interesting is that they shed light on some typical traits of schizophrenia, such as disembodiment, self-fragmentation and a tendency towards the “explication of the implicit”, or hyperreflexivity. The writings of Artaud will serve us as a key to understanding the schizophrenic corporeity, since his words reflect the tormented relationship that all the patients have with their own body. We will address the topic of the problematic subject-body relationship starting with one of the most peculiar features of schizophrenic alienation: the distorted, inharmonious, mask-like perception of one’s own and others’ face.

Understanding Schizophrenia: Genetic Causes and Treatment

Schizophrenia is a severe mental disease. The word schizophrenia literally means split mind. There are three major categories of symptoms which include positive, negative and cognitive symptoms. The disease is characterized by symptoms of hallucination, delusions, disorganized thinking and speech. Schizophrenia is related to many other mental and psychological problems like suicide, depression, hallucinations. Including these, it is also a problem for the patient’s family and the caregiver. There is no clear reason for the disease, but with the advances in molecular genetics; certain epigenetic mechanisms are involved in the pathophysiology of the disease. Epigenetic mechanisms that are mainly involved are the DNA methylation, copy number variants. With the advent of GWAS, a wide range of SNPs is found linked with the etiology of schizophrenia. These SNPs serve as ‘hubs’; because these all are integrating with each other in causing of schizophrenia risk. Until recently, there is no treatment available to cure the disease; but anti-psychotics can reduce the disease risk by minimizing its symptoms. Dopamine, serotonin, gamma-aminobutyric acid, are the neurotransmitters which serve as drug targets in the treatment of schizophrenia. Due to the involvement of genetic and epigenetic mechanisms, drugs available are already targeting certain genes involved in the etiology of the disease.

Diagnosis of postoperative delirium in older adults using the Confusion Assessment Method for the intensive care unit in non-intensive care unit settings: A test modification might improve its diagnostic performance.

To evaluate the diagnostic performance of the Confusion Assessment Method for the intensive care unit (CAM-ICU) among postoperative older patients in non-ICU settings. The CAM-ICU was used by trained staff to prospectively evaluate postoperative patients for delirium. The patients were aged ≥60 years, were in general wards and had no critical illnesses. The assessments occurred for 7 consecutive days after surgery. The results were compared with delirium diagnoses obtained by geriatricians using Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria as the reference standard. The sensitivity of delirium detection for the CAM-ICU was 31.6% (95% confidence interval [CI] 12.6-56.6), while the specificity was 97.6% (95% CI 94.9-99.1), positive predictive value was 50.0% (95% CI 26.3-73.7) and negative predictive value was 95.0% (95% CI 93.3-96.3). Feature 4 (disorganized thinking) yielded the highest sensitivity (60%; 95% CI 14.7-94.7), whereas feature 2 (inattention) had low sensitivity (36.8%; 95% CI 16.3-61.6). Further analyses to explore the highest sensitive criteria showed that if CAM-ICU diagnoses were made by the presence of any two out of feature 1 (acute change or fluctuation of cognition), feature 3 (altered level of consciousness) or feature 4, the sensitivity increased substantially to 80.0% (95% CI 28.4-99.5), with a reasonably high specificity of 81.8% (95% CI 48.2-97.7). Modification of the flow of delirium diagnosis using the CAM-ICU appears to offer a better sensitivity for detecting delirium in non-ICU settings. Furthermore, changing feature 2 to evaluate patients' attention levels over a longer period of time might yield a better diagnostic performance. Geriatr Gerontol Int 2019; 19: 762-767.

Theory of Narcissism and Schizophrenia in Arthur Miller’s Death of a Salesman

In Death of a Salesman, we observe the psychological aspect which makes this play different from other plays. Trough the characters of the play, we are going to analyze the narcissism and schizophrenia in the play. Arthur Miller’s plays are not only the study of social issues but also the study of psychological issues. His characters resemble modern society and its problems. Narcissism and Schizophrenia are the mental disorders of man which are responsible for the destruction of man. These disorders not only affect the individual person but also affect his surroundings. The aim of this paper is to highlight the inner conflict of man and his struggle in modern time in which people are so materialistic. The feeling of grandiosity, special, lying and many others are the symptoms of narcissism. Hallucinations, delusions, disorganized thinking, and movement disorders are the symptoms of schizophrenia.

The efficacy of cariprazine in negative symptoms of schizophrenia: Post hoc analyses of PANSS individual items and PANSS-derived factors

BackgroundNegative symptoms in schizophrenia are heterogeneous and multidimensional; effective treatments are lacking. Cariprazine, a dopamine D3-preferring D3/D2 receptor partial agonist and serotonin 5-HT1A receptor partial agonist, was significantly more effective than risperidone in treating negative symptoms in a prospectively designed trial in patients with schizophrenia and persistent, predominant negative symptoms. MethodsUsing post hoc analyses, we evaluated change from baseline at week 26 in individual items of the Positive and Negative Syndrome Scale (PANSS) and PANSS-derived factor models using a mixed-effects model for repeated measures (MMRM) in the intent-to-treat (ITT) population (cariprazine = 227; risperidone = 227). ResultsChange from baseline was significantly different in favor of cariprazine versus risperidone on PANSS items N1-N5 (blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking) (P < .05), but not on N6 (lack of spontaneity/flow of conversation) or N7 (stereotyped thinking). On all PANSS-derived negative symptom factor models evaluated (PANSS-Factor Score for Negative Symptoms, Liemburg factors, Khan factors, Pentagonal Structure Model Negative Symptom factor), statistically significant improvement was demonstrated for cariprazine versus risperidone (P < .01). Small and similar changes in positive/depressive/EPS symptoms suggested that negative symptom improvement was not pseudospecific. Change from baseline was significantly different for cariprazine versus risperidone on PANSS-based factors evaluating other relevant symptom domains (disorganized thoughts, prosocial function, cognition; P < .05). ConclusionsSince items representing different negative symptom dimensions may represent different fundamental pathophysiological mechanisms, significant improvement versus risperidone on most PANSS Negative Subscale items and across all PANSS-derived factors suggests broad-spectrum efficacy for cariprazine in treating negative symptoms of schizophrenia.

Abstract WP413: Deconstructing Post-Stroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage

Introduction: Post-stroke delirium is associated with worse outcomes, yet is likely underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurological deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in a cohort of patients with intracerebral hemorrhage (ICH). Methods: Consecutive patients admitted with ICH received daily assessments for delirium by an expert clinician, all of which included the Confusion Assessment Method for the ICU (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), a focused bedside cognitive exam, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using DSM-5 criteria, then compared performance of the CAM-ICU and ICDSC with reference-standard diagnosis. Results: We performed 257 assessments on 60 patients (mean age 68.0 [SD 18.4], 62% male, median ICH score 1.5 [IQR 1-2]), of whom 55% had delirium. Symptom fluctuation (61% of all assessments), impaired arousal (37%), psychomotor changes (46%), and sleep-wake disturbances (46%) had a high prevalence and were never rated “unable to assess” (UTA), while inattention (36%), disorganized thinking (18%), and disorientation (27%) were also common but were often UTA (32%, 44%, and 43% of assessments, respectively), most frequently due to aphasia (present in 32% of patients). As the ICDSC may be positive without the presence of symptoms that require verbal assessment, it was more accurate ( Sensitivity= 77%, Specificity= 97%) than the CAM-ICU ( Sensitivity= 41%, Specificity= 88%) relative to the DSM-5-based reference standard. Allowing non-verbal assessments of attention using visual and auditory stimuli decreased the frequency of UTA assessments to 11%. Conclusion: Delirium is common after ICH, but reliance on verbal interaction with patients may confound its assessment and lead to underdiagnosis. The ICDSC’s inclusion of non-verbal features makes it more accurate than the CAM-ICU, but novel tools specifically designed for patients with neurological deficits may be warranted.