Welcome to the EPA 2022 Interactive Programme 

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Homicide and suicide are complex phenomena raising questions and interest which go far beyond the medical and psychiatric field, as they represent a challenge for an understanding which is, first of all, human. In older adults, homicide and suicide may present together in the homicide-suicide phenomenon. The most common motive underlying this behavior in intimate partner relationships is the so-called “mercy killing”, where the perpetrator kills the partner to eventually allow relief from declining health conditions, and then commits suicide. Actually, older adults account for a disproportionately high number of suicide deaths and approximately 55% of late-life suicides are associated with physical illness, notwithstanding psychiatric comorbidity. Physical illness is more likely to eventually lead to suicidal behaviour when it represents a threaten for the individual’s independence, autonomy, self-esteem and dignity, and when it impacts on quality of and pleasure with life, sense of meaning, usefulness and purpose in life. As the current historical period is one marked by opportunities which have allowed a rapid increase of life expectancy and longevity, it clearly emerges the need to balance benefits and harms of curative and palliative therapies, especially for painful, terminal illnesses. The expression of suicidal thoughts in older adults, as well as behaviours suggesting “silent” or indirect suicidal attitudes, should be carefully investigated and clinicians should try to decode the possible communicative role of suicidal behaviour while avoiding premature conclusions about the “rationality” of patients’ decision to die.

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We’ll present the Catalan experience of follow up by phone contats of suicide attempters, and the results up to 10 years. We develop a Suicide Prevention Program that started with the EAAD project in 2008 in a 0,5 M people catchment area, later generalized to 7,5 M people through the Catalonia Suicide Risk Code (SRC-Cat).

The SRC-cat is a real-time registry of suicide attempts (65% women) that allows immediate attention and telephone follow-up and ensures continuity of care for 12 months.

To evaluate the effectiveness of our telephone management plan, we conducted two types of analysis; a) 12-month short-term analysis: non-randomised controlled analysis of suicide reattempts comparing two cities (2007-2008); b) 8-year long-term analysis with the evolution of suicide rates (men and women) between our area, and two other cities (territorial differences and over time from 2010 to 2017).

Results: a) the SRC-Cat in our catchment area reduced significantly the proportion of people who re-attempt suicide by 57% over 12 months (from 14% to 6 %); b) we found lower standardized suicide death rate among women in our catchment area (both territorially and over time).

Conclusions: a) Short-term telephone management (12-month), ensuring chain of care after hospital discharge, reduces more than 50% the proportion of patients who re-attempt; b) Long-term telephone management (8-year) of suicide attempt survivors over 12 months, significantly reduces suicide deaths in women only (64% of patients in telephone follow-up are women).

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Background: Virtual Reality (VR) is increasingly used for treatment of psychiatric disorders. With immersive VR, people can be gradually exposed to situations they fear, they can practice new behaviour in a safe and controlled way. The threshold for engaging in therapy is lower in VR than in real life. VR applications for psychosis have been introduced fifteen years ago, and are rapidly expanding.

Methods: In our VR mental health lab, several VR therapies for psychotic disorders have been developed and investigated. Results of recent randomized controlled trials (RCT) will be presented, and ongoing and future projects will be discussed, including VR cognitive behavioral therapy (VRcbt) for paranoid delusions, social cognition training, stress management and avatar therapy for auditory hallucinations

Results: The RCT of VRcbt for paranoid delusions (N=116) had strong and statistically significant effects on paranoid ideations, anxiety and safety behavior. Facial emotion recognition was improved by VR social cognition training (RCT N=81), but other domains of social cognition proved more difficult to improve. A VR relaxation tool (RCT N=50) had strong immediate effects on perceived stress and emotional states. Ongoing VR intervention studies are a modular VR intervention aimed at improving social functioning (VR SOAP) and an empowering intervention for patients with auditory hallucinations (VR VOICES).

Discussion: VR is a powerful tool for treatment of psychotic disorders, offering interventions for multiple symptom domains and functioning. Next generation VR studies hold the promise to expand and substantially improve psychosocial treatment of psychotic disorders.

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Background

Urban birth, urban living, and ethnic minority status are established risk factors for schizophrenia, but the mechanisms are unclear. Previous evidence suggests a causal role of social exposures and adverse experiences, but experimental evidence is scarce.

Methods

We combine multimodal neuroimaging with ecological momentary assessment, geolocation and geospatial analysis in an epidemiological longitudinal sample in Germany.

Results

We find that established risk factors converge on the perigenual cingulate-amygdala-ventral striatal pathway as shown by structural and functional imaging, supporting a role for the ventral-striatal system in psychosis risk. Using a combination of PET and fMRI data in migrants, we suggest a mechanistic link to psychosis by increased dopamine release and synthesis in striatum secondary to prefrontal dysregulation. Importantly, the regulatory system identified overlaps with that implicated in racial stereotyping and prejudice. Moreover, an experiment measuring information flow during an exchange between migrants and non-migrants indicates that during a trust interaction, cultural distance governs the exchange.

Conclusions

This work shows a convergent risk circuit related to minority position and migration that could guide primary prevention of schizophrenia through reduction of manifestation risk by contextual intervention.

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The risk rate of criminality is increased in ADHD, especially in children who, in addition to ADHD, express externalizing behavior of oppositional defiant disorder (ODD), later followed by conduct disorder (CD), substance misuse and antisocial personality disorder (ASPD). Studies report ADHD to be about ten times more common in prison populations than in the general adult population. Prisoners with ADHD have compared to prisoners without ADHD, an earlier onset of offending, higher rates of coexistent psychiatric disorders, and are more often incarcerated due to violent- and drug-related offences. Within prison settings, inmates with ADHD are more often reported for intra-institutional aggression and they are often experienced as more difficult to manage and costly to rehabilitate. Further, they relapse comparably more often and faster into criminality after being conditionally released. Despite high prevalence rates of ADHD within prisons and serious consequences related to untreated ADHD, few controlled trials have evaluated methylphenidate treatment in prisoners with ADHD and coexistent disorders. Evidence and clinical experience of pharmacological and psychosocial interventions of prison populations with ADHD will be presented briefly.

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Intimate partner violence (IPV) has a very high prevalence (25%) in society and has serious consequences for its victims. As former studies showed minimal effectiveness of therapeutic interventions addressing IPV, the Dutch guideline for Familial/Domestic Violence (NVVP, 2008) recommends to focus more on systemic factors and on individual risk factors of IPV. ADHD is one of these individual risk factors.

This presentation focuses on the association between ADHD and IPV, presenting data and clinical examples. ADHD was missed in 56% of a sample of forensic outpatients. Reasons for this issue of underdiagnosis of ADHD in case of aggression and IPV are discussed. Also, data of the ITAP (impact of treatment of ADHD on IPV) study are presented, showing that ADHD in offenders of IPV with ADHD scored higher on minor physical aggression, minor and severe psychological aggression and clinician-rated IPV than offenders without ADHD. Further, after a one year treatment of ADHD and IPV, decrease in IPV was mainly associated with decrease in ADHD symptoms. The importance of screening and treatment of ADHD symptoms in all IPV offenders is discussed to make treatment of IPV more effective.

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Introduction: The social defeat hypothesis of psychosis posits that an outsider status or subordinate position is a common denominator of several psychosis risk factors, leads to elevated striatal dopamine function and thereby to an increased risk for the disorder. The purpose of this paper is to examine whether this hypothesis offers a good explanation for the increased psychosis risk for migrants from developing countries.

Method: Review of literature.

Results: The outsider status and subordinate position of many migrants from developing countries in Europe, and of Africans in particular, is evident. It is also clear that racism contributes to this situation. An interpretation of racism as psychotogenic is supported by findings of increased risks for other discriminated groups, such as homosexuals, individuals with a low IQ or a hearing impairment. The single study that examined dopamine function in migrants reported indeed elevated stress-induced dopamine release and dopamine synthesis capacity (Egerton et al., 2017). Recently, we examined the time course of the RR of treatment for psychosis for all migrants to the Netherlands (Termorshuizen & Selten, submitted). Contrary to our expectations, the RR for migrants from sub-Saharan Africa was already increased in the year of arrival (RR=2.5; 2.0-3.1), particularly for those aged 10-20 years (RR=6.1; 2.9-12.6).

Conclusion: The social defeat hypothesis accords well with a psychotogenic effect of racism, but replications of the dopamine study are needed. The finding of an increased risk for Africans in the year of arrival suggests that racism is not the single cause of their increased risk.

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Young migrants arriving in Belgium are almost always given a legal statute of "unaccompanied minor". Next to the traumatising experiences they've lived, this status imposed on them, implies that they get a guardian, most of the time an adult volunteer. They have to live in a protective environment and live according to the rules of institution thattakes care of them.

For many of them, having left behind a rather autonomous way of living in the past months before arriving in Belgium, though sometimes in very dangerous and abusive situations, it's a significant change to be put in a position that seems almost childish to them.

This contribution will address issues the presenter has encountered as a child and adoelscent psychiatrist, working with a service linked to a the biggest welfare orgaisation in Flanders (Belgium), while taking care of mental health problems these nonaccompanied minors present with.