Our knowledge of prognostic factors and optimal treatment organisation in schizophrenia is incomplete. The disparity of outcome measures used has been a major obstacle for research. Increasing evidence has shown that schizophrenia is associated with increased cardiovascular mortality, development of obesity and autonomic nervous system imbalance. Assertive community treatment (ACT) has been suggested as a promising direction for organising treatment services for first-episode schizophrenia, but its long-term effect has not been evaluated. One aim of the present thesis was to investigate prognostic factors for 5-year symptomatic and functional outcome and obesity development. A further aim was to evaluate a recently proposed definition of remission and examine the long-term effects of introducing a modified ACT programme (mACT). Thus, we performed a follow-up study of all consecutive first-episode psychosis patients in Uppsala County, Sweden during 1995-2000 (n=144). In the first study we investigated the changes in a broad 5-year outcome of symptoms and function among patients presenting first time ever to psychiatric health care during 3 years before and during 3 years after the implementation of mACT. This change in the psychiatric service, however, was not followed by any long-term clinical benefits. In the second study, we examined the association between remission of eight core schizophrenia symptoms and functional outcome. Remission was strongly associated with having good function and having a higher self-rated satisfaction with life. In the third study, we explored a set of biochemical markers as predictors of weight gain and development of obesity. Haemoglobin, red blood cell count, hematocrit, γ-glutamyltransferase and creatinine were associated with the development of obesity in first-episode schizophrenia. In the fourth and final study, we tested electrocardiographic measures of autonomic imbalance as predictors of symptomatic remission. Higher heart rate and high ST and T-wave amplitudes were related to symptomatic remission, indicating that cardiac autonomic imbalance at baseline may have a prognostic value in first-episode schizophrenia.

La esquizofrenia está considerada un síndrome clínico heterogéneo con una etiopatogenia de origen multifactorial, en el que se incluyen factores ambientales, caracteriales y genéticos. A pesar de que más del 50% de la variabilidad de la enfermedad se puede deber a uno o varios factores genéticos, sólo un número limitado de variantes de riesgo genético y con un efecto muy débil han podido ser identificados. Muchos de ellos no han podido reproducirse tanto por la diversidad de las muestras y poblaciones estudiadas como por su asociación a diversas enfermedades mentales. Parte de esta heterogeneidad ha intentado ser solventada mediante el uso de endofenotipos o fenotipos intermedios y marcadores biológicos, usados como marcadores de vulnerabilidad genética. El gen de la Catecol-O-Metil Transferasa (COMT), que codifica un enzima catabolizador de dopamina en el córtex prefrontal ha sido estudiado como uno de los genes candidatos más prometedores en el estudio de la etiopatogenia de la esquizofrenia, especialmente el polimorfismo rs4680 (COMT Val158Met). La posibilidad de asociar alteraciones en la regulación dopaminérgica prefrontal se encontraría refrendada por la hipótesis dopaminérgica revisada, según la cual, en la esquizofrenia existiría un desequilibrio dopaminérgico, con un incremento en la función dopaminérgica subcortical D2 y un déficit de estimulación D1 cortical. El polimorfismo COMT Val158Met no ha podido confirmar su asociación con esquizofrenia, existiendo en todo caso un riesgo muy débil asociado al alelo hiperfuncionante Val158. El estudio de endofenotipos y marcadores biológicos ha sugerido la asociación del polimorfismo con alteraciones cognitivas, neurofisiológicas, neuroanatómicas y a fenotipos clínicos como agresividad, suicidio, síntomas psicóticos, edad de inicio y respuesta clínica, encontrándose resultados heterogéneos, así como la existencia de una modulación del riesgo de asociación por el consumo de cannabis. Gran parte de la heterogeneidad puede explicarse por problemas metodológicos, relacionados con la validez y representatividad de las muestras, que podrían solventarse con la recogida sistemática de variables en muestras epidemiológicas en fases iniciales de la enfermedad. Partiendo de la hipótesis de la existencia de una alteración dopaminérgica prefrontal en la esquizofenia, el alelo Val158 del gen COMT estaría asociado a una expresión de síntomas psicóticos más graves, especialmente los negativos y a factores de mal pronóstico. Igualmente el consumo de cannabis podría modular este riesgo, incrementando el riesgo o contrarrestando los factores protectores. El objetivo principal fue estudiar la asociación de la presentación clínica y evolución a las seis semanas de tratamiento antipsicótico de pacientes con un primer episodio de psicosis y las variantes del polimorfismo COMT Val158Met así como su interacción con el consumo de cánnabis premórbido. Los objetivos secundarios fueron estudiar la incidencia de esquizofrenia y validar la representatividad de la muestra, analizar la relación entre el polimorfismo Val158Met y sintomatología clínica, edad de inicio, respuesta al tratamiento y estimar la presencia de interacciones gen-ambiente con el consumo de cánnabis premórbido. Para ello, se reclutaron 174 pacientes consecutivos con un primer episodio de psicosis de esquizofrenia, trastorno esquizofreniforme, trastorno esquizoafectivo, trastorno psicótico breve o trastorno psicótico no especificado, incluidos dentro del programa PAFIP, diseñado para la detección y tratamiento de los casos incidentes en la comunidad de Cantabria de Febrero 2001 a Febrero 2005. Los pacientes fueron evaluados con una entrevista semiestructurada, las escalas SANS, SAPS, HDRS, CDS, YMRS y la entrevista SCID-I. Fueron seguidos durante las primeras seis semanas de tratamiento antipsicótico de asignación aleatoria (olanzapina, risperidona o haloperidol). El genotipo del polimorfismo rs4680 se determinó en muestras de sangre venosa. Un primer estudio mostró una incidencia tratada de 1.38/10000 y la asociación de esta incidencia a factores de riesgo como edad menor de 25 años, sexo masculino, estado marital soltero, desempleo nivel educativo primario, ambiente urbano y consumo de cannabis. Un segundo estudio encontró una asociación del alelo Val158 con sintomatología negativa al inicio y edad de inicio temprana, diagnóstico de esquizofrenia y duración de psicosis sin tratar prolongada en mujeres. En un tercer estudio se mostró la asociación del consumo de cánnabis premórbido con edad de inicio más temprana y una interacción entre consumo de cannabis y el genotipo, de modo que el consumo de cannabis contrarresta el efecto protector del alelo 158 Met. Finalmente, en un cuarto estudio se confirmó la persistencia de la asociación del genotipo Val158Met con mayor sintomatología negativa tras seis semanas de tratamiento, no encontrando diferencias en cuanto a la respuesta clínica. Los resultados muestran que el polimorfismo COMT Val158Met pueden estar asociados a una edad de inicio más temprana y una mayor gravedad de síntomas negativos. Del mismo modo, el consumo de cánnabis premórbido se asocia a una menor edad de inicio y se encuentra un patrón de interacción con el polimorfismo, eliminando los efectos protectores del alelo Met158. Los hallazgos sugieren la importancia del polimorfismo COMT Val158Met y del consumo de cannabis en la etiopatogenia de la esquizofrenia, que podría explicarse por la disminución de trasmisión dopaminérgica prefrontal. / The schizophrenia is considered a heterogeneous syndrome which has multifactorial causes, including environmental, characterial and genetic factors. Despite the fact that 50% of the variability of the illness is explained by genetic factors, only a limited number of genetic variants have been identified as weak risk factors. Most of them have not been replicated because of the heterogeneity of the studied samples and the association with other mental illnesses. This variability has been tried to be solved by the use of endophenotypes and biological markers, as indicators of genetic vulnerability. Catechol-O-Methyltransferase gene, that codifies a dopamine degradation enzyme active in prefrontal cortex, has been studied as one of the most promising candidates in the etiopathogenesis of schizophrenia, particularly the rs4860 polymorphism (Val158Met). The possible association with an altered prefrontal dopaminergic transmission would be supported by the revised dopaminergic theory. Following this theory, there is a dopaminergic disequilibrium in schizophrenia, with an increase in subcortical D2 dopaminergic transmission and a deficit in D1 cortical stimulation. COMT Val158Met polymorphism has not consistently associated with schizophrenia. The study of endophenotypes and biological markers has suggested associations with cognitive deficits, neurophysiologic and neuroanatomic markers and with clinical phenotypes, such as aggressiveness, suicide, psychotic symptoms, age of onset and clinical response. It also has been reported an interaction with cannabis in the modulation of the risk of psychosis. This heterogeneity could be explained by methodological biases, related to the validity and representativeness of the studied samples and may be solved with the systematic study of epidemiological samples of patients in the initial phases of psychosis. Following the hypothesis of the existence of an altered prefrontal dopaminergic transmission, the Val158 allele in the COMT gene would be associated with more severe psychotic symptoms, particularly negative symptoms and with poor prognostic factors. Likewise, the premorbid use of cannabis could modulate this risk, increasing the risk or counteract the protective factors. The main objective was to study the association between the clinical onset and evolution in the first 6 weeks of treatment and the COMT Val158Met polymorphism as well as the interaction with premorbid cannabis use. The secondary objectives were to study the incidence of schizophrenia and validate the representativeness of the sample, to analyse the relation between the Val158Met polymorphism and clinical symptoms, age of onset, clinical response to treatment and to estimate the presence of gen-environment interactions with the premorbid cannabis use. 174 consecutive first episode psychosis patients with a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder or psychosis non-otherwise specified were included in the PAFIP program. The program was designed for the detection and treatment of all cases in the region of Cantabria, form February 2001 to February 2005. The patients were assessed with a semi-structured interview, SANS, SAPS, HDRS, CDS, YMRS scales and the SCID-I interview. They were followed up to 6 weeks and treated with a randomly assigned antipsychotic (olanzapine, risperidone or haloperidol). Rs4680 polymorphism was assessed in peripheric blood samples. A first study showed a treated incidence of 1.38/10000 and the association with several risk factors such as age under 25 years, male gender, single marital status, unemployment, primary educational level, urban environment and cannabis use. A second study found an association between the Val158 allele and negative symptoms severity at onset, early age of onset, schizophrenia diagnosis and longer duration of untreated psychosis in females. A third study showed an association between premorbid cannabis use and early age of onset and an interaction between cannabis use and genotype, indicating that the cannabis use counter act the protective effect of the Met158Met allele in age of onset. Finally, in a fourth study the association between the Val158 allele and negative symptoms was confirmed after 6 weeks of treatment, although no relation was found with clinical response. The results showed that the COMT Val158Met polymorphism could be associated with an earlier age of onset and a higher severity of negative symptoms. Likewise, the premorbid use of cannabis was associated with an earlier age of onset and there was found a gene-environmental interaction, deleting the protective effect of the Met158 Allele. These findings suggest the importance of COMT Val158Met polymorphism and premorbid cannabis use in the etiopathogenesis of the schizophrenia that could be explained by a decrease in the prefrontal dopaminergic transmission.

Introducció: Són molts els estudis que, en els darrers quinze anys, han demostrat l'efectivitat delsprogrames d'intervenció precoç en la esquizofrènia i el seu impacte sobre el pronòstic de lamalaltia. De fet, la intervenció preventiva a la fase prodròmica i posterior al primer episodi haesdevingut una de les línies principals de recerca i d'aplicació clínica per l'abordatge de laesquizofrènia.Objectiu: Avaluar l'impacte d'una intervenció psicoterapèutica durant la fase inicial de laesquizofrènia sobre la millora clínica i les recaigudes d'un grup que va rebre una intervencióprecoç (PIPE) en comparació amb un grup control (GC) que va rebre controls psiquiàtrics rutinaris.Mètode: Es va realitzar un assaig clínic controlat a simple cec per tal de comparar un grup que vaser tractat amb un programa de controls rutinaris (CG) amb un grup que va participar en elprograma PIPE. Es van aleatoritzar 34 pacients que estaven a la fase inicial de l'esquizofrènia aambdós grups: GC (n=13) i GC+PIPE (n=21). El programa PIPE va estar conformat per teràpiaindividual i familiar cognitivo-motivacional, tenint una duració de 18 mesos (entre 34-36sessions). Les avaluacions clíniques es van portar a terme a la valoració basal, als 3,6,9,12 i 18mesos per avaluadors externs, a més del seguiment als 6 mesos d'haver finalitzat la intervenció. Esva avaluar als pacients mitjançant l'escala PANSS (versió espanyola de l'Escala dels síndromespositiu i negatiu; Cuesta i Peralta, 1994) , l'escala BPRS (Brief Psychiatry Rating Scale; Overall iGorham, 1962), l'escala CGI (Clinical Global Impressions; National Institute of Mental Health,1976) i l'EEAG (Escala d' Avaluació de l'Activitat Global; American PsychiatricAssociation,1995). A més, es van recollir els índexs de recaigudes globals i específiques en númerode hospitalitzacions, estades a l'hospital de dia, visites a urgències, visites no programades,agudització simptomàtica i els increments de medicació.Resultats principals: S'observen diferencies estadísticament significatives entre els dos grupsesmentats ja als tres mesos d'intervenció respecte a l'avaluació basal (p=0,000) que es mantenenestables fins al seguiment als 6 mesos (p=0,000) a l'avaluació amb l'escala BPRS. Respecte al'avaluació del síndrome positiu, negatiu i de psicopatologia general puntuat amb la PANSSs'observen també diferències notables als sis mesos que es mantenen fins al final de la intervencióals 18 mesos (PANSS-P, p=0,02;PANSS-N, p=0,004;PANSS-PG, p=0,000). D'acord amb aquestsresultats es presenten diferències estadísticament significatives a les puntuacions de les escales CGIi EEAG amb resultats notables ja als sis mesos (CGI, p=0,000; EEAG, p=0,001) i que es mantenenfins al seguiment (CGI, p=0,000; EEAG, p=0,000). Respecte a les recaigudes s'observendiferències estadísticament significatives entre els grups als 18 i als 6 mesos de seguiment ennúmero d'hospitalitzacions (p=0,000), en estades a l'hospital de dia (p=0,000), visites al serveid'urgències (p=0,048) i en augments de medicació (p=0,002). Resultats semblants s'observen a lesmesures de recaigudes globals en la comparació entre grups tant al final de la intervenció comdurant el seguiment als 6 mesos (p=0,018; p=0,048 respectivament).Conclusió principal: El programa d'intervenció precoç PIPE té un impacte alt sobre la milloraclínica i les recaigudes als 18 mesos d'intervenció que es manté durant el període de seguiment als6 mesos.<(p> / Introducción: Son muchos los estudios que en los últimos quince años han demostrado laefectividad de los programas des intervención precoz en la esquizofrenia y su impacto sobre elpronóstico de la enfermedad. De hecho, la intervención preventiva en la fase prodrómica yposterior al primer episodio se ha convertido en una de las líneas principales de investigación y deaplicación clínica para el abordaje de la esquizofrenia.Objetivo: Evaluar el impacto de una intervención psicoterapéutica durante la fase inicial de laesquizofrenia sobre la mejoría clínica y las recaídas de un grupo que recibió una intervenciónprecoz (PIPE) en comparación con un grupo control (GC) que recibió controles psiquiátricosrutinarios.Método: Se realizó un ensayo clínico controlado a simple ciego para comparar un programa decontroles rutinarios (CG) con el programa PIPE. Se aleatorizaron 34 pacientes que estaban en lafase inicial de la esquizofrenia a ambos grupos: GC (n=13) y GC+PIPE (n=21). El programa PIPEestuvo conformado por terapia individual y familiar cognitivo-motivacional, teniendo una duraciónde 18 meses (entre 34-36 sesiones). Las evaluaciones clínicas se llevaron a cabo en la valoraciónbasal, a los 3,6,9,12 y 18 meses por evaluadores externos, además del seguimiento a los 6 meses.Se evaluó a los pacientes mediante la escala PANSS (versión española de la Escala de lossíndromes positivo y negativo; Cuesta y Peralta, 1994), la escala BPRS (Brief Psychiatry RatingScale; Overall y Gorham, 1962), la escala CGI (Clinical Global Impressions ; National Institute ofMental Health, 1976) y la EEAG (Escala de Evaluación de la Actividad Global; AmericanPsychiatric Association,1995). Además, se recogieron los índices de recaídas globales y específicasen número de hospitalizaciones, estancias en hospital de día, visitas a urgencias, visitas noprogramadas, agudización sintomática e incrementos de medicación.Resultados principales: Se observan diferencias estadísticamente significativas entre los gruposmencionados ya a los tres meses de intervención respecto a la evaluación basal (p=0,000) que semantienen estables hasta el seguimiento a los 6 meses (p=0,000) en la evaluación con la escalaBPRS. Respecto a la evaluación del síndrome positivo, negativo y de psicopatología generalpuntuado con la PANSS se observan también diferencias notables a los seis meses que semantienen hasta el final de la intervención a los 18 meses (PANSS-P, p=0,02;PANSS-N,p=0,004;PANSS-PG, p=0,000). En acorde con estos resultados se presentan diferenciasestadísticamente significativas en las puntuaciones de las escalas CGI y EEAG con resultadosnotables ya a los seis meses (CGI, p=0,000; EEAG, p=0,001) y que se mantienen hasta elseguimiento a los 6 meses (CGI, p=0,000; EEAG, p=0,000). Respecto a las recaídas se observandiferencias estadísticamente significativas entre los grupos a los 18 meses y los 6 meses deseguimiento en número de hospitalizaciones (p=0,000), en estancias en hospital de día (p=0,000),en visitas al servicio de urgencias (p=0,048) y en aumentos de medicación (p=0,002). Resultadossimilares se observan en las recaídas globales en la comparación entre grupos tanto al final de laintervención como en el seguimiento a los 6 meses (p=0,018; p=0,048 respectivamente).Conclusión principal: El programa de intervención precoz PIPE tiene un impacto alto sobre lamejoría clínica y las recaídas a los 18 meses de intervención que se mantiene durante el periodo deseguimiento a los 6 meses. / Introduction: Many studies have shown the effectiveness of early intervention programs forschizophrenia and its impact on illness outcome. In fact, the preventive intervention in theprodromical period and after the first episode of psychosis has become the main way for theresearch and clinical procedures for schizophrenia treatments.Objective: The aim of the current study is to assess the improvement and relapse rates of patientswith a diagnosis of schizophrenia (initial phase), which were taking part in a specific Cognitive-Motivational Therapy program (PIPE) in comparison with patients who received the usualpsychiatric treatment (Routine Care, RC).Method: A randomized, controlled, single-blind clinical trial was carried out. A total of 34 patientsand families who were in the initial phase of schizophrenia were allocated either to theexperimental intervention program plus routine care (PIPE, n=21) or to routine care alone (RC,n=13). PIPE consisted of an individual and a family Cognitive-Motivational Therapy, with 18months of length (between 34-36 therapy sessions). Clinical assessments were carried out byexternal raters at baseline, at 3,6,9,12 and 18 months, and the follow-up after 6 months. Patientswere assessed by the PANSS (spanish version of Positive and Negative Syndrome ofSchizophrenia, Cuesta & Peralta, 1994), the BPRS scale (Brief Psychiatry Rating Scale; Overall &Gorham, 1962), the CGI scale (Clinical Global Impressions; National Institute of Mental Health,1976) and the EEAG (Escala de Evaluación de la Actividad Global; American PsychiatricAssociation,1995). On the other hand, global and specific relapses rates were collected attending tothe number of admissions in acute care, admissions in day hospital, emergencies, non programmedvisits and deterioration of symptoms that require intervention by professionals (increase in / changeof medication or non-scheduled visits).Main results: Significantly clinical effects were observed in patients treated within PIPE program(pre-treatment vs. post-treatment at p=0,000) on the BPRS, already after three months. That resultsremain stable to the follow-up after 6 months (p=0,000). In reference to the evaluation for thepositive, negative syndrome and general psychopathology scored with the PANSS were alsoobserved remarkable differences from the 6th month of the intervention to the 18th month(PANSS-P, p=0,02;PANSS-N, p=0,004;PANSS-PG, p=0,000). According to those results,significant statistical differences were observed in CGI and EEAG scores. Those differences wereobserved already after six months (CGI, p=0,000; EEAG, p=0,001) with respect to the baselineassessment and remained stable to the follow-up after 6 months (CGI, p=0,000; EEAG, p=0,000).Statistical significant differences were found between groups with respect to relapses after 18 and 6months follow-up in admissions in the acute care unit (p=0,000), admissions at day hospital(p=0,000), emergencies (p=0,048) and pharmacological treatment increase (p=0,002). Analogueresults were observed in global relapses between groups at the end of the intervention and thefollow-up after 6 months (p=0,018; p=0,048 respectively).Main conclusion: The results show a positive impact of the PIPE intervention program on theimprovement of symptoms and the relapses in patients who are in the initial phase ofschizophrenia.

Bakgrund: En psykos innebär att tappa fotfästet i verkligheten. Risken för att drabbas av försämrad livskvalitet med stort lidande är hög. Tidigt insatta interventioner hos personer med nydebuterad psykos kan hindra ett ogynnsamt sjukdomsförlopp men forskning av nyinsjuknade genererar sällan kunskap gällande omvårdnad. Patienters symptombild med starka vanföreställningar och oro komplicerar ofta försök att interagera och en gynnsam vårdrelation kan vara svår att utveckla i och med patienternas speciella tillstånd. Syfte: Att beskriva hur personalen kan skapa en vårdprocessfrämjande relation med personen som drabbats av nydebuterad psykos på en slutenvårdsavdelning. Metod: Systematisk litteraturöversikt inkluderat femton artiklar med kvalitativt perspektiv för att besvara syftet. Data har analyserats med hjälp av kvalitativ metasummering. Resultat: Resultatet antyder på fördelar med att skapa tillit på ett tidigt stadium med hjälp av vårdrelationen. I och med ökande tillit till omgivningen ökar också behovet av att ha personalen som stöd med kunskap och förståelse för att kunna lösa problem i ett ömsesidigt samarbete. Personalen bör vara tillgänglig, vänlig, kunnig, tydlig, empatisk, flexibel med positiv hållning för gynnsamt skapande av hälsoprocessfrämjande omvårdnad.  Diskussion: I den optimala vårdrelationen sker ett samarbete runt mål och hälsoprocessfrämjande interventioner där personalen stöttar patienternas val med kunskap, uppmuntran och positiv feedback. Att få patienten att acceptera sin situation, att det kanske aldrig blir som förr och att leda in patienten på nya realistiska banor som inger livsmod och hopp kan vara en av personalens största utmaningar. / Background: A psychosis brings a lost sense of reality and generates a high risk of impaired quality of life with great suffering. Research shows that early intervention can prevent a disadvantageous health course whilst seldom generates knowledge regarding nursing as such. The nurse patient relationship is essential but often complicated by lack of trust due to symptoms such as strong delusions and anxiety. Aim: To describe how staff can create a care process promoting relationship with persons affected by recent-onset psychosis at an inpatient ward. Methods: Systematic literature review based on fifteen articles with a qualitative perspective. A qualitative meta-summary was chosen as method for synthesizing and analyzing the findings. Results: The result shows that the caring relationships focus may be on gaining trust at an early stage. As the patient gains trust in the surrounding environment the need for support from staff increases. Problem solving, together with staff, becomes more appreciated as symptoms fade away. Staff who are accessible, friendly, knowledgeable, clear, empathetic, flexible with a positive attitude are beneficial in creating a healthy process of promoting nursing. Discussions: Optimal nurse patient relationship interacts around goals and health process promotion interventions where staff supports the patients’ choices with the use of knowledge, encouragement and positive feedback. Getting the patient to accept their situation, making them realize that life may never be the same, leading them onto new realistic paths inspiring courage and hope, can be one of the staff's greatest challenges.

No description available.

Multimodality MR imaging of pathological changes in schizophrenia Aim: To prove structural changes of the neocortex and white matter of the brain indicating connectivity disorder in early phases of schizophrenia. Material and methods: A prospective monocentric study comparing a cohort of patients after the first episode of schizophrenia (on average 15.6 days after the initial hospitalization) with a control group of healthy persons. Probands were examined using a complex MRI protocol. Twenty-six patients and twenty-four healthy persons were examined in total. Three dimensional T1 and T2 data and DWI data were analyzed using TBSS FA, FBA a surface- based morphometry. Results: Large areas of dispersively decreased FA were found in patients compared to control group using TBSS. Several fixels of decreased FD metric were found using FBA in the anterior commissure of patients and one sporadic fixel of decreased FDC metric was found in frontal white matter of the brain. No statistically significant areas of cortical surface area and cortical thickness differences were found using SBM. Conclusions: Large areas of decreased microstructural integrity of the white matter of the brain were found. However, it was not possible to specify the nature of its corruption using FBA. Our findings indicate the crucial role of...

Bakgrund: Psykossjukdom är en av de allvarligaste psykiatriska sjukdomarna. Trots att det finns effektiva behandlingsstrategier får inte alla med psykossjukdom specialiserad vård, vilket kan ha allvarliga konsekvenser för deras livslängd och välbefinnande. Diskriminering och stigma kring psykossjukdom kan påverka patientens hälsa och prognos. Det är viktigt att tidigt upptäcka och behandla psykossjukdomar för att minimera funktionsnedsättning och förbättra prognosen. En utmaning inom vården för personer med förstagångsinsjuknande är att bibehålla terapeutisk allians och främja återhämtning. Syfte: Syftet var att beskriva patienters erfarenheter av vården vid förstagångsinsjuknande i psykos. Metod: En litteraturstudie med strukturerat tillvägagångssätt och kvalitativ ansats. 15 originalartiklar inkluderades och tematisk dataanalys genomfördes enligt Braun och Clarke. Resultat: Litteraturstudien sammanställer tidigare forskning inom området och efter dataanalys framkom tre teman: Värdefulla relationer, Hjälpande insatser, Hinder och utmaningar för delaktighet med respektive subteman. Slutsats: Erfarenheterna från vården för personer med förstagångsinsjuknande med psykos berör relationer till personal och medpatienter, praktiskt stöd och psykoedukation, och faktorer som rädsla för vården, bristande tillit och kontinuitet. / Background: Psychotic disorders are among the most severe psychiatric illnesses. Despite the availability of effective treatment strategies, not all individuals with psychotic disorders receive specialized care, which can have serious consequences for their longevity and well-being. Discrimination and stigma surrounding psychotic disorders can impact the patient's health and prognosis. Early detection and treatment of psychotic disorders are crucial to minimize disability and improve prognosis. One challenge in the care of individuals experiencing first-episode psychosis is maintaining therapeutic alliance and promoting recovery. Aim: The objective was to describe patients' experiences of care during first-episode psychosis. Method: A literature study with a structured approach and qualitative approach. 15 original articles were included and thematic data analysis was conducted according to Braun and Clarke. Results: The literature review compiles previous research in the field, and after data analysis, three themes emerged: Valuable relationships, Supportive interventions, and Barriers and challenges to engagement, each with respective sub themes. Conclusions: The experiences of healthcare for individuals with first-episode psychosis involve relationships with staff and fellow patients, practical support and psychoeducation, as well as factors such as fear of healthcare, lack of trust, and continuity.

De nos jours, l’idée selon laquelle bon nombre d’individus atteints de psychose peuvent se rétablir sensiblement au fil du temps est de plus en plus répandue. Alors que le milieu médical associe le rétablissement à la rémission symptomatique, les usagers de services en santé mentale le voient plutôt comme un processus où l’absence de symptômes n’est pas une condition sine qua non. Ne s’opposant à ni l’un ni l’autre de ces points de vue, le traitement actuel des psychoses vise le retour à un fonctionnement social approprié. Chez les jeunes atteints d’un premier épisode psychotique, une diminution marquée des symptômes après un traitement pharmacologique se traduit rarement en une amélioration significative du fonctionnement, ce qui justifie la mise en place d’interventions psychosociales. On connait aujourd’hui quelques variables associées au fonctionnement social chez cette population, mais celui-ci a peu été étudié de façon spécifique. De même, on connait mal la manière dont ces jeunes vivent leur rétablissement en tant que processus. Cette thèse porte donc sur le rétablissement et le fonctionnement social de jeunes en début de psychose. La première partie consiste en une introduction aux concepts de rétablissement et de réadaptation, et en une revue de la littérature des interventions psychosociales pouvant favoriser leurs rétablissement et fonctionnement. Plus spécifiquement, nous illustrons comment ces interventions peuvent s’appliquer aux adolescents, clientèle sur laquelle peu de littérature existe actuellement. La deuxième partie présente les résultats d’une étude sur la valeur prédictive de variables sur trois domaines du fonctionnement social de 88 jeunes adultes en début de psychose. Des équations de régression multiple ont révélé qu’un niveau plus élevé de dépression était associé à une vie sociale moins active, qu’un moins bon apprentissage verbal à court terme était associé à un plus bas fonctionnement vocationnel, que le fait d’être de sexe masculin était négativement associé aux habiletés de vie autonome, et qu’un niveau plus élevé de symptômes négatifs prédisait de moins bonnes performances dans les trois sphères du fonctionnement. Finalement, la troisième partie s’intéresse au processus de rétablissement en début de psychose par l’analyse de récits narratifs selon un modèle en cinq stades. Nous avons découvert que l’ensemble de notre échantillon de 47 participants se situaient dans les deux premiers stades de rétablissement lors du premier temps de mesure, et que le fait de se trouver au deuxième stade était associé à de meilleurs scores d’engagement social et de fonctionnement occupationnel, à un meilleur développement narratif, à moins de symptômes négatifs et positifs, et à plus d’années de scolarité. Par ailleurs, l’examen des stades à deux autres temps de mesure a révélé des profils relativement stables sur une période de neuf mois. En somme, les résultats démontrent la nécessité d’évaluer le fonctionnement social de façon plus spécifique et l’importance d’offrir des interventions psychosociales en début de psychose visant notamment le développement des relations et l’intégration scolaire/professionnelle, ou visant à améliorer le faible développement narratif. Cette thèse est, de plus, un premier pas dans l’étude du processus de rétablissement des jeunes atteints de psychose. / Currently, the idea that several individuals experiencing psychosis can show evidence of recovery over time is gaining in popularity. Although recovery is viewed as the disappearance of symptoms in the medical field, consumers of mental health services see it more as process in which the complete absence of symptoms is not a sine qua non. Nevertheless, the current treatment for psychosis is aimed at regaining a satisfactory level of social functioning. In individuals experiencing a first psychotic episode, a noticeable decrease in symptoms is rarely associated with a significant improvement in functioning. Therefore, psychosocial interventions are necessary to assist in recovery. The literature has identified a number of variables associated with social functioning in this population, but to date, there are no studies investigating this aspect in details. Furthermore, very little is known about how these youth experience the process of recovery. This thesis dissertation will therefore address recovery and social functioning in young people experiencing a first episode of psychosis. A first section will serve as an introduction to the concepts of recovery and rehabilitation and a review of the literature on psychosocial interventions promoting recovery and functioning. Specifically, we will illustrate how these interventions can apply to adolescents, a population for which very few studies have been published. A second section will present the results of a study on the predictive value of variables on three domains of social functioning in 88 young adults in early psychosis. Multiple regression analyses showed that a more severe depression was associated with a less active social life; that a poorer short term verbal learning ability was associated with poorer vocational functioning; and that men showed poorer independent living skills. Furthermore, more severe negative symptoms were associated with poorer performances in all three spheres of social functioning. Finally, the third section will address the recovery process in early psychosis through the analysis of narratives using a five stage recovery model. We determined that overall, our sample of 47 individuals were classified within the first two stages of recovery at baseline and that those classified in the second stage showed better social engagement and vocational functioning scores, a better narrative development, less severe positive and negative symptoms, and had attained a higher educational level. Furthermore, the analysis of the stages of recovery across two others time points show that these profiles are relatively stable over a 9 month period. In conclusion, these results show that it is necessary to evaluate social functioning in a more detailed manner, and reaffirms the importance of making psychosocial interventions available to service users experiencing early psychosis. It highlights, in particular, the need for services aimed towards the development of social relationships and educational/vocational integration, or interventions addressing deficits in narrative development. Moreover, this thesis dissertation is a first step towards the study of the recovery process of young adults experiencing psychosis.

Au Canada, chaque nuit, en moyenne 6000 jeunes sont sans-abri. Ceux souffrant de psychose et de toxicomanie sont particulièrement à risque d’itinérance. La littérature suggère qu’il y a nécessité de soins adaptés pour cette population. Une équipe d’intervention intensive de proximité ÉQIIP SOL (ES) fut créée au CHUM en 2012 afin de mieux offrir une approche adaptée la clientèle des jeunes itinérants souffrants d’un premier épisode psychotique et de toxicomanie (JIPEPT). Objectif : Étudier l’impact de l’ajout de l’ES aux services de la Clinique spécialisée d’intervention précoce pour la psychose (CIP) sur l’évolution symptomatique et fonctionnelle et l’utilisation de services des JIPEPT. Méthode : Étude de suivi longitudinale comparant l’évolution des JIPEPT suivis par l’ES en ajout à une CIP depuis 2012 à ceux suivis dans une CIP (2005-2011). La stabilité à l’hébergement (issue primaire), l’autonomie en hébergement, l’évolution fonctionnelle (SOFAS) et clinique globale (GAF, CGI), la sévérité de la toxicomanie (AUS, DUS), et l’utilisation de services (consultations à l’urgence et hospitalisations) ont été collectées de manière prospective durant 24 mois. Résultats : Le suivi de l’ES+CIP est associé à un taux plus élevé de JIPEPT en hébergement stable que le traitement régulier CIP seul (RR=2,38, p=0,017). L’évolution fonctionnelle, clinique et de la toxicomanie des 2 groupes sont similaires. Conclusion : L’ajout de l’ES à une CIP semble permettre d'augmenter le taux de stabilité en hébergement chez les JIPEPT. Toutefois, les facteurs de mauvais pronostic prémorbides et l’intensité déjà élevée du traitement comparateur (CIP) expliquent possiblement que l’ES n’ait pas d’impact supplémentaire sur l’évolution du fonctionnement et de la toxicomanie à court terme. / In Canada, every night, about 6000 youths are homeless. Those suffering from psychosis and substance use disorder (SUD) are at higher risk for homelessness. Today’s literature suggests the need for dedicated interventions for this population. In 2012, an intensive outreach team (ÉQIIP SOL (ES)) was created at the CHUM, to help homeless youth suffering from psychosis and SUD (HYPS). Objective: Explore the impact of ES added to an early intervention for psychosis clinic (EIC) on service use and the symptomatic and functional outcome for the HYPS. Method: Longitudinal study comparing the outcome of HYPS who received care from ES in addition to an early intervention for psychosis clinic (EIPC) (2012-2015) to an HYPS historical cohort who received care from EIPC only (2005-2011). Housing stability (main outcome), living arrangement autonomy, global assessment of functioning scale (SOFAS), clinical global assessment scales (GAF, CGI), SUD severity (AUS, DUS) and services use (Emergency consultations and hospitalizations) have been collected prospectively for 24 months. Results: With ES + EPIC, there is a higher rate of HYPS in stable housing than with EIPC only (RR=2,38, p=0,017). Symptomatic and functional outcomes as well as drug and alcohol misuse are somewhat similar for the 2 groups. Conclusion: The addition of ES to an EIPC seems to benefit HYPS in increasing housing stability. However, poor prognostic factors of HYPS and the high intensity of the comparator treatment (EPIC) may explain why ES does not seem to have an additional impact on shortterm symptomatic, functional and SUD outcome.

L'objectif général de cette thèse est d'examiner le lien entre les traits de personnalité évalués selon l'approche des cinq facteurs et les résultats des traitements psychosociaux auprès de jeunes adultes présentant un premier épisode psychotique. Afin d'atteindre cet objectif, 129 personnes ont été recrutées à participer à une étude expérimentale randomisée. Les participants ont été assignés soit à un groupe de thérapie cognitive-comportementale, soit à un groupe d'entraînement aux habiletés sociales visant la gestion des symptômes, soit à une liste d'attente. Les participants ont complété pré- et post-traitement le Questionnaire bref de personnalité NEO Révisé (Costa & McCrae, 1992), l'Échelle abrégée d'évaluation psychiatrique (Lukoff et al., 1986; Ventura et al., 1993) et l'Échelle d'adaptation cybernétique (Edwards & Baglioni, 1993). Dans le premier article, les profils de personnalité et la stabilité temporelle des traits de personnalité des jeunes adultes présentant un premier épisode psychotique ont été étudiés. Les résultats révèlent différents profils de personnalité et une stabilité des traits de personnalité. Dans le second article, les profils de personnalité et la valeur prédictive des traits de personnalité ou des profils sur les résultats thérapeutiques ont été investigués. Les résultats révèlent aussi différents profils de personnalité, aucun spécifiquement lié aux symptômes. Aucun lien n'a pu être rapporté entre les traits de personnalité et l'amélioration symptomatologique. Toutefois, les traits de personnalité et les profils sont liés à l'amélioration des stratégies actives d'adaptation. Dans le dernier article, la valeur prédictive des traits de personnalité sur les résultats thérapeutiques selon le groupe de traitement spécifique a été étudiée. Les résultats démontrent un lien entre les traits de personnalité et l'amélioration symptomatologique et des stratégies d'adaptation selon le traitement. Les traits de personnalité sont particulièrement liés aux résultats thérapeutiques des stratégies actives d'adaptation. Cette thèse contribue à l'avancement des connaissances en se penchant sur l'importance des traits de personnalité dans le traitement psychosocial des jeunes adultes présentant un premier épisode psychotique et en soulignant la nécessité d'étudier davantage les différences individuelles de la personnalité de cette clientèle. Les implications cliniques des résultats et les recommandations pour la recherche sont présentées. / The aim of this thesis was to elucidate the link between personality traits based on the Five Factor Model of personality and therapeutic outcomes of two group treatments for first episode psychosis: cognitive behavior therapy and skills training for symptom management. One hundred and twenty-nine individuals with first episode psychosis were recruited to participate in a randomized controlled trial. Participants were randomized to one of two group treatments or to a wait-list control group. Measures pre- and post-treatment included the shorter version of the Revised NEO personality Inventory (Costa & McCrae, 1992), measures of Brief Psychiatric Rating Scale-Expanded (Lukoff et al., 1986; Ventura et al., 1993) and the shorter version of the Cybernetic Coping Scale coping strategies (Edwards & Baglioni, 1993). In the first article, personality profiles and stability over time of personality traits of individuals with a first episode of psychosis were investigated. Results showed that individuals with a first episode of psychosis present with different personality profiles. Moreover, personality traits of the first episodes showed stability over time. In the second article, personality profiles and predictive value of personality traits or profiles on therapeutic outcomes of treatments for first episode psychosis were investigated. Results revealed also different personality profiles, none specifically linked to psychotic symptoms. No links could be demonstrated between personality traits and symptom improvements but personality traits and profiles were linked to therapeutic improvements in active coping strategies. In the last article, predictive value of personality traits on therapeutic outcomes accordingly to specific group treatments for first episode psychosis was investigated. Results showed links between personality traits, symptoms and coping outcome measures, according to specific group treatments. Personality traits were particularly linked to therapeutic improvements in active coping strategies. In sum, this thesis contributed to the field of personality traits in those with a first episode psychosis by investigating the pertinence of personality traits in the choice of psychosocial treatments and highlighting the need for further study considering individual differences in psychosis. Clinical implications are discussed and recommendations for clinical research offered.