The concept of “dissociation” covers a rather wide array of psychopathological conditions, ranging from dissociation of consciousness (e.g., post-traumatic conditions), to dissociation of personality, (i.e., multiple personality disorder) and dissociation of the basic structures of the pre-reflexive self (as it is the case with schizophrenic abnormal experiences). I will focus on this last issue and describe the dissociation of time experiences in people with schizophrenia as a characterizing feature of this condition.

Schizophrenic persons often describe their sense of temporal reality as: “things to a standstill”, “immobility, but not calm”, “time going back to same moment over and over”, “people like statues”, “frozen moment”, “out of time”, “marmoreal”, “unreal stillness”. Time is fragmented, there is a breakdown in time Gestalt, and an itemization of now-moments. The mere succession of conscious moments as such cannot establish the experience of continuity. Another typical phenomenon is that a revelation is on the verge to happen, the world is on the verge of ending, a new world is coming, one's own life is on the point of undergoing a radical change. The schizophrenic mood can be characterized as the dawn of a new reality, an eternally pregnant now in which what is most important is not present, what is really relevant is not already there, but is forever about to happen. Time in the schizophrenic mood is “a state of suspense”, “pregnant now”, “being is hanging”, “something imminent”, “something… I didn’t know what … was going to happen … between inspiration and expiration”. The main feature of abnormal time experience in schizophrenia is disarticulation – a breakdown of the synthesis of past, present and future. This includes four subcategories: disruption of time flowing, “déjà vu/vécu”, premonitions about oneself and the external world. The integrity of time consciousness is the condition of possibility of the identity through time of an object of perception as well as of the person who perceives it. Abnormal time experience may be related to the manifold of other schizophrenic subjective abnormal experiences and symptoms, including anomalies of phenomenal consciousness (e.g., disintegration of the appearance of external objects and itemization of external world experience), selfhood (e.g., disruption of the implicit sense of being a unified, bounded and incarnated entity), and sociality (e.g., breakdown of one's sense of being naturally immersed in a meaningful flow of social interactions with others).

Disarticulation of time experience includes four subcategories. Disruption of time flowing: Patients live time as fragmented. Past, present and future are experienced as disarticulated. The intentional unification of consciousness is disrupted. The present moment has no reference to either past or future. The external world appears as a series of snapshots. Déjà vu/vécu: Patients experience places, people and situations as already seen and the news as already heard. This abnormal time experience entails a disarticulation of time structure as the past is no more distinguishable from the present moment. The already-happened prevails. Premonitions about oneself: patients feel that something is going to happen to them or that they are going to do something. This abnormal time experience entails a disarticulation of time structure as the immediate future intrudes into the present moment. The about-to-happen prevails. Premonitions about the external world: patients feel that something is going to happen in the external world. As the previous one, this abnormal time experience entails a disarticulation of time structure as the immediate future intrudes into the present moment. The about-to-happen prevails.

Established in 2008, the Research Working Group of the European Federation of Psychiatric Trainees (EFPT) creates a platform for trainee-led collaborative studies. Several large-scale transnational studies on training-related subjects have been initiated and carried out, driven by psychiatry trainees. Examples of recent and ongoing projects are the Brain Drain study, which investigated migratory experiences and attitudes among trainees in Europe, and the TEO-PC project, which aims to raise awareness on UEMS Psychiatric competencies as well as to compile data on trainees’ experiences and satisfaction with their national training programs.

Earlier projects leading to publications have looked into drug prescription habits of trainees [1,2] and the interactions trainees with pharmaceutical industry [3]. Besides these projects, EFPT yearly gathers reports from the representatives of the national trainees associations on the structure, content and conditions of psychiatry training in all member countries. The information obtained through these channels is used actively to guide and influence policy related to psychiatry training, through collaboration with relevant organizations involved in the creation of guidelines, and through the EFPT statements, which serve to empower trainees themselves.

Despite the ongoing reality of workforce migration, information on medical migration is missing, with lack of detailed evidence of transnational migrations within Europe, obscuring the extent of how migration occurs amongst the different medical specialties.

The European Federation of Psychiatric Trainees (EFPT) has been pioneer in researching workforce migration in junior doctors, conducting the EFPT Brain Drain study, which explored the reasons and patterns of mobility and migration in 33 European countries among junior doctors training in psychiatry.

The intention has been to better understand the migration phenomena, its reasoning and effects in order to give practical proposals to improve education, training and work conditions and ultimately the health care itself in both donor and host countries.

Migration among medical professionals can take place throughout the career: before, during or after training. Exploring attitudes towards migration among junior doctors can help to understand the factors that shape the decision-making processes related to migration in future specialists.

These findings provide objective data that can assist policy makers, providing instruments to address the critical conditions leading to migration from at-risk countries, adjusting the pull factors and improving the standards of education, work and salaries.

Future studies should explore whether the presented results differ for junior doctors in other medical disciplines, as well as physicians in general and psychiatric consultants in Europe and in other areas of the world. Furthermore, the follow up of the respondents from this study could assess to what extent the migratory tendency and intention predicts the future migration itself.

The presentation intends to examine a new kind of clinical psychiatric syndrome, called by the author “synthetic psychosis”, which can occur in people who abuse novel psychoactive substances (NPS). This syndrome will be considered from both a psychopathological and a phenomenological perspective. The contemporary trend of poly-abuse of NPS in young people can lead to a sort of very intense paraphrenic state characterised by continuous hallucinations and formed by a mental automatism syndrome and by secondary (interpretative) delusions. The clinical case of G., discussed in this paper, is an exemplary case of this synthetic psychosis. The psychopathological understanding of the core symptomatology of the patient examined has been fundamental for the successive therapeutic approach. If this attempt at understanding is ineffective, the frequent consequences include: the worsening of the psychopathology and addiction; the patient's admission into a psychiatric hospital; his/her arrest for crimes related to antisocial behaviour; a diffusion of infective diseases commonly found in addicts; more frequent overdoses; aggressive behaviour; an increase in the costs of public health system and, finally, the suicide of the patient [1].

There is considerable interest in identifying biomarkers of antipsychotic response in schizophrenia. Glutamate is one key candidate. The development of brain imaging techniques for measuring brain glutamate levels has allowed this hypothesis to be tested directly in patients. This talk will present our ongoing research examining the relationship between brain glutamate levels and antipsychotic response in first-episode psychosis and in treatment-resistant schizophrenia. I will summarise our results from both our completed and ongoing studies, to consider whether glutamate imaging might be useful in the future to identify patients who would benefit from non-dopaminergic antipsychotic drugs and inform novel, glutamate-based, treatment strategies.

Rates of comorbid affective disorders in alcohol-dependent individuals are significant. Biomarkers of alcohol use may support the diagnosis of high and frequent alcohol use in these individuals. The aim of these analyses of the WHO-ISBRA Study on State and Trait Markers of Alcohol Use and Dependence is to compare biomarkers of alcohol use across individuals with and without comorbid alcohol dependence and affective disorders. Significantly, higher values of these biomarkers are hypothesized in individuals with comorbid disorders compared to alcohol dependence only. Assessment of Alcohol dependence and comorbid depression and bipolar disorders were conducted using an adapted version of the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS). Altogether, n = 1863 individuals were included into the analyses, of whom n = 299 had a lifetime history of depression and n = 20 a bipolar disorder. Clinical characteristics like mean alcohol intake last month and biomarkers including ASAT, GGT, CDT, 5-HTOL/5-HIAA ratio and MAO-Activity were included into the analyses. Results indicate that AD only subjects had higher measures of all biomarkers compared to comorbid bipolar and depression subjects, while the latter had a higher alcohol intake during last month.

Since this is a cross-sectional study, conducted in emergency rooms of several countries, this allegedly divergent result in alcohol intake in comorbid subjects compared to higher biomarkers in AD only subjects may indicate that drinking is more frequent in alcohol-dependent individuals while bipolar and depressed subjects may have more episodic pattern of alcohol intake. The latter may lead to shorter periods of intake compared to the chronic and frequent use of this substance in alcohol-dependent individuals and higher biomarkers of alcohol use.

Pharmacological therapy in mental disorders is usually effective in 60–70%, the treatment reaction is worsening with the disease progression, and proper medication and early treatment regimen choice is crucial. Research showed that specific brain changes (structural and functional) are present in depressed patients. These abnormalities are probably linked to neurodegeneration. There is also an evidence that inflammation contributes to the depression pathophysiology, and both these processes – neurodegeneration and inflammation are related.

Novel biological markers allow us to better understand the individual mechanisms of treatment response in depression. Recently, several biological measures have been proposed, amongst them – neuropsychological dysfunction, decreased GABA level in proton magnetic resonance spectroscopy (1H MRS), body weight, genetic factors and peripheral inflammatory markers. Latest research found that brain changes assessed with neuroimaging methods (including 1H MRS, e.g. glutamatergic system abnormalities), correlate with peripheral inflammatory markers. Furthermore, both these factors taken together may serve as one integrated treatment prediction marker in depressed patients.

This presentation will highlight how the early phase of major mental illness may provide a critical window of opportunity in which to prevent future life-restricting and life-shortening physical comorbidities.

Despite many recent advances in our understanding of severe mental illnesses, those affected still lose 15–20 years of life on average compared to the general population. Most premature deaths arise from the same common disorders that affect the general population such as cardiovascular disease, infections and cancers. Of these cardiovascular diseases is now the single biggest cause, far greater than suicide. Shockingly the mortality gap is still widening as the reduction in CVD morbidity and mortality seen in the general population over the last three decades continues to elude people with severe mental illnesses, for whom the prevalence of CVD, obesity and diabetes are now of epidemic proportion.

And yet, much of this epidemic can be predicted. High rates of tobacco use, physical inactivity and poor nutrition point to underlying health inequalities. Furthermore, initiation of antipsychotic treatment is associated with aggressive weight gain and metabolic disturbance from the early phase of psychosis, and yet often these adverse effects remain unmonitored and untreated.

This presentation will argue that these potentially modifiable risk factors provide natural targets for prevention from the onset of psychosis and its treatment. Extending the early intervention paradigm to embrace a far more holistic body & mind approach is overdue.

In the UK, the National Institute for Health and Care Excellence (NICE) sets standards for interventions to drive improvement in the quality of services delivered. The actual update of clinical guidelines remains patchy and difficult to ascertain.

NICE most recent guideline on the management of bipolar disorder in adults will be reviewed. A concept tool to facilitate adherence to NICE clinical standards will be presented along with detailed outcomes of its pilot application in a naturalistic treatment setting, which drove the average concordance from 32% for a team providing treatment as usual, to 92% for a team supporting their practice with the tool. This presentation will also address additional impacts of its use including allowing drawing key clinical characteristics of an index population of individuals suffering from bipolar disorder, supporting education and auditing the actual service delivery.

The usefulness of the tool to shape clinical practice according to NICE evidence-based standards will be outlined. Its versatility and limitations will be debated. The discussion of the findings will include epidemiological considerations as well as implications for mental and physical well-being.

About half of all murders are committed in Western industrialized countries by subjects under the influence of alcohol. Chronic alcohol use also increases the rate of violent attacks. These findings appear to be due to an interaction between acute and chronic environmental effects (acute alcohol consumption and chronic social isolation stress) on the one hand and limbic processing of aversive stimuli modulated by neurotransmitter systems such as dopamine and serotonin on the other. Animal experiments showed that early social isolation stress can induce serotonin dysfunction and appears to predispose individuals towards increased threat perception. Studies in humans revealed that depending on serotonergic neurotransmission and serotonin transporter genotype, some individuals are prone to show elevated functional activation elicited by aversive and threatening cues. Previous experience with alcohol-related aggression seems to further predispose an individual towards a “fight vs. flight” reaction when confronted with perceived threat during alcohol intake. Together, these findings point to complex gene-environment interactions and a specific role of social isolation stress in the development of alcohol-related aggression.

Homelessness is the most visible indicator for social marginalization and vulnerability. It is a risk factor for subsequent health threats and especially individuals with a history of trauma, substance use and severe persistent mental illness are at high risk to loose their homes, jobs and social networks.

The Canadian At Home/Chez Soi study aimed to better understand the entanglement of homelessness and mental illness and possible strategies to provide care to the most vulnerable. In 5 Canadian centers, over 2000 patients were included and randomized to different intervention arms based on a housing first approach.

Early trauma and foster care were as rampant as poly substance use, which explains a significant increase in mortality too.

The use of coercive measures remains one of the great challenges in psychiatry.

Increased focus on patient rights and autonomy, concern from user and relatives organizations as well as from human rights organizations all have contributed to that the use of all kinds of coercion is high on the agenda. And yet, we are still faced with that a number of psychiatric patients will experience that coercive measures are used as part of their treatment.

The EPA Ethical Committee carried out a survey comprising the European associations of psychiatry in which a questionnaire was circulated regarding what the different associations found were the major ethical challenges in their respective countries.

Among the issues that have given rise to particular concern are the use of physical restraints including why some countries avoid physical restraints while other – e.g. Denmark – use it extensively. Why do we find such large differences? Is this due to different approaches to coercion, different traditions? Shortage of resources?

Another concern is that certain groups seem more likely to be subject to coercion compared to others. Thus, it has been demonstrated that patients belonging to ethnic minority groups are more likely to experience this.

The paper will focus on ethical problems and issues of concern related to the use of coercion. The focus will be on facets of international relevance with the aim to remain critical towards the use and when needed to strengthen the quality of coercive treatment care. URL: http://www.mariannekastrup.dk

Coercive measures have always been part of the psychiatric armamentarium; however, the clinical and ethical dilemma between the use of a “therapeutic” coercion and the loss of patients’ dignity is one of the most controversial issues in mental health practice. According to International guidelines, coercive measures should be adopted only when all the other less restrictive approaches failed and should be considered as the “last restrictive alternative”. Although coercive measures are frequently used to manage patients’ aggressive behaviors and self-harm, refusal of medication and impulsivity, their effect on patients’ outcome is not clear. In fact, the use of coercive measures can reduce patients’ aggressiveness and improve psychiatric symptoms, but can also have a negative impact in terms of therapeutic relationship, engagement with mental health services and self-stigma, arising negative feelings on patients and on mental health professionals. International attempts have been made to improve and harmonize the use of involuntary treatments. Recommendations of good clinical practice on the use of coercive involountary treatments and forced medications have been proposed by the EUNOMIA consortium, and the effect of coercion on the outcome of patients with severe mental disorders have been described. Results of this study will be reported as well as lessons learnt from other international experiences.

Psychological pain is an important variable in the understanding of suicidal individual.

This presentation describes the how psychological pain interacts with problems in communication to set up risk for serious suicidal behavior and describes some empirical studies supporting a model for using this concept in suicide prevention strategies.

Borderline personality disorder (BPD) is characterized by affective dysregulation and non-suicidal self-injurious behaviour (NSSI), which is closely linked with reduced pain perception. Several experimental studies revealed reduced pain sensitivity in BPD as well as significant correlations between pain perception, aversive inner tension and dissociation. Psychophysiological experiments revealed no deficit in the sensory-discriminative pain component in BPD. However, neurofunctional investigations point at alterations of the affective-motivational and the cognitive pain component in BPD. Preliminary evidence suggests that disturbed pain processing normalizes when patients stop NSSI after successful psychotherapeutic treatment. We could demonstrate that pain leads to a decrease in affective arousal and amygdala activity in patients with BPD and to an increase in amygdala-prefrontal connectivity. We are currently investigating the role of seeing blood and the importance of self-infliction of pain in the context of NSSI.