Highlights of this issue

PTSD and aggression

The new International Classification of Diseases version 11 (ICD-11) is awaited, and the contentious diagnosis of post-traumatic stress disorder (PTSD) has been simplified into three factors representing symptoms related to re-experiencing, avoidance and hyperarousal. However, Forbes and colleagues (pp. ) found that a two-factor solution collapsing re-experiencing and avoidance factors provided an equivalent fit to the three-factor model. They suggest that the two-factor model, derived from their factor analysis on symptoms present in 613 patients with PTSD, provides a more useful inclusive algorithm for diagnosis. The management of acute aggression or behavioural disturbance is always difficult to assess in clinical studies; Calver and colleagues (pp. ) are to be commended for their randomised controlled study of intramuscular droperidol v. haloperidol. They found that both resulted in effective sedation within 20–25 minutes, with no differences in efficacy between them; however, there were some trends towards greater use of additional sedation with haloperidol, but with fewer adverse effects.

Childhood adversity and psychosis

There is a reported association between childhood adversity and the development of psychosis. Upthegrove et al (pp. ) did not confirm this link in their large study of patients with bipolar disorder. However, there were specific associations of hallucinations with childhood sexual abuse, death of loved one and being victimised. These were not associated with the development of delusions. The authors suggest that, given the phenomenological specificity of their findings, future studies need to examine these subtypes in more detail if we are to identify and improve outcomes in those at increased risk. On a related topic, Barker and colleagues (pp. ) review putative biological mechanisms that could underpin the association between childhood adversity and psychosis, with a focus on alterations within the hypothalamic–pituitary–adrenal axis mediated by expression of brain-derived neurotrophic factor in the hippocampus sand the neuropeptide oxytocin. In their editorial, they propose epigenetic mechanisms as the key feature by which environmental effects can influence longer-lasting phenotypic change, and use attachment theory as a psychological construct to frame these changes at the cognitive level. They caution against a simplistic translation into therapy, highlighting the caveats that much of this work is in animal models, with weaker data in humans. The use of technology to improve assessment of hallucinatory symptoms is the focus of an editorial by Demeulemeester et al (pp. ). They review the increasing use of health apps in assessing symptoms in mental health; and then describe the development of the Multisensory HAllucination Scale for Children (MHASC), designed to be used on tablets, and the advantages of using an approach that is set as part game and part standardised test.

Reducing the incidence of repeated self-harm

There is an enormous personal, economic and societal cost associated with suicide and self-harm. Given the difficulty in predicting and preventing self-harm de novo, it is essential to optimise our response to people presenting with self-harm, in order to reduce the frequency of any subsequent attempts. In a review of brief contact interventions after self-harm Milner and colleagues (pp. ) found that overall these methods did not confer a significant benefit on repetition rates or suicide. The authors suggest that larger-scale studies are necessary to examine some of the more promising individual approaches, such as postcard interventions. A study of a package of measures, including postcards and problem-solving therapy, in people presenting to hospital after self-harm supported the findings of the review; there were no significant differences in outcomes at a 1 year follow-up post-intervention. Hatcher et al (pp. ) suggest that despite the lack of consistent positive differences, low-cost interventions such as postcards may still be worth implementing as they may be helpful for some people.

Neural change in psychiatric disorder

It is unusual to compare neural signatures across many different diagnostic groups; Fonzo and colleagues (pp. ) demonstrate that amygdala activation was related to greater negative affect or anxiety, whereas patients with panic disorder were more likely to show activation in the posterior insula. The authors suggest that this multidiagnostic approach has utility in clarifying dimensional characterisation of mental illness. A similar approach was used by Regenbogen et al (pp. ), who compared brain activation using functional magnetic resonance imaging during a dynamic social cognition task in patients with schizophrenia and patients with depressive illness. They suggest that patients with schizophrenia were characterised by disturbance of neural networks associated with processing semantic context, whereas patients with depression showed greater change in mentalising networks. They suggest that dynamic social stimuli may offer useful probes for differentiating between different psychiatric diagnoses.