There is an ongoing search for suitable endophenotypic parameters in schizophrenia. Neuroimaging evidence suggests that there is a disturbance of the frontal gyrification pattern in schizophrenia. Interestingly, this disturbance is correlated to cognitive deficits and negative symptoms. Furthermore it is interesting to note that there are new developmental disorders like the Williams Syndrome being accompanied by disturbed gyrification where the exact mutation is already known. The aim of this symposium is to gather the knowledge about disturbed gyrification in psychosis which is very likely to be a future endophenotypic marker to monitor persons at-risk and possible even the long-term cause of the illness.

The simultaneous presence of a substance use disorder (SUD) along with a psychiatric disorder represents a challenge to the clinician. The self-medication hypothesis suggests that drugs of abuse are used as a means of alleviating the distress associated with the mental disorder. Borderline Personality Disorder (BPD) and Attention Deficit/Hyperactivity Disorder (ADHD) show high comorbidity with substance use disorders, with 40%-60% of patients with the former and 9%-30% of adults with the latter also have an SUD. It is clear that these comorbidities seriously complicate both the detection and the treatment, in as much as the presenting disorder can mask the other, the upshot of which all to frequently the substance abuse or BPD and ADHD remain untreated. SUDs tend to increment the chronicity of BDP and ADHD, and vice versa. Differential diagnosis between BDP and ADHD is complex as some symptoms such as impulsivity, distractibility and low self-esteem are common to both disorders. The co-occurrence of ADHD and BPD further complicates matters, particularly when comorbid with an SUD. Accurate diagnosis and identification of all mental disorders present is essential for effective treatment. Psychostimulants have been found to be effective in the treatment of adults with ADHD, and psychological treatments have been identified for the treatment of both ADHD and BPD, but effective pharmacological treatment of BDP remains elusive. Further research is required to clarify the relationship between ADHD, BPD and substance abuse, and to identify optimal psychopharmacological and psychological treatment for ADHD and BPD when comorbid with an SUD.

A theoretical overview is given on the advancement of cognitive psychotherapy achieved by schema-theoretical concepts.

In a psychotherapy study the interactional behavior of clients within the therapeutic process was analysed with the “Bochumer Bearbeitungs- und Beziehungs-Skalen” (BBBS).

The interactional styles of clients with anxiety disorders and clients with narcissistic or histrionic personality disorders have been compared.

The theory of Sachse (1992) leads to the hypothesis, that clients with personality disorders clearly show more dysfunctional styles of interaction at the beginning of psychotherapy (high images, high appeals, manipulative strategies) than clients with anxiety disorders. This hypothesis could be verified empirically: clients with personality disorders show problematic patterns of interaction concerning the interpersonal level; beyond that they also show a higher level of avoidance and a lower level of explication.

Therapeutic consequences of the results will be discussed.

At present there is a paucity of standardised group behaviour therapy approaches targeting different kinds of personality disorders. On this background, our research group developed a new manualised treatment approach ("Schema-focused Emotive Behavioral Therapy"; SET), which integrates schematherapeutic, emotion-focused, cognitive and behavioural therapy methods. A multi-centre RCT-study evaluated SET based on a sample of 93 patients with personality disorders of clusters B and C. This study compared SET (n=47) with a classical Social Skills Training (SST, n=46) over 30 sessions. Patients were assessed before and after treatment and one year after study intake (follow-up). SET showed significantly higher improvements in several domains such as interpersonal behaviour, emotional coping, and symptomatic impairments. Clinically relevant effects on the SET occurred both in a reduction of the suffering from the disorder, severeness of the disorder, and hope for improvement. Furthermore, SET obtained a highly significant reduction of the dropout rate and a significantly increased use of therapy. Similar results for both comparison groups were found regarding behavioural coping and self-effectiveness. Results indicate that SET both entails a high acceptance of treatment and offers an adequate and effective group therapy for patients with personality disorders. From a clinical and economic point of view, SET promises to significantly contribute to mental health care.

During recent years the treatment of personality disorders has increasingly come into focus. As the psychotherapeutic interventions are still limited with respect to these demanding disorders there is a considerable need for further efficacy and, particularly, therapy process investigations. A promising approach is the development of integrated psychotherapy which combines cognitive-behavioral interventions with further change mechanisms such as the clarification of maladaptive schemata. On top of that, interventions should maintain a focus on emotional aspects of the therapeutic alliance (emotion regulation). In a study on “Schema-focused Emotive Behavioral Therapy” (SET), 93 patients with personality disorders of clusters B (predominantly narcissistic and Borderline PS) and C (avoidant and dependent PS) were randomised into one arm with SET group therapy and a control arm with manualised social skills training (SST). Therapies lasted for approximately 30 two-hour sessions.

Therapy process was closely monitored using therapy session reports both from the patients' and therapists' perspectives. Therapy outcome was assessed prior to and after therapy.

We report here on the change mechanisms, which were derived from modeling therapy session reports with novel time series methods (vector autoregression based on the estimation of session-to-session changes). It was found that the two therapy approaches differed with respect to change mechanisms. In SET (yet not in SST) therapy groups, clarification and insight reduced feelings of being rejected and disrespected, which was a major concern of many patients. In addition to this, a contrast was found between the prototypical therapy processes of cluster B and C patients. In conclusion, these results lay the ground for a disorder-specific application of integrated psychotherapy in personality disorders.

Migration, cultural identity and mental distress are linked. In addition, social support can provide a buffer against mental illness. Other vulnerability factors in migrants include the type of society they originate from and the type of society they settle in. Societies and cultures have been described as being individualistic or collectivist (also called ego-centric or socio-centric). Similarly, individuals are idiocentric or allocentric. When individuals migrate from one type of culture to another it is likely that, depending upon their own personality traits (along with their biopsycho social vulnerabilities), they may develop psychiatric disorders. It is possible that response to stress as a result of migration will depend upon the type of culture people migrate to. However, the cultural identity of the individuals will also determine their coping strategies. Under these circumstances, it is crucial that clinician are aware of the impact cultural identity has on the expression of distress and coping among individuals The cognitions and idioms of distress will be influenced by cultural factors. The clinicians must take into account cultural background when planning any interventions to enable a stronger therapeutic alliance.

The Department of Transcultural Psychiatry (TCH) of the Regional Institute for Mental Health Care (Riagg) Rijnmond, Rotterdam, the Netherlands, set up an outreaching program, the Rif-Project, in response to the need for adjusting mental health care services to a more diverse and mobile client population while containing costs. In the past, TCH observed a decline in mental health status in Moroccan clients following their stay in Morocco, which was linked to uncoordinated eclectic health care consumption in Morocco, the pursuit of personally more acceptable diagnoses, somatic checkups or medication, and the occasional use of (stress-inducing) traditional healing methods. Rif-Project is based on the assumption of providing continuation of care to its Moroccan clients who spend their summer months in Morocco, through strategic positioning of TCH care-deliverers across the kingdom. Their activities include the continuation of the treatment program that was initiated in the Netherlands, visiting clients in their preferred environment and system, psycho-education and preventive activities. By monitoring their clients health care consumption, coordinating services in collaboration with local institutions, treatment interventions and psycho-education, TCH-workers were successful in providing and maintaining stability to their clients, which reduced the incidence of deterioration and crisis.

In recent years there has been increased recognition of the importance of developing culturally sensitive treatment in European psychiatry. A key area that requires further attention, however is related to the efficacy and security of psychopharmacological agents. It is increasingly well understood that drug metabolism can vary considerably across populations groups. At the same time, psychopharmacological research, from initial development of a new molecule to efficacy and security studies, to the identification of new indications, is generally carried out in Europe or North America, primarily using research subjects who are of White European descent. Furthermore, the development of the medication is predicated on the specific clinical issues that are of relevance to the target population. The upshot of this is that psychopharmacological research may be of limited relevance for those patients who are not of European or European American descent. To make psychopharmacological research more relevant requires that clinical issues relevant to the target population are included in the research protocol, that genetic variations are taken into consideration and identified, that the instruments used to measure the disorder in question are culturally valid, and that the overall research project is designed with the objective of understanding how cultural and genetic differences can impact pharmacodynamics and pharmacokinetics. This presentation will conclude with a brief description of a culturally sensitive ethnopsychopharmacological research project.

The database supporting Internet delivered minimal therapist contact cognitive behavioral therapy (CBT) is growing rapidly. Several randomized trials show that this novel treament approach can work for anxiety disorders and major depression of mild to moderate character. However, in clinical practice the implementation of Internet delivered CBT is not straightforward, as it can be difficult to target the right audience and client might worsen following or during the first “low cost” treatment attempt. The aim of this talk is to describe a model for the stepped care implemention of Internet CBT and data supporting the model. Results from a randomised trial on major depression will be presented as well as a summary of the available evidence regarding Internet CBT vs. regular CBT in individual or group format and the potential for stepped care. The data obtained so far raises some doubts regarding the widespread implementation of stepped care. For example, it is not clear why more intensive therapist contact should work when minimal contact therapy has not. However, at the same time stepped care approaches can help us think more clearly regarding different levels of intervention and cost effectiveness. Further research in this field is encouraged.

During the last 15 years we have seen a dramatic increase in the administration of effective drug treatment for anxiety disorders and major depression due to the introduction of SSRIs. Lately psychological treatments has been shown to be similarly effective in these conditions. Thus evidence from repeated randomized clinical trials (RCT) shows that CBT is an evenly effective alternative to SSRIs for major depression and anxiety disorders. However, due to limited availability of skilled CBT therapists we have an effective alternative to drug treatment out of reach for most patients regardless of preferences.

Fortunately, CBT provided in self-help-based approaches seems to be effective for e.g. depression, panic disorder, phobias, depression, eating disorders, PTSD and social phobia. A significant number of patients may however find it difficult to complete the treatment on their own. Thus Internet treatment with CBT in self-help format accompanied with minimal therapist contact by email seems to be a cost effective procedure to provide effective treatment to an increasing number of patients. This approach may to some extent overcome the limitation in therapist number and increase treatment accessibility. Patients may still enjoy the benefit of an individual therapist contact and thus improve the number of treatment program completers. Results from RCTs with Internet treatment in clinical settings with patients referred from general practitioners will be provided. Moreover, issues of patient selection/recruitment, web-technology and treatment limitations and clinical impressions of treating patients in this way will be discussed.

Today, internet-based technologies are used in all phases of psychosocial services. Current psychotherapeutic applications focus on the implementation of traditional approaches in the Internet. For instance, self-help material is posted onto the net, therapies are conducted via email, and groups meet in virtual chatrooms. However, recent advancements in web-based technologies are providing even greater opportunities for psychotherapy on the Internet. Today, many different aspects of psychotherapy on the Internet can be provided on a single integrated Web platform.

Recently, we have created an Internet platform that offers various aspects of a cognitive behavioral approach to social phobia. This includes an interactive self-help guide, contact with therapists, a continuous monitoring and feedback of patient response, as well as collaborative elements, offering patients the opportunity to share their experiences with other patients. The aim of this presentation is to provide insight into the concrete application of such a platform. Experiences, pitfalls and opportunities are discussed along with the primary results of a controlled study.

Attention-deficit/hyperactivity disorder (ADHD) is a clinically heterogeneous, highly heritable and genetically complex disorder. The pathways from genes to behaviour are still unknown. Endophenotypes, or intermediate phenotypes that are more closely linked to the neurobiological substrate than the core symptoms of ADHD, may help to disentangle these complex relationships between genes and behaviour and to clarify its etiology and pathophysiology. Heritability and stability represent key components of any useful endophenotype. Various other criteria for the selection of useful endophenotypes have been proposed. A review of the current state of the research on potential endophenotypes for ADHD will be given.

Adolescent suicide is a worldwide troubling phenomenon that has high comorbidity, including impulsivity, depression, and personality disorders. Attention Deficit Hyperactivity Disorder (ADHD) includes attention, impulsivity and hyperactivity. Comorbidity includes depression and substance abuse, and has a higher rate in adolescents and adults. Studies considering the association between these phenomena are surprisingly rare. This pilot study estimated the percentage of ADHD in a population of adolescents who attempted suicide. Population included all adolescents (12-18 yrs.) who were brought to local ER after attempting suicide. Assessment included an interview according to the DSM-IV criteria, the Strengths and Difficulties Questionnaire parents (SDQ-P) the Conners' Rating Scale parents (CRS-P), and Kiddie-SADS. Test Of Variables of Attention (TOVA) with methylphenidate (MPH) challenge was done after the clinical evaluation to those diagnosed as ADHD.