Assessment of personality functioning in different stages of psychotic disorders could provide valuable information on psychopathology, course of illness and treatment planning, but empirical data are sparse.

To investigate personality functioning and sense of self in individuals at ultra-high risk (UHR) for psychosis and with first-episode psychosis (FEP) in comparison with a clinical control group of individuals with borderline personality disorder (BPD) and healthy controls.

In a cross-sectional design, we investigated personality functioning (Structured Interview of Personality Organization, STIPO; Level of Personality Functioning Scale, LPFS) and disturbances of the basic self (Examination of Anomalous Self-Experience, EASE) in 107 participants, comprising 24 individuals at UHR, 29 individuals with FEP, 27 individuals with BPD and 27 healthy controls.

The UHR, FEP and BPD groups had moderate to severe deficits in personality organisation (STIPO) compared with the healthy control group. Self-functioning with its subdomain (facet) ‘self-direction’ (LPFS) was significantly worse in participants with manifest psychosis (FEP) compared with those at-risk for psychosis (UHR). The FEP group showed significantly worse overall personality functioning than the UHR group and significantly higher levels of self-disturbance (EASE) than the BPD group, with the UHR group lying between these diagnostic groups. Hierarchical cluster analysis based on the seven STIPO domains yielded three clusters differing in level of personality functioning and self-disturbances.

Our data demonstrate that psychotic disorders are associated with impaired personality functioning and self-disturbances. Assessment of personality functioning can inform treatment planning for patients at different stages of psychotic disorder.

The COVID-19 pandemic has had a drastic effect on the mental health of the global population that is likely to be felt for years to come. One group particuarly likely to be affected by this in the immediate future are the healthcare professionals working on the frontline of the NHS pandemic response. As members of a foundation cohort of these junior doctors we aimed to create a way to quanitfy the wellbeing of ourselves and our colleagues at this challeging time. We aimed to use a combination of numerous tools to monitor foundation doctors in Blackburn during this crisis. This would inform which measures would be best suited to be put in place to protect this cohort from early burnout and poor mental health in the future.

We designed a survey of 25 questions which we invited our foundation colleagues to fill in anonymously during the first and second waves of the pandemic in response to times when foundation doctors were redeployed to aid the frontline. The survey has been based on the PHQ9, GAD7, Epworth Sleepiness scale, Physician wellbeing index, Medical students wellbeing index, Maslach burnout inventory BMA burnout questionnaire and the QOL scale.

From a cohort of around 140 foundation doctors we had 46 participants in our trial of this tool; 46% had been redeployed and 54% not redeployed. Over 50% of survey respondents reported high stress, poor motivation and depersonalisation over the two weeks at the peak of the pandemic, key early signs of burnout. Lack of interest in their work, poor sleep and anhedonia were increased across both groups (redeployed and non redeployed). The interventions after the first wave data which repondents found beneficial included; financial reassurances during redeployments, protected non clinical areas for rest, a named individual senior staff member for wellbeing support.

Key issues the survey raised were fed back to foundation programme leads in monthly meetings. This allowed us with our foundation leads to make targeted changes in order to support foundation doctors at this time. Without the data from this tool which we tailored to the foundation experience we believe these rapidly worsening issues during the pandemic would not have been addressed so swiftly. We then resurveyed the foundation cohort to assess which of these interventions have been most widely used and appreciated.

Studies have shown that over half of individuals with bipolar disorder experience early-life trauma, which may influence clinical outcomes, including suicidality and presence of psychotic features. However, studies report inconsistent findings regarding the effect of trauma on cognitive outcomes in bipolar disorder.

Our study explores the effect of lifetime trauma on the level of vulnerability to psychosis and cognitive performance in participants with bipolar disorder.

We evaluated lifetime trauma history in 236 participants with a diagnosis of bipolar disorder type 1 or 2, using the Structured Clinical Interview for DSM-IV and the Childhood Trauma Questionnaire. We classified trauma types based on the Substance Abuse and Mental Health Services Administration's concept of trauma, which characterises the type of experienced trauma (e.g. interpersonal and intentional, accidental or naturally occurring). Our primary outcome measures of interest were vulnerability to psychosis (Schizotypal Personality Questionnaire), cognitive performance (MATRICS Consensus Cognitive Battery) and social functioning (Social Adjustment Scale Self-Report).

Multivariate analysis of covariance showed a significant effect of trauma type on the Schizotypal Personality Questionnaire cognitive–perceptual domain (F(3) = 6.7, P < 0.001). The no-trauma group had lower cognitive–perceptual schizotypal features compared with the accidental and intentional trauma (P < 0.001) and interpersonal and intentional trauma (P = 0.01) groups.

Our results highlight the need for careful trauma inquiry in patients with bipolar disorder, and consideration of how trauma-focused or -informed treatments may be an integral part of treatment planning to improve outcomes in bipolar disorder.

Current assessment and management models often do not adequately address the many aspects of managing complex brain disorders involving disordered affect, behaviour and cognition (ABC). A more collaborative model of care, where several specialties can jointly assess and manage patients with complex brain disorders, is gaining attention.

In this case report, we present two cases that highlight the benefits of the ‘brain medicine’ clinical model.

The Brain Medicine Clinic employs an integrated clinical model in which psychiatrists and neurologists provide integrated interdisciplinary assessments of patients with complex brain disorders, leading to comprehensive assessment. We describe the clinical model and the trajectories of two patients with complex brain disorders seen in this clinic. In these case descriptions, we explain how the brain medicine clinical approach leads to an improved patient experience.

The Brain Medicine Clinic assessments resulted in a neurobiopsychosocial formulation of symptoms and, consequently, holistic individualised treatment plans for two patients with complex brain disorders. This approach to patients’ conditions emerges from the understanding that there are multifactorial causes of brain disorders at the social, cultural, psychological and biological level.

Integrated interdisciplinary assessments allow for tailored treatment plans for individuals experiencing complex brain disorders, while creating efficiencies for the patient and the healthcare system.

Despite considerable preclinical evidence, clinical trials assessing the effects of probiotics on individuals with major depressive disorder (MDD) are scarce. This study aimed to provide further evidence of the acceptability, tolerability and putative efficacy of probiotics in this patient group and to improve our understanding of the underlying mechanisms of action.

This double-blind randomised placebo-controlled pilot and mechanistic trial investigated the effects of an 8-week adjunctive multi-strain probiotic intervention in adults with MDD taking antidepressants. Psychiatric data and stool and blood samples were collected at baseline, week 4 and week 8. A computer-based emotion recognition task was also administered. Stool samples from 25 matched healthy controls were also obtained.

49 participants, randomised to probiotic (n = 24) or placebo (n = 25), were included in intent-to-treat analyses. Standardised effect sizes (SES) from linear mixed models demonstrated that the probiotic group attained greater improvements in depressive (HAMD week 4: SES [95%CI] = 0.70[0.01, 0.98]; IDS week 8: SES [95%CI] = 0.64 [0.03, 0.87]) and anxiety symptoms (HAMA week 4: SES [95%CI] = 0.67 [0.00, 0.95]; week 8: SES [95%CI] = 0.79 [0.06, 1.05]), compared to the placebo group. Attrition was 8% (n = 3 placebo, n = 1 probiotic), adherence was 97.2% and there were no serious adverse reactions. The probiotic modified the composition of the faecal microbiota by normalising richness and diversity towards healthy control levels. The probiotic also increased levels of specific taxa, including Bacillaceae (FDR p < 0.05), which correlated with reductions in anxiety scores (FDR p < 0.05). There was no impact of treatment on levels of inflammatory cytokines (CRP, TNFα, IL-1β, IL-6, IL-17) or BDNF. However, probiotics showed a tendency to increase positive affective bias and improved the accuracy of recognition of all emotions, except sadness.

Compared to placebo, the probiotic group had greater improvement in depressive and anxiety scores, from as early as 4 weeks. The acceptability, tolerability and estimated effect sizes on key clinical outcomes are promising and encourage further investigation of this probiotic as add-on treatment in MDD. The beneficial effects of probiotics in this patient group may be partially mediated by modification of the composition of the gut microbiota and improvement of affective biases, inherent to depressive disorders.

Depression is a highly recurrent disorder, with more than 50% of those affected experiencing a subsequent episode. Although there is relatively little stability in symptoms across episodes, some evidence indicates that suicidal ideation may be an exception. However, these findings warrant replication, especially over longer periods and across multiple episodes.

To assess the relative stability of suicidal ideation in comparison with other non-core depressive symptoms across episodes.

We examined 490 individuals with current major depressive disorder (MDD) at baseline and at least one subsequent episode during 9-year follow-up within the Netherlands Study of Depression and Anxiety (NESDA). The Inventory of Depressive Symptomatology (IDS) was used to assess DSM-5 non-core MDD symptoms (fatigue, appetite/weight change, sleep disturbance, psychomotor disturbance, concentration difficulties, worthlessness/guilt, suicidal ideation) at baseline and 2-, 4-, 6- and 9-year follow-up. We examined consistency in symptom presentation (i.e. whether the symptom met the diagnostic threshold, based on a binary categorisation of the IDS) using kappa (κ) and percentage agreement, and stability in symptom severity using Spearman correlation, based on the continuous IDS scores.

Out of all non-core depressive symptoms, insomnia appeared the most stable across episodes (r = 0.55–0.69, κ = 0.31–0.47) and weight decrease the least stable (r = 0.03–0.33, κ = 0.06–0.19). For suicidal ideation, correlations across episodes ranged from r = 0.36 to r = 0.55 and consistency ranged from κ = 0.28 to κ = 0.49.

Suicidal ideation is moderately stable in recurrent depression over 9 years. Contrary to prior reports, however, it does not exhibit substantially more stability than most other non-core symptoms of depression.

Research in the area of mHealth, has shown much promise in the development of mobile phone interventions which look at the assessment and treatment in real-time of psychiatric disorders. Within the context of Severe Mental Illnesses (SMI), such as psychosis, communication and understanding between health professionals and service users in the reporting of distress and reoccurrence of symptoms is essential in reducing the chances of relapse. An alternative pathway which uses mobile technology to engage with services, may hold the key to gaining a deeper understanding of the lived experiences of those with mental health difficulties, in particular experiences of recovery from SMI's. AIM: The aim of the study was to explore the perspectives and opinions of health professionals on the development and refinement of the TechCare App for psychosis. A qualitative approach was adopted for data collection, which provided an understanding of factors in relation to the development of the intervention.

A total of two focus groups were held with health professionals to elicit their views on optimising the utility of the TechCare App. The total sample size for the focus groups was n = 16 with a total of 6 males and 10 females. This qualitative study was part of a feasibility study, investigating a novel intervention (TechCare) (Husain et al., 2016; Gire et al., 2021) which monitored participants symptoms and provided a tailored psychosocial response in real-time. Data obtained from the focus groups was transcribed. Framework analysis were used to analyse the data for emerging themes, focusing on feasibility, acceptability and further development.

The key themes that emerged from the data were; access and usage of digital technologies, implications for clinical practice, challenges & barriers to delivery and development and refinement considerations for the TechCare App.

Results of the focus group with health professionals provided a unique perspective of conducting mHealth research within an EIS context, and the differing challenges professionals anticipated facing in delivering the TechCare App intervention. The main finding of the focus group was that professionals saw the potential for the TechCare App to increase access to digital technologies, providing service users with an alternative medium to communicate with EIS health professionals. However, the participants felt that despite mHealth Apps being a useful platform to deliver interventions, face-to-face contact should remain an important aspect of routine care.

Intensive treatment for eating disorders include day treatment programme and specialist inpatient. COVID-19 pandemic led to lockdown in the UK on the 23rd March 2020. Adult Eating Disorders Day Treatment Programme in Surrey started delivering their care on the virtual platform from that date. It offered a combination of ‘virtual’ only and ‘blended’ care (virtual and in person) for more than a year. This service evaluation examined the safety of delivering intensive eating disorders treatment on the virtual platform.

Data from March 2020 to March 2021 were retrospectively collected from Electronic patient record. Two clinicians collected the data on age, referral origin, accommodation, employment status, diagnosis (subtype), length of illness, comorbid mental and physical health diagnosis, duration of day care treatment, medication, admission weight and BMI, discharge weight and BMI, changes in bloods and ECG, acute hospital admission, risk-to-self events, admissions to Specialist Eating Disorders Unit and reasons for discharge.

Data indicated that 21 patients were admitted in day treatment programme over 1 year period. 10 patients had solely virtual treatment and 11 patients had blended day treatment programme. 11 patients had anorexia nervosa restrictive subtype, 5 patients had Anorexia Binge purge subtype and 5 patients had Anorexia Nervosa, Unspecified.

Average length of illness was 4.49 years. Mean age for the group was 24.7 years and most patients lived with family (n 18) and were unemployed (n 11). More than 2/3rd (76%) patients had comorbid mental health diagnosis and 48% (n 10) had comorbid physical health diagnosis.

Average length of admission was 5.26 months. Mean BMI on admission was 15.3 (Range 12–19) and mean BMI on discharge was 16.9 (Range 13.65–22).

Safety and outcome data indicated that there were no serious incidents recorded in that time period. 1 (5%) patients required admission to acute hospital as their physical health deteriorated. 8 (38%) patients required specialist inpatient admission as the day care did not affect any changes to their eating behaviours, and 4 (19%) patients had events indicating self harm episodes(19%).

Our service evaluation data indicated that it is relatively safe to deliver day treatment programme on the virtual platform. Weekly face to face physical health monitoring (weight, BP, Pulse, temperature) and regular physical health investigations (Blood tests and ECG) were integral part of managing risks to health. On the other hand, delivering day treatment programme on the virtual platform has enabled the day treatment programme to prevent any significant outbreak of COVID-19 in a vulnerable group of patients and allowed them to receive uninterrupted support during pandemic.

Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder (RAD). However, access to interventions varies widely, and there are no evidence-based interventions for RAD.

To modify an existing parenting intervention for children with RAD in the UK foster care setting, and test the feasibility of conducting a randomised controlled trial (RCT) of the modified intervention.

The intervention was modified with expert input and tested on a case series. A feasibility and pilot RCT compared the new intervention with usual care. Foster carers and children in their care aged ≤6 years were recruited across nine local authorities, with 1:1 allocation and blind post-treatment assessments. The modified intervention was delivered in-home by trained mental health professionals over 4–6 months. Children were assessed for RAD symptoms, attachment quality and emotional/behavioural difficulties, and foster carers were assessed for sensitivity and stress.

Minimal changes to the intervention programme were necessary, and focused on improving its suitability for the UK foster care context. Recruitment was challenging, and remained below target despite modifications to the protocol and the inclusion of additional sites. Thirty families were recruited to the RCT; 15 were allocated to each group. Most other feasibility outcomes were favourable, particularly high numbers of data and treatment completeness. The revised intervention was positively received by practitioners and foster carers.

A large-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended.

Aggression and violent incidents are a major concern in psychiatric in-patient care. Nutritional supplementation has been found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems.

To assess whether multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation would reduce the number of aggressive incidents among long-stay psychiatric in-patients.

The trial was a pragmatic, multicentre, randomised, double-blind placebo-controlled study. Data were collected from 25 July 2016 to 29 October 2019, at eight local sites for mental healthcare in The Netherlands and Belgium. Participants were randomised (1:1) to receive 6-month treatment with either three supplements containing multivitamins, minerals and n-3 polyunsaturated fatty acid, or placebo. The primary outcome was the number of aggressive incidents, determined by the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcomes were patient quality of life, affective symptoms and adverse events.

In total, 176 participants were randomised (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (s.d. 14.5) and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in supplement (1.03 incidents per month, 95% CI 0.74–1.37) and placebo groups (0.90 incidents per month, 95% CI 0.65–1.19), with a rate ratio of 1.08 (95% CI 0.67–1.74, P = 0.75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes.

Six months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric in-patients.

Refugees and asylum seekers (RAS) in Germany need tailored and resource-oriented mental healthcare interventions.

To evaluate the cost-effectiveness of group psychotherapy for RAS with moderate depressive symptoms.

This is a post hoc cost-effectiveness analysis of Empowerment group psychotherapy that was embedded in a stratified stepped and collaborative care model (SCCM) from the multicentre randomised controlled MEHIRA trial. One hundred and forty-nine participants were randomly assigned to SCCM or treatment as usual (TAU) and underwent Empowerment (i.e. level 3 of the SCCM for adults) or TAU. Effects were measured with the nine-item Patient Health Questionnaire (PHQ-9) and quality adjusted life-years (QALY) post-intervention. Health service and intervention costs were measured. Incremental cost-effectiveness ratios (ICER) were estimated and net monetary benefit (NMB) regressions with 95% confidence intervals were performed. Cost-effectiveness was ascertained for different values of willingness to pay (WTP) using cost-effectiveness acceptability curves for probable scenarios. Trial registration number: NCT03109028 on ClinicalTrials.gov.

Health service use costs were significantly lower for Empowerment than TAU after 1 year. Intervention costs were on average €409.6. Empowerment led to a significant change in PHQ-9 scores but not QALY. Bootstrapped mean ICER indicated cost-effectiveness according to PHQ-9 and varied considerably for QALY in the base case. NMB for a unit reduction in PHQ-9 score at WTP of €0 was €354.3 (€978.5 to −€269.9). Results were confirmed for different scenarios and varying WTP thresholds.

The Empowerment intervention was cost-effective in refugees with moderate depressive symptoms regarding the clinical outcome and led to a reduction in direct healthcare consumption. Concerning QALYs, there was a lack of confidence that Empowerment differed from TAU.

Psychosis is more prevalent among people in prison compared with the community. Early detection is important to optimise health and justice outcomes; for some, this may be the first time they have been clinically assessed.

Determine factors associated with a first diagnosis of psychosis in prison and describe time to diagnosis from entry into prison.

This retrospective cohort study describes individuals identified for the first time with psychosis in New South Wales (NSW) prisons (2006–2012). Logistic regression was used to identify factors associated with a first diagnosis of psychosis. Cox regression was used to describe time to diagnosis from entry into prison.

Of the 38 489 diagnosed with psychosis for the first time, 1.7% (n = 659) occurred in prison. Factors associated with an increased likelihood of being diagnosed in prison (versus community) were: male gender (odds ratio (OR) = 2.27, 95% CI 1.79–2.89), Aboriginality (OR = 1.81, 95% CI 1.49–2.19), older age (OR = 1.70, 95% CI 1.37–2.11 for 25–34 years and OR = 1.63, 95% CI 1.29–2.06 for 35–44 years) and disadvantaged socioeconomic area (OR = 4.41, 95% CI 3.42–5.69). Eight out of ten were diagnosed within 3 months of reception.

Among those diagnosed with psychosis for the first time, only a small number were identified during incarceration with most identified in the first 3 months following imprisonment. This suggests good screening processes are in place in NSW prisons for detecting those with serious mental illness. It is important these individuals receive appropriate care in prison, have the opportunity to have matters reheard and possibly diverted into treatment, and are subsequently connected to community mental health services on release.

None.

This evaluation was done with the focus to improve the quality of pre-ARCP corporate report for core-trainees. The pre-ARCP corporate report is a document compiled by the medical education department guided by other departments to capture certain competencies. The area of interest was how the report could be up-to-date and accurate. This would ultimately lead to a fair and objective summation of facts for the Psychiatric and Educational Supervisor report which will be reviewed by the ARCP panel.

This evaluation included all full-time core trainees within the Northern training scheme of the Trust who have undergone ARCP in January and July 2022. Exclusion criteria included less-than full-time trainees and core trainees who did not take part in an ARCP panel in January and July 2022. The questionnaire was designed by the Project Team and approved by the Trust Audit Team prior to data collection. The data were collected from 11th July to 31st July 2022. Electronic questionnaires were sent out to 33 postgraduate doctors.

A total of 12 postgraduate doctors responded (36%). Out of the 12 doctors that responded, 11 (92%) had taken part in the ARCP panel in July 2022. 11/12 (92%) reported having received their pre-ARCP corporate report prior to the ARCP and in adequate time. Similarly, 11/12 (92%) of postgraduate doctors agreed with the record of both the RCPsych teaching attendance and audit involvement recorded on their pre-ARCP corporate report. In relation to capturing locality teaching attendance, 58% of postgraduate doctors reported the information as accurate. Inaccurate capturing of leaves, on-calls and/or rest days were pointed out by respondents as reasons for the discrepancy in attendance. Of those who contacted medical education, 10/10 (100%) reported that the issue was resolved before the portfolio submission date for ARCP. Of those who did not take action, 50% (1/2) reported the reason as being “I did not see the need to take action”.

We found that core trainees felt that capturing accurate RCPsych teaching attendance as well as accurate audit involvement before ARCP are areas that required improvement. There is room for improvement regarding recording locality teaching attendance and absences due to leaves, on-calls, and compensatory rest. It brings us back to reflect on the time spent by each affected postgraduate doctor to clarify their records when discrepancies are noted. Results were discussed with Medical Education department and suggestions for improvement implemented. A re-evaluation is scheduled to take place in July 2023.

In England, a range of mental health crisis care models and approaches to organising crisis care systems have been implemented, but characteristics associated with their effectiveness are poorly understood.

To (a) develop a typology of catchment area mental health crisis care systems and (b) investigate how crisis care service models and system characteristics relate to psychiatric hospital admissions and detentions.

Crisis systems data were obtained from a 2019 English national survey. Latent class analyses were conducted to identify discernible typologies, and mixed-effects negative binomial regression models were fitted to explore associations between crisis care models and admissions and detention rates, obtained from nationally reported data.

No clear typology of catchment area crisis care systems emerged. Regression models suggested that provision of a crisis telephone service within the local crisis system was associated with a 11.6% lower admissions rate and 15.3% lower detention rate. Provision of a crisis cafe was associated with a 7.8% lower admission rates. The provision of a crisis assessment team separate from the crisis resolution and home treatment service was associated with a 12.8% higher admission rate.

The configuration of crisis care systems varies considerably in England, but we could not derive a typology that convincingly categorised crisis care systems. Our results suggest that a crisis phone line and a crisis cafe may be associated with lower admission rates. However, our findings suggest crisis assessment teams, separate from home treatment teams, may not be associated with reductions in admission and detentions.

Suicidal behaviour remains a major public health concern and countries have responded by authoring guidelines to help mitigate death by suicide. Guidelines can include family-based recommendations, but evidence for the level and category of family-based involvement that is needed to effectively prevent suicide is unclear.

To explore the association between family-based recommendations in guidelines and countries’ crude suicide rates. PROSPERO registration: CRD42019130195.

MEDLINE, Embase, PsycInfo, Web of Science and WHO MiNDbank databases and grey literature were searched within the past 20 years (1 January 2000 to 22 June 2020) for national guidelines giving family-based recommendations in any of three categories (prevention, intervention and postvention).

We included 63 guidelines from 46 countries. All identified guidelines included at least one family-based recommendation. There were no statistically significant differences seen between mean World Health Organization crude suicide rates for countries that included only one, two or all three categories of family-based recommendations. However, a lower spread of crude suicide rates was seen when guideline recommendations included all three categories (mean crude suicide rates for one category: 11.09 (s.d. = 5.71); for two categories: 13.42 (s.d. = 7.76); for three categories: 10.68 (s.d. = 5.20); P = 0.478).

Countries should work towards a comprehensive national suicide guideline that includes all categories of family-based recommendations. Countries with previously established guidelines should work towards the inclusion of evidence-based recommendations that have clear implementation plans to potentially help lower suicide rates.

Although there is an established but complex relationship between violence and psychosis, the nature of this relationship remains unclear. To date, there has been a predominant focus within group-level quantitative studies on specific types of psychopathology such as threat/control-override and command hallucinations. However, the literature has not produced a consensus on the profile of psychopathological predictors of violence. Furthermore, there is an emerging literature suggesting the predictive paradigm has limited clinical utility in the management of harm-related behaviour. In the way that phenomenological analysis has produced a fuller understanding of psychosis (that can inform improved aetiological and interventional frameworks), the authors assert that such an approach (with its focus on subjectivity) has the potential to advance our understanding of the relationship between psychosis and violence in a way that has clinical applicability. To test this assertion, it is necessary to develop a model of assessment and analysis. The aim of this paper is to develop an evidence-based model to explore the phenomenological underpinnings of violence in psychosis.

A two-stage method was followed. Firstly, drawing on existing phenomenological accounts of psychosis and approaches to understanding the subjectivity of violence perpetration, the authors developed a pilot evaluation model. This was tested and revised by applying the model to phenomenological case reports of psychosis and violence.

The findings so far demonstrate that as well as the role of circumscribed psychopathology on the likelihood of violence, other experiences within the psychotic spectrum such as operative hyperreflexivity and disturbances of ipseity play an important role. Additionally, feelings of disconnectedness and loss of recognising others as real combined with impaired theory of mind can lead to loss of normal inhibitory processes and violent behaviour. In keeping with a recent shift in focus from strict diagnostic criteria to individual psychotic phenomena, existential analysis can be applied to explore changes in self-identity and sense of belonging in the world to develop our understanding of the association between psychosis and violence.

The phenomenological model developed produces a fuller picture of the association between psychosis and violence. As such it may generate insight into the association between psychosis and violence that has greater clinical utility than existing psychopathology-based theories do. This needs to be evaluated by field testing of the approach.

People with a personality disorder have a higher mortality and reduced life expectancy than the general population. Childbearing is thought to have a protective effect on morbidity and mortality. Yet, there are no studies on whether childbearing is related to a lower mortality among women with personality disorder.

This study examined associations between childbearing and mortality among women with personality disorder. Our hypothesis was that parity would be associated with lower mortality.

This register-based cohort study included 27 412 women treated for personality disorder in in-patient or specialised out-patient care between 1990 and 2015. We used nationwide population-based registers to obtain information on sociodemographics, child delivery, healthcare use and mortality. Mortality risk estimates were calculated as hazard ratios (HRs) with 95% CIs using Cox regression. Adjustments were made for year of birth, educational level, age at diagnosis, comorbidity and severity of personality disorder.

Nulliparous women had a nearly twofold increased mortality risk (adjusted HR = 1.78, 95% CI 1.50–2.12) compared with parous women and over twofold mortality risk (adjusted HR = 2.29, 95% CI 1.72–3.04) compared with those giving birth after their first personality disorder diagnosis. Those giving birth before their first personality disorder diagnosis had a 1.5-fold higher risk of mortality than those giving birth after their first personality disorder diagnosis (adjusted HR = 1.48, 95% CI 1.06–2.07). There was a threefold risk of suicide in nulliparous women compared with those giving birth after their first personality disorder diagnosis (adjusted HR = 2.90, 95% CI 1.97–4.26).

Childbearing history should be an integral part of the clinical evaluation of women with personality disorder.