Reinier van Arkel

A Structuralist Approach in Psychiatry presents an alternative view of the psychiatric patient and highlights a connection with continental post-structuralist thinking to provide a new approach to psychiatry. After outlining the problems facing psychiatry, and the historical development of the field, this book outlines a structuralist model of the subject that does greater justice to the complexity involved while avoiding physicalist reductionism. It draws heavily on French structuralism, in which language plays a central structuring role that also influences the subject. The author draws on the works of Foucault, Lacan, and Bergson, as well as Nietzsche, Heidegger, and Žižek. The structuralist model proposed engages with the intricate relationships between the Real, the Imaginary, and the Symbolic in relation to the subject, particularly in the marginality of psychosis. Three clinical examples are provided to illustrate this: the syndromes of Cotard, Capgras, and negative hallucination. These examples demonstrate how the negative within the subject manifests itself in their symptomatology. However, the negative also plays a role in the normal development of the subject when they encounter the Symbolic and enter the world of language. Time and again, the subject must reinvent themselves through speech. This model, grounded in the concept of the zero point, has implications for an alternative anthropology and for psychiatry, where speaking and listening take center stage. This book will be of interest to mental healthcare professionals, including psychiatric nurses, psychiatrists, psychologists, and physician assistants, and those studying to enter these professions.

Abstract Background Prescribing pharmaceutical agents during pregnancy requires a balance between maternal therapeutic needs and foetal risks. Quetiapine, an atypical antipsychotic, is prescribed in psychiatric disorders and increasingly used off-label in low-dosages (<200mg daily) for insomnia during pregnancy. This study aimed to investigate the possible relationship between using quetiapine in a low dosage during pregnancy and the neonatal outcome within the first three days after birth. Methods A retrospective cohort study was conducted at the Radboud University Medical Centre (RadboudUMC), Nijmegen, The Netherlands. Liveborn neonates admitted to the RadboudUMC during the years 2017-2024 whose mothers used at least one dose of quetiapine (≤ 200mg daily) during pregnancy were included. Maternal characteristics and neonatal outcomes were analysed using SPSS, dose-dependent outcomes were also assessed. Results 30 neonates were included. Of these, 7 (23.3%) were born preterm, 7 (23.3%) were small for gestational age (SGA), 6 (20.0%) were admitted to the neonatal intensive care unit (NICU) and 2 (6.3%) exhibited withdrawal symptoms. Most neonates were admitted to the hospital for 3 days. Conclusion This study is the first to evaluate neonatal outcome after maternal low dose quetiapine in pregnancy in the Netherlands. We found relatively high rates of preterm birth, SGA and NICU admissions. As this was a single-centre study without a control group and with a small sample size in an academic population, results should be interpreted with caution. We recommend further prospective and multicentre studies including control groups.

In measurement-based care or routine outcome monitoring self-report questionnaires are used to monitor how a patient fares in therapy. Interpretation and utilization of test results are improved and communication facilitated when raw scores are converted to common metrics, such as standard scores (T-scores) and percentile rank scores. Both types of common metrics are described and reviewed and a warning is issued that percentiles may be misinterpreted at the tails of the scale. Data from the Manchester Short Assessment (MANSA) was used to investigate various approaches to obtain T-scores. The study analyzed cross-sectional data from two normative samples: a representative sample of the Dutch general population (N = 11,789) and a clinical sample (N = 9987) of patients with substance use disorder. Linear, normalized, and IRT-based T-scores were compared.Results revealed that T-scores derived from a linear conversion were biased at the lower end of the scale. Normalizing raw test scores through either Rankit normalization or by an IRT approach yielded improved and quite similar T-scores. For all possible raw scores on the MANSA, corresponding normalized T-scores are presented, as well as Percentile Rank scores for the two reference groups. Finally, cut-off values for reliable change and clinically significant change are presented for raw scores and T-scores. Practical guidance is offered for converting raw test scores into two common metrics: normalized T-scores and Percentile Rank scores. For T-scores, simple linear conversions yielded biased results. These findings have implications for test developers, practitioners, and researchers who want to express test results in valid and unbiased common metrics. The online version contains supplementary material available at 10.1007/s10862-025-10266-0.

BackgroundSocial functioning, symptoms, cognition and well-being are all considered important recovery domains for patients with schizophrenia spectrum disorders (SSD). In the current study, we investigated to what extent longitudinal changes in one recovery domain moderated changes in another recovery domain, and which personal, clinical or social patient characteristics influence changes in recovery domains for patients with SSD.MethodsWe investigated data from GROUP, a prospective, longitudinal six-year study of patients with SSD. We analyzed longitudinal changes in 15 outcomes (i.e., subdomains of symptoms, social functioning, cognition, quality of life or well-being), through a linear mixed-effects model analysis. Changes in other outcomes, patients’ duration of illness (DOI), and personal, clinical, or social patient characteristics at baseline were treated as covariates in the analyses.ResultsWe observed long-term improvement in all outcomes, except for depressive symptoms and subjective well-being. Larger improvements in positive symptoms, social functioning and executive functioning were indicated for patients with a short DOI. We found multiple, moderating effects, mainly for patients with a short DOI, between changes in cognition, social functioning, symptoms and quality of life. Limited moderating effects were indicated between these recovery domains and well-being. Baseline levels of outcomes, schizophrenia diagnosis, education level, ethnicity, living situation, employment status and marital status were all moderators for changes in most outcomes.ConclusionsSymptoms, social functioning, cognition and quality of life often concurrently improved over the course of SSD. These longitudinal changes were mostly driven by social patient characteristics, such as education level, ethnicity, living situation, employment status and marital status.Clinical trial numberNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12888-025-07700-8.

People with complex psychosis admitted to inpatient mental health rehabilitation units (IMRU) constitute a low volume, high need, high cost group with a complicated recovery process. To generate hypotheses regarding successful delivery of guideline care to patients with complex psychosis in IMRUs, based on clinical profiles and (historical) patterns of care delivery. A retrospective passive consent chart study of patients with complex psychosis in IMRUs in The Netherlands, mapping sociodemographic and clinical profiles, care trajectories and delivery of pharmacological (focusing on clozapine delay), psychological and social guideline interventions. We assessed relationships between non-delivery of psychological and social interventions, delay in clozapine treatment, and current symptom severity. The 62 included patients had a mean illness duration of 21.6 years (SD 9.4); 89% were diagnosed with a schizophrenia spectrum disorder. They exhibited severe symptoms (GAF-s: mean 33, SD 12.2), substantial functional impairment (GAF-f: mean 32, SD 9.5), a history of physical violence (74%) and/or severe substance use problems (61%), and limited or absent insight (87%). Care trajectories showed long-term instability of living environment, and frequent current compulsory care (76%). Of 54 patients with a clozapine treatment indication, 65% currently used it, of whom 94% started in IMRU setting, and 43% had one or more earlier aborted trials. Support in developing day activities was accepted by 87% of total sample, including patients without a day activity goal on beforehand. 66% developed day activities. We found associations between symptom severity, clozapine delay, declining psychological treatment, and not having day activity goals. For some people with complex psychosis, clozapine treatment and psychosocial interventions may only materialize in specialized, long term, high structure settings offering continuity of care. Support in developing day activities may present a pathway to collaborative engagement. Early identification of those in need remains a challenge.

Introduction: Self-disturbance phenomena are increasingly recognized as fundamental and debilitating features for patients with a schizophrenia spectrum disorder (SSD). The concept of personal recovery describes the process of building a meaningful and satisfying life despite persistent symptoms or challenges related to mental illness. No previous study has investigated the association between self-disturbance phenomena and personal recovery in patients with SSD. Understanding the impact of self-disturbance could strengthen the therapeutic alliance with patients and contribute to the development of treatment strategies supporting their recovery. Aim: The aim of this study was to investigate whether severity of self-reported self-disturbance phenomena is associated with the level of self-reported personal recovery in patients with SSD, their unaffected siblings, and healthy controls. Methods: In a cross-sectional design with 522 patients with SSD, 608 unaffected siblings, and 369 healthy controls, the frequency and distress of self-disturbance phenomena was measured with the Self-Experience Lifetime Frequency Scale (SELF). Personal recovery was assessed with the Recovery Assessment Scale (RAS-24). Spearman’s rank correlation coefficients between both scales were examined. Subsequent multiple hierarchical regression analyses were conducted to assess additional explained variance in personal recovery by severity of self-disturbance phenomena, adjusting for positive, negative, and general symptomatology. Results: Significant correlations were reported between higher SELF and lower RAS-24 scores for patients (ρ = −0.20, p < 0.001), siblings (ρ = −0.24, p < 0.001), and controls (ρ = −0.16, p < 0.005). The severity of self-disturbance phenomena significantly albeit modestly predicted total personal recovery score after adjusting for positive, negative, and general symptoms for patients (R2 change = 0.035, β = −0.19, p < 0.001). Conclusion: Current findings suggest that self-reported self-disturbance phenomena are relevant for the personal recovery of patients with SSD. Healthcare practitioners are urged for attention to patients’ first-person perspectives, including experiences of self-disturbance.

BackgroundSelective serotonin reuptake inhibitors (SSRIs) are the preferred pharmacological treatment for obsessive–compulsive disorder (OCD). However, insufficient response is common and it remains unclear whether specific patient-level factors influence the likelihood of treatment response.AimsTo determine the efficacy and acceptability of SSRIs in adult OCD, and to identify patient-level modifiers of efficacy.MethodsWe conducted an individual patient data meta-analysis (IPDMA) of industry-sponsored short-term, randomised, placebo-controlled SSRI trials submitted for approval to the Dutch regulatory agency to obtain marketing approval for treating OCD in adults. We performed a two-stage meta-analysis, using crude data of available trials. The primary outcome was the difference in Yale–Brown Obsessive–Compulsive Scale (YBOCS) change between active treatment and placebo. Secondary outcomes were differences in response (defined as the odds ratio of ≥35% YBOCS point reduction) and acceptability (defined as the odds ratio for all-cause discontinuation). We examined the modifying effect of baseline characteristics: age, gender, illness severity, depressive symptoms, weight, illness duration and history of antidepressant use.ResultsAfter excluding three trials because of missing data, we analysed results from 11 trials (79% of all submitted trials, n = 2372). The trial duration ranged from 10 to 13 weeks. Mean difference of SSRIs relative to placebo was 2.65 YBOCS points (95% CI 1.85–3.46, p < 0.0001), equalling a small effect size (0.33 Hedges’ g). The odds ratio for response was 2.21 in favour of active treatment (95% CI 1.72–2.83, p < 0.0001), with a number needed to treat of seven. Patient characteristics did not modify symptom change or response. Acceptability was comparable for SSRIs and placebo.ConclusionsOur IPDMA showed that SSRIs are well accepted and superior to placebo for treating OCD. The effects are modest and independent of baseline patient characteristics.

ABSTRACTIntroductionPatients with schizophrenia spectrum disorders (SSD) improve in several outcome domains over the course of illness, but to different degrees. In this meta‐analysis, we investigated whether longitudinal changes in different outcome domains are associated with each other and which factors moderate these changes over time.MethodsOur protocol was preregistered in PROSPERO (CRD42024504253). We included 109 studies, identified through searches in PsycInfo, PubMed, CINAHL, and Cochrane up until November 2023, investigating longitudinal changes in at least two outcome domains (symptoms, social functioning, cognition or personal recovery) for patients with SSD with at least 1 year follow‐up. We calculated Pearson correlation coefficients for associations of changes between outcome domains. Potential moderating effects of demographic, clinical, social, or study characteristics were explored. Quality assessment was executed using the QUIPS tool.ResultsWe found substantial positive associations between changes in symptoms, social functioning, and cognition. Especially, changes in negative symptoms and overall social functioning were associated with changes in several outcome domains. Changes in personal recovery were only associated with changes in symptoms. We found more substantial improvements in combinations of outcomes for patients with a shorter illness duration, females, a lower percentage of patients diagnosed with schizophrenia, and patients receiving treatment focused on targeted outcomes.ConclusionsSymptoms, social functioning, and cognition often concurrently improve and may boost each other. This suggests that an integrated approach targeting several outcome domains jointly boosts long‐term improvement. However, changes in personal recovery seem to occur separately from other outcome domains. Therefore, targeted attention for personal recovery is needed.Trial Registration: PROSPERO: CRD42024504253

Within the Dutch clinical field of specialized mental health care for youth, an increasing subgroup of female adolescents with severe chronic suicidal behavior is recognized. This group was also identified in a Dutch psychological autopsy study among 35 relatives of adolescents (aged 10-19 years old) who died by suicide. There seems to be a lack of knowledge and consensus how to treat this severe chronic suicidal behavior, resulting in stagnation of care and growing demoralization among patients, parents, and mental health care providers. The aim of this paper is to describe characteristics of the suicidal process, to identify challenges experienced in providing mental health care for this subgroup, and to formulate preliminary recommendations. A case description from the psychological autopsy study and a review of the relevant literature. The persistent suicidal threat and the resulting despair of the patient and their parents are forcing the mental health care provider into an impasse: the primary focus of treatment slowly moves to guarantee the patient's safety, which leaves the treatment of underlying problems underexposed. Due to the chronicity of the suicidal ideation and behavior in a phase in which identity formation and developing cognitive and emotional regulation skills are important developmental tasks, we identify a risk of developing a suicidal identity. Based on expert knowledge, we make recommendations on (1) treating suicidality as a transdiagnostic phenomenon with its own meaning and function, (2) implementing treatment considerations promoting the autonomy, (3) aiming at continuity of care and prevention of repeated patient referrals by creating a multidisciplinary network of care providers, and (4) making chronic suicidality tolerable for the care provider. We propose preliminary practical recommendations in our quest for optimal mental health care for chronically suicidal adolescents.

Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder. To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941. We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder. Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010). Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.