Poor diet habits and a more sedentary life may contribute to a worse physical health outcome of persons with schizophrenia, who are subjected to an increased risk of diabetes mellitus and other metabolic complications. These patients report greater euphoria and stimulatory effects in response to alcohol that may contribute to the increased risk for alcohol use disorders, which complicate the functional outcome of schizophrenia. Among subjects in this diagnostic group, those exposed to caffeine consumption tend to drink heavier amount of it, although the psychobiological implication of this finding has not been elucidated. Finally, there is worldwide a greater prevalence of tobacco smoking, heavy smoking and high nicotine dependence; and the available date support a theory of shared vulnerability to both smoking and schizophrenia rather than a self-medication hypothesis. The authors, all of whom have been contributors in this area, will discuss each other presentations

Successful schizophrenia management should concentrate on treatment non-adherence, lack of information about the disease, poor insight, depressive symptoms, cognitive decline and stressful family atmosphere. We introduce clinically-based 6-week structured comprehensive program for out-patients with schizophrenia-spectrum disorders in the stabilization phase of the treatment. The group program consists of individual and family psychoeducation, life style improvement intervention, social skills training, cognitive rehabilitation and information technology aided relapse prevention program (ITAREPS). To assess the feasibility and effectiveness we designed one-year prospective follow-up field study. Data on psychopathology (PANSS) and quality of life (Schwartz Outcomes Scale, WHO-QOL-BREF and Social Integration Survey) will be presented. Preliminary analyses (N=58) show statistically significant improvement in total PANSS scores and in quality of life (psychological domain, WHO-QOL-BREF). Patients and their relatives welcome the opportunity to participate in such a comprehensive program.

Antipsychotics have for half a century been the mainstay for the pharmacological management of schizophrenia patients. While efficacy has been the primary outcome variable in short term clinical trials many additional variables need to be accounted for when judging the usefulness of these medications over longer periods of time. Classic continuation studies and relapse prevention trials have mostly focused on symptom control, while safety/tolerability and subjective acceptance of these medications have generally been seen as secondary outcome measures. The concept of effectiveness attempts to provide a comprehensive outcome variable which encompasses all the relevant issues that determine longer term treatment success. Lately a number of large scale effectiveness trials, sometimes called large pragmatic clinical trials, have been undertaken, especially in the context of the attempt to evaluate differential drug effects. CATIE and CUTLASS have already been published, CAFE data have been presented in rough outlines and EUFEST results are still pending. While the first two studies have included patients with chronic schizophrenia, first episode patients have been allocated to the latter two trials. Although the available results from these trials are discussed very controversially, they unquestionably present an important addition to the traditional randomized controlled clinical trial design. Information from all types of research will have to be amalgamated in order to allow a rational choice for the long term management of schizophrenia patients. Unfortunately, the results available so far do not allow generalizable statements with regard to differential efficacy/effectiveness of antipsychotic drugs in the long term management of schizophrenia.

Psychotic depression is subject to many controversies. Geriatric psychotic depression has even more, and will be addressed in the presentation. The first controversy relates to whether depression with psychotic features is more frequent in elderly patients. Another controversial issue is the possibility that psychotic depression might be a different entity from the non-psychotic counterpart. The role of an organic component will be discussed as well as the possible presence of cognitive impairment. Differential diagnosis can be difficult in elderly patients that may deny symptoms, have medical conditions or dementia.

Treatment options for psychotic depression include the use of antidepressants, antipsychotics and electroconvulsive therapy among others. The preference of those treatments or its combinations is also controversial and will be discussed and put into context. In addition, current and novel treatment options for treatment resistant or partially responsive psychotic depression will be reviewed. These strategies include optimization, substitution, combination, or augmentation of antidepressants and other agents and different non-pharmacological techniques, all of which will be explained and related to the specificities of the geriatric patient

The reforming process of Psychiatric care carried out in Spain over the last decades brought about the relocation of many psychotic patients in different nursing homes whilst some of them stay at Psychiatric Hospitals. Those people's real needs, formerly widely debated among psychiatric professionals, are scarcely known.

This paper assesses the situation of elderly psychotic patients received at a Psychiatric Hospital; its data are compared with those arising from other papers by our group which have been carried out in different nursing homes located in Galicia, Spain.

Nineteen patients over 60 years are residing at the Rebullón Psychiatric Hospital. A comprehensive evaluation of their health, functional capacity and social situation has been carried out. The Camberwell Assessment of Needs of the Elderly (CANE) has been used to systematize the met and unmet needs. The CANE distinguishes between 24 areas of needs and they are assessed by the patient and a carer.

Preliminary results: a) their basic material and health needs are met; b) the most important unmet needs are those related to recreational and leisure activities, as well as the existence of intimate personal relationships.

Moreover, the evaluation of psychotic patients living at nursing homes has showed they lack accurate psychiatric assessment and treatment; many centres are not the adequate ones to fulfil their needs.

In conclusion, these patients suffer the double stigma the WHO is alerting about: because of their mental disease and because of their advanced age.

Paranoid Schizophrenia (PS), yet included within the same nosological category than Non-Paranoid Schizophrenia (NPS), may in fact constitute a different disorder. In this study, the above both schizophrenia subtypes are compared with Delusional Disorder (DD). We hypothesized that, phenomenologically PS could either be a half-way category between DD and NPS or part of a phenomenological continuum of psychotic and cognitive symptoms between these three psychotic categories.

102 patients fulfilling DSM-IV-TR criteria of schizophrenia (with 56 PS and 46 with NPS) and 80 DD patients were included in this study (n=182). We compared outcome groups (DD vs. PS vs. NPS) on clinical dimensions, global functioning and sociodemographics. Clinical dimensions were extracted from the PANSS and neuropsychological scales using Principal-Component-Analysis and, subsequently, cluster analysis to assign subjects to empirically emerging clinical groups. The associations between such groups and DSM-IV-TR groups were explored using polynomial regression.

We found lineal associations demonstrating empirically that, from the psychopathological, neuropsychological and functioning perspectives, it is reasonable to consider PS as an intermediate and independent category right in between DD and NPS. Thus, the distribution of subjects assigned to three empirically emerging clinical groups (Paranoid-Affective, Paranoid-Hostile and Negative) associated, significantly and preferentially, with DSM-IV categories along the following fashion: The proportion of paranoid-hostile and, particularly, paranoid-affective subjects decreased progressively along DD, PS and NPS categories; On the contrary, the proportion of negative subjects increased lineally along those categories (Mante-Haenszel-X2= 18.02;p=0.0001). Our results question, on the bases of an empirical study, the current categorical division of paranoid psychoses.

Over the past two decades schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Spain. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. This presentation tackle these various elements in the endeavour to reduce the impact of schizophrenia, particularly in long-term care elderly patients.

The term narcissism when used clinically, is broad and its boundaries are diffused. Freud first referred to narcissism to describe a libidinal position in which cathexes were invested in the subject's own ego and not in objects. Dynamically, significant advances have been made in the clarification of the methapsychological dimensions of narcissistic disorders. Two authors, Otto Kernberg (1984, 1986, 1998) and Heinz Kohut (1971, 1977), have advanced well-developed metapsychologies for these disorders and proposed comprehensive techniques for their treatment through appropriately modified psychoanalytically based interventions. In both cases, treatment is deemed to be plagued by problems, to last long, and to result in uncertain outcomes. The metapsychological clarity achieved by authors such as Kohut and Kernberg has so far not generated a proportionate therapeutic optimism.

In this paper, a review will be presented of the current status of the outcome of the treatment, through short-term dynamic psychotherapy, of a spectrum of psychoneurotic disorders, with special emphasis on the treatment of patients suffering from syndromes that reflect complex dynamic constellations resulting from the interaction of impulse problems and problems of object loss at key developmental moments, which affect the patient's relationships with developmentally key objects. Also presented will be techniques derived from this framework for the treatment of patients suffering from a range of narcissistic disorders, including Narcissistic Personality Disorder, as well as innovative techniques designed by the author to meet the unique treatment needs of self-disordered patients in shorter time frames than are common in the classically open-ended psychodynamic technique.

Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful on the basis of intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). The capacity develops during childhood within the context of an attachment relationship. It is suggested that the borderline patient shows a reduced capacity to mentalize and that this has resulted from disruption of the attachment relationship because of adverse interaction between biological and environmental factors.

We mentalize interactively and emotionally when with others. Each person has the other person's mind in mind (as well as their own) leading to self-awareness and other awareness. We have to be able to continue to do this in the midst of emotional states but borderline personality disorder is characterised by a loss of capacity to mentalize when emotionally charged attachment relationships are stimulated. This leads to misinterpretations about the motives of others, difficulty in managing emotional states, and self-destructive behaviour as the individual seeks some stability and tries to re-gain some mentalizing capacity. Therapy has to help a patient develop and maintain mentalizing even when emotional states are aroused. Some therapeutic techniques will be described to aid this process and some principles discussed which guide the naïve therapist on when to give which intervention.

The treatment of Borderline personality disorders continues to be a challenge for psychotherapists, because it is difficult to predict the successful clinical outcomes.

Scientific evidence about the efficacy of the long term psychodynamic oriented psychotherapy in Borderline personality disorders is now available. Nevertheless, it is necessary to look for effective types of psychodynamic psychotherapy which could be delivered in a limited or short time. The reason is that the long term psychotherapies are not accessible for the majority of borderline patients. The scientific literature about short term dynamic psychotherapy in borderline personality disorders is scarce.

The short term dynamic psychotherapy for this kind of patients sets out some practical and theoretical controversies:

1. • It is difficult to establish a therapeutic attachment, which has to be solved in a limited time avoiding an iatrogenic proceeding. It is due to the difficulty of this patients to have an enough symbolic representation of the therapist and the therapeutic relationship.

2. • It is difficult to establish the treatment objectives around a focus in the psychotherapy.

3. • The management of temporality, both in the own past time and in the future is difficult for this patients.

Nevertheless, we support the possibility to put into practice short term psychodynamic psychotherapy in a number of selected patients. We discuss the technical adaptations that would be necessary: to include supportive elements, to limit the interpretation, to increase the mentalization capacity with an active position of the therapist or to focus in the difficulties with the object relationships.

Several well designed studies have shown a reduction of significant symptoms in patients with borderline personality disorder on inpatient or day hospital basis with cognitive-behavioural or dynamic medium length programs.

In present study we asses the socio-demographic and clinical variables that predict the evolution of 90 patients (60 BPD) who attended a Day Program with a dynamic approach based on the theory of object relations, during 66 days average stay.

Group therapy is part of a multidimensional programme, including the prescription and control of medication, offering a range of corrective experiences which allow the modification of the symptoms of the patient, his or her social adaptation and, ideally, their relationship structures.

Favourable results have been found in patients with borderline personality disorders when compared to those of patients with other diagnoses and with their status during the year preceding their admission to the hospital program.

Co-morbidity, substance abuse, early onset of the symptoms, bad social adjustment and other clinical and social variables were detected as poor outcome predictors.

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.