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In Europe, the incidence of psychotic disorder is high in certain migrant and minority ethnic groups (hence: ‘minorities’). However, it is unknown how the incidence pattern for these groups varies within this continent. Our objective was to compare, across sites in France, Italy, Spain, the UK and the Netherlands, the incidence rates for minorities and the incidence rate ratios (IRRs, minorities v. the local reference population).
The European Network of National Schizophrenia Networks Studying Gene–Environment Interactions (EU-GEI) study was conducted between 2010 and 2015. We analyzed data on incident cases of non-organic psychosis (International Classification of Diseases, 10th edition, codes F20–F33) from 13 sites.
The standardized incidence rates for minorities, combined into one category, varied from 12.2 in Valencia to 82.5 per 100 000 in Paris. These rates were generally high at sites with high rates for the reference population, and low at sites with low rates for the reference population. IRRs for minorities (combined into one category) varied from 0.70 (95% CI 0.32–1.53) in Valencia to 2.47 (95% CI 1.66–3.69) in Paris (test for interaction: p = 0.031). At most sites, IRRs were higher for persons from non-Western countries than for those from Western countries, with the highest IRRs for individuals from sub-Saharan Africa (adjusted IRR = 3.23, 95% CI 2.66–3.93).
Incidence rates vary by region of origin, region of destination and their combination. This suggests that they are strongly influenced by the social context.
First episode psychosis (FEP) patients who use cannabis experience more frequent psychotic and euphoric intoxication experiences compared to controls. It is not clear whether this is consequent to patients being more vulnerable to the effects of cannabis use or to their heavier pattern of use. We aimed to determine whether extent of use predicted psychotic-like and euphoric intoxication experiences in patients and controls and whether this differs between groups.
We analysed data on patients who had ever used cannabis (n = 655) and controls who had ever used cannabis (n = 654) across 15 sites from six countries in the EU-GEI study (2010–2015). We used multiple regression to model predictors of cannabis-induced experiences and to determine if there was an interaction between caseness and extent of use.
Caseness, frequency of cannabis use and money spent on cannabis predicted psychotic-like and euphoric experiences (p ⩽ 0.001). For psychotic-like experiences (PEs) there was a significant interaction for caseness × frequency of use (p < 0.001) and caseness × money spent on cannabis (p = 0.001) such that FEP patients had increased experiences at increased levels of use compared to controls. There was no significant interaction for euphoric experiences (p > 0.5).
FEP patients are particularly sensitive to increased psychotic-like, but not euphoric experiences, at higher levels of cannabis use compared to controls. This suggests a specific psychotomimetic response in FEP patients related to heavy cannabis use. Clinicians should enquire regarding cannabis related PEs and advise that lower levels of cannabis use are associated with less frequent PEs.
The ‘jumping to conclusions’ (JTC) bias is associated with both psychosis and general cognition but their relationship is unclear. In this study, we set out to clarify the relationship between the JTC bias, IQ, psychosis and polygenic liability to schizophrenia and IQ.
A total of 817 first episode psychosis patients and 1294 population-based controls completed assessments of general intelligence (IQ), and JTC, and provided blood or saliva samples from which we extracted DNA and computed polygenic risk scores for IQ and schizophrenia.
The estimated proportion of the total effect of case/control differences on JTC mediated by IQ was 79%. Schizophrenia polygenic risk score was non-significantly associated with a higher number of beads drawn (B = 0.47, 95% CI −0.21 to 1.16, p = 0.17); whereas IQ PRS (B = 0.51, 95% CI 0.25–0.76, p < 0.001) significantly predicted the number of beads drawn, and was thus associated with reduced JTC bias. The JTC was more strongly associated with the higher level of psychotic-like experiences (PLEs) in controls, including after controlling for IQ (B = −1.7, 95% CI −2.8 to −0.5, p = 0.006), but did not relate to delusions in patients.
Our findings suggest that the JTC reasoning bias in psychosis might not be a specific cognitive deficit but rather a manifestation or consequence, of general cognitive impairment. Whereas, in the general population, the JTC bias is related to PLEs, independent of IQ. The work has the potential to inform interventions targeting cognitive biases in early psychosis.
Increasing evidence suggests psychosis may be more meaningfully viewed in dimensional terms rather than as discrete categorical states and that specific symptom clusters may be identified. If so, particular risk factors and premorbid factors may predict these symptom clusters.
(i) To explore, using principal component analysis, whether specific factors for psychotic symptoms can be isolated. (ii) To establish the predictors of the different symptom factors using multiple regression techniques.
One hundred and eighty-nine inpatients with psychotic illness were recruited and information on family history, premorbid factors and current symptoms obtained from them and their mothers.
Seven distinct symptom components were identified. Regression analysis failed to identify any developmental predictors of depression or mania. Delusions/hallucinations were predicted by a family history of schizophrenia and by poor school functioning in spite of normal premorbid IQ (F = 6.5; P < 0.001); negative symptoms by early onset of illness, developmental delay and a family history of psychosis (F = 4.1; P = 0.04). Interestingly disorganisation was predicted by the combination of family history of bipolar disorder and low premorbid IQ (F = 4.9; P = 0.003), and paranoia by obstetric complications (OCs) and poor school functioning (F = 4.2; P = 0.01).
Delusions and hallucinations, negative symptoms and paranoia all appeared to have a developmental origin though they were associated with different childhood problems. On the other hand, neither mania nor depression was associated with childhood dysfunction. Our most striking finding was that disorganisation appeared to arise when a familial predisposition to mania was compounded by low premorbid IQ.
To test the hypothesis that recent onset psychotic patients who use cannabis will have psychotic symptoms that are more severe and more persistent than those who do not use cannabis.
Subjects and methods
We carried out a 4-year follow-up study of a cohort of 119 patients with recent onset of psychosis. The patients were divided into four groups according to duration of cannabis use, taking index admission and follow-up as reference points.
Those subjects who persisted in the use of cannabis had more positive (but not negative) symptoms and a more continuous illness at follow-up.
The main limitations of the study were: the relatively small sample size, and that the excess of male subjects and the presence of cannabis induced psychosis could have a confusing impact on the interpretation of the results.
It is possible that psychotic patients who use cannabis are at a greater risk of a more continuous illness with more positive symptoms than those who do not.
While it is known that patients with schizophrenia recognize facial emotions, specifically negative emotions, less accurately, little is known about how they misattribute these emotions to other emotions and whether such misattribution biases are associated with symptoms, course of the disorder, or certain cognitive functions.
Outpatients with schizophrenia or schizoaffective disorder (n = 73) and healthy controls (n = 30) performed a computerised Facial Emotion Attribution Test and Wisconsin Card Sorting Test (WCST). Patients were also rated on the Positive and Negative Syndrome Scale (PANSS).
Patients were poor at recognizing fearful and angry emotions and attributed fear to angry and angry to neutral expressions. Fear-as-anger misattributions were predicted independently by a longer duration of illness and WCST perseverative errors.
The findings show a bias towards misattributing fearful and angry facial emotions. The propensity for fear-as-anger misattribution biases increases as the length of time that the disorder is experienced increases and a more rigid style of information processing is used. This, at least in part, may be perpetuated by subtle fearfulness expressed by others while interacting with people with schizophrenia.
Daily use of high-potency cannabis has been reported to carry a high risk for developing a psychotic disorder. However, the evidence is mixed on whether any pattern of cannabis use is associated with a particular symptomatology in first-episode psychosis (FEP) patients.
We analysed data from 901 FEP patients and 1235 controls recruited across six countries, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. We used item response modelling to estimate two bifactor models, which included general and specific dimensions of psychotic symptoms in patients and psychotic experiences in controls. The associations between these dimensions and cannabis use were evaluated using linear mixed-effects models analyses.
In patients, there was a linear relationship between the positive symptom dimension and the extent of lifetime exposure to cannabis, with daily users of high-potency cannabis having the highest score (B = 0.35; 95% CI 0.14–0.56). Moreover, negative symptoms were more common among patients who never used cannabis compared with those with any pattern of use (B = −0.22; 95% CI −0.37 to −0.07). In controls, psychotic experiences were associated with current use of cannabis but not with the extent of lifetime use. Neither patients nor controls presented differences in depressive dimension related to cannabis use.
Our findings provide the first large-scale evidence that FEP patients with a history of daily use of high-potency cannabis present with more positive and less negative symptoms, compared with those who never used cannabis or used low-potency types.
Ethnic minority groups in Western countries face an increased risk of psychotic disorders. Causes of this long-standing public health inequality remain poorly understood. We investigated whether social disadvantage, linguistic distance and discrimination contributed to these patterns.
We used case–control data from the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study, carried out in 16 centres in six countries. We recruited 1130 cases and 1497 population-based controls. Our main outcome measure was first-episode ICD-10 psychotic disorder (F20–F33), and exposures were ethnicity (white majority, black, mixed, Asian, North-African, white minority and other), generational status, social disadvantage, linguistic distance and discrimination. Age, sex, paternal age, cannabis use, childhood trauma and parental history of psychosis were included as a priori confounders. Exposures and confounders were added sequentially to multivariable logistic models, following multiple imputation for missing data.
Participants from any ethnic minority background had crude excess odds of psychosis [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.69–2.43], which remained after adjustment for confounders (OR 1.61, 95% CI 1.31–1.98). This was progressively attenuated following further adjustment for social disadvantage (OR 1.52, 95% CI 1.22–1.89) and linguistic distance (OR 1.22, 95% CI 0.95–1.57), a pattern mirrored in several specific ethnic groups. Linguistic distance and social disadvantage had stronger effects for first- and later-generation groups, respectively.
Social disadvantage and linguistic distance, two potential markers of sociocultural exclusion, were associated with increased odds of psychotic disorder, and adjusting for these led to equivocal risk between several ethnic minority groups and the white majority.
Explanations for the successes or failures of militaries in both war and peace have traditionally focused on key factors such as technology, leadership, personnel, training, or a combination of all of these. A more recent addition to the list of possible variables contributing to military effectiveness is the concept of organizational culture – the pattern of shared assumptions that an organization learns as it solves problems, that has worked well enough to be considered valid, and that is therefore taught to new members as the correct way to approach those problems. This chapter combines the organizational culture concepts of Edgar Schein with the nine cultural dimensions of the GLOBE research program. The resulting model provides a useful framework to analyze a military’s organizational culture. Perhaps more importantly, the model also provides prescriptive actions leaders can take to align a military’s organizational culture with its mission and environment.
Culture has enormous influence on military organizations. One can broadly define organizational culture as the assumptions, ideas, norms, and beliefs, expressed or reflected in symbols, rituals, myths, and practices, that shape how an organization functions and adapts to external stimuli and that give meaning to its members. Except in unique circumstances, culture grows slowly, embedding itself so deeply that members often act unconsciously according to its dictates. Because culture lies hidden under more visible organizational doctrine and symbols, one can easily overlook its power. Culture creates organizational identity and establishes expectations of how group members will act. Three important external factors impact military culture: geography, history, and the environment in which navies, armies, and air forces exist. Of all the factors involved in military effectiveness, culture is perhaps the most important. Yet it also remains the most difficult to understand, because it involves so many external factors that distort its formation and continuities, even in different military organizations within the same nation. Organizational culture will shape how military organizations respond to challenges. The hardship is that changing military culture represents an extraordinarily difficult task that may require years, if not decades, to accomplish.
Culture is a key determinant in organizational effectiveness and plays an enormous role in the lives of military organizations. Cultural biases often result in unstated assumptions that have a deep impact on strategy, operational planning, doctrinal creation, and organization and training of armed forces. The impact of culture on military affairs often remains opaque for years, if not decades, after the events it has affected. Leadership is essential to creating and maintaining organizational culture. Leaders who can shape an organization’s culture from its inception have an outsized influence on its future orientation. Leaders, therefore, must be discriminating when establishing the initial culture of an organization, for once embedded, that culture will prove extraordinarily difficult to change. But even superb leaders are limited. Selection of the right subordinate leaders is critical if an organization’s culture is to survive a leadership transition. Some military organizations do change, assisted by cultures that embrace innovation and a reasonable degree of risk-taking. Organizational culture takes on the characteristics of wider societal culture, but when the military becomes a caste apart, the result can be the degradation of its ethical foundations. Military organizations often have subcultures with significant influence on the larger organization. Technology-centric forces must not allow a culture focused on technological excellence to turn into one centered on technological determinism. Professional military education is critical in sustaining organizational culture.
Dissatisfaction with the Royal Navy’s World War I performance led a generation of officers to analyze the fleet’s wartime record. This analysis revealed three problems: over-centralization of authority, a reluctance to fight night actions, and an overly defensive use of destroyers. In an effort to correct these issues, the Royal Navy made changes to its doctrine, training, and professional military education that improved the Navy’s World War II performance, especially in surface warfare. Reforms flowed from a variety of sources, including First Sea Lord Adm. David Beatty, contributors to the Naval Review, and Mediterranean Fleet exercise. The interwar reforms reflected an organizational culture that pursued improvement and learning in response to the perception that in World War I, the Navy failed to live up to historical standards of success.
This chapter describes how the world’s first independent air force, led by Air Chief Marshal Sir Hugh Trenchard, reacted to the threats to its existence by maximizing the Royal Air Force’s (RAF) operational utility and financial efficiency, while simultaneously contriving a credible narrative about its future strategic potential. In pursuing these twin narratives, the RAF developed a unique culture of beliefs and taken-for-granted attitudes that thrived because of the conceptually incurious nature of the men it selected to become officers. Few of these technically able "practical men" were willing to challenge their superiors’ intuitive and speculative belief that the morale of civilian populations was especially vulnerable to bombing. Instead, like their leaders, they became consciously complicit in acceding to the societal prophecies, articulated in books, films, and newspapers, that bombing would have apocalyptic effects, and that civil societies subjected to its effects would wish to sue for peace. The chapter concludes by analyzing how this culture impeded the realization that the anticipated outcomes were not being achieved and explains how this stymied options to pursue alternative strategies.
The American Civil War presented an exceptional state of affairs in modern warfare, because strong personalities could embed their own command philosophies into field armies, due to the miniscule size of the prior US military establishment. The effectiveness of the Union Army of the Tennessee stemmed in large part from the strong influence of Ulysses S. Grant, who as early as the fall of 1861 imbued in the organization an aggressive mind-set. However, Grant’s command culture went beyond simple aggressiveness – it included an emphasis on suppressing internal rivalries among sometimes prideful officers for the sake of winning victories. In the winter of 1861 and the spring of 1862, the Army of the Tennessee was organized and consolidated into a single force, and, despite deficits in trained personnel as compared to other Union field armies, Grant established important precedents for both his soldiers and officers that would resonate even after his departure to the east. The capture of Vicksburg the following summer represented the culminating triumph of that army, cementing the self-confident force that would later capture Atlanta and win the war in the western theater.
Culture has an enormous influence on military organizations and their success or failure in war. Cultural biases often result in unstated assumptions that have a deep impact on the making of strategy, operational planning, doctrinal creation, and the organization and training of armed forces. Except in unique circumstances culture grows slowly, embedding so deeply that members often act unconsciously according to its dictates. Of all the factors that are involved in military effectiveness, culture is perhaps the most important. Yet, it also remains the most difficult to describe and understand, because it entails so many external factors that impinge, warp, and distort its formation and continuities. The sixteen case studies in this volume examine the culture of armies, navies, and air forces from the Civil War to the Iraq War and how and why culture affected their performance in the ultimate arbitration of war.
Clay minerals from the Indus Canyon and eastern clinoform since ~12 ka are uniformly rich in smectite and illite, similar to those from the Holocene Indus flood plains. A systematic enrichment of smectite in the proximal delta compared to the canyon and eastern clinoform argues for preferential capture of smectite close to the river mouth since ~12 ka. There is a rapid shift to a more smectite-rich assemblage in the canyon and eastern clinoform after ~5 ka. This change is probably caused by a change in sediment source, with less direct flux from the Himalaya and more erosion of older, weathered, smectite-rich sediment from the Indus River flood plains, driven by incision of the Indus and its tributaries into the floodplain as summer monsoon rains weakened. This influx of smectite is consistent with lower kaolinite/smectite values since ~5 ka. The onset of large-scale agricultural activities since ~5 ka, especially starting with the Harappan Civilization, may also have enhanced incision and erosion of floodplain sediments over the same time period. This study reports for the first time how monsoon strength variations since ~12 ka affected the clay mineral assemblages and sediment provenance in a major submarine canyon.