F141. DUTY TO WARN FOR POTENTIAL RISK OF PSYCHOLOGICAL HARM: A CASE REPORT

Abstract Background Under the current ethical and legal standards physicians are expected to breach confidentiality when a third party is at risk. However, the law has mainly focused on risk of bodily harm and there is no legal guidance on physicians’ responsibilty when it comes to risk of psychological harm to a potential targeted victim Methods This case report illustrates a clinical dilemma on duty to warn for mental health professionals. Results N/A Discussion This case report illustrates an unconventional perspective on a psychiatrist’s duty to warn: consideration of risk of psychological harm to the potential target of their patient. Psychological trauma can have a potential negative impact on victims, affecting their mental health and well being as well as their physical health. The ethicolegal dilemma discussed in this case has implications for policies related to the care of psychiatric patients.


F139. INCLINATION OF STIGMA TOWARD SCHIZOPHRENIA, ATTENUATED PSYCHOSIS, PSYCHOTIC-LIKE EXPERIENCES AND DEPRESSION AMONG DIFFERENT SUBPOPULATIONS IN TAIWAN
Chen-Chung Liu* ,1 , Yen-Chin Wang 2 1 National Taiwan University Hospital and College of Medicine, National Taiwan University; 2 National Taiwan University Hospital Background: Stigma toward mental illness may lead to delayed detection, impaired treatment adherence, and poorer recovery. The fear of being labeled as at risk of psychosis can be barriers to early identification of putative prodromal subjects. Compounded by an intriguing feature, psychotic-like experience with no apparent impact on functioning, we wonder if people will generalize their prejudice and discrimination towards schizophrenia to subjects with subthreshold psychotic symptoms. Methods: A cross-sectional survey using a structuralized questionnaire modified from a previous study conducted by the Hong Kong University Early Psychosis research team was employed. Participants were recruited from various channels; including laypersons in general population invited after their attending talks about mental health topics, patients with mental illness and their key caregivers of 2 hospitals, and mental health professionals. The key component of this questionnaire is comprised by 4 case vignettes describing the symptoms and disabilities of patients with attenuated psychosis syndrome (APS), schizophrenia, depression, and psychoticlike experiences (PLE), respectively; followed by 2 sets of questions using 4-point Likert scale with 19 and 21 items for each set to measure social distance as a proxy for discrimination and prejudices. Basic demographic information, including age, gender, education level, current occupation, and previous contact with persons with mental illness were also collected. Results: A total of 354 subjects completed this survey, including 239 lay publics, 32 psychiatric patients, 29 patient's main caregivers, and 54 mental health professionals. Stigmas, especially prejudice, toward PLE are significantly higher in the patient group compared to the other 3 groups. Prejudice, but not discrimination, toward depression is significantly lower in professionals group. Stigmas toward schizophrenia and APS are in general not significantly different among groups, although the general public showed marginally higher scores in discrimination compared to the patient group. In each individual group, the patterns of attitude reflecting discrimination and prejudice are almost identical; that is, highest toward schizophrenia, followed by APS and depression (almost equivalent to each other), and lowest toward PLE, except the patient group which failed to reveal significant differences in ratings of 4 clinical case vignettes.
Discussion: APS seems to be a clinical entity too new to be judged. The majority of participants, except the patient group, reported a similar gradient of stigma toward different clinical severities. Such a result is consistent with previous studies that APS shared similar level of stigma with depression, not as high stigma as towards schizophrenia, but higher than PLE. Interestingly, patients with psychosis might have assimilated PLE to symptoms of schizophrenia based on their personal experiences, so they might have overrated the severity of subjects with PLE.

. Herman Foundation
Background: Violence towards mental health care workers, and towards physicians in general, is a common occupational hazard. The goal of this work was to determine to what extent violence escalates to actual homicides, both for mental health workers and for physicians in general. Characteristics of the victims, the perpetrators and of the methods of homicide were examined in order to formulate recommendations for violence assessment and safety measures in healthcare settings. Methods: A systematic search for accounts describing homicides of mental health workers between 1981 and 2014, and for physicians between 1981 and 2017 was conducted. Cases of homicides committed by patients, family members of patients, and co-workers of the victims were included. Cases of homicide that occurred in correctional setting, or in agencies not focused on health care (such as child protective services) were excluded. News outlet accounts, internet sources, and the medical literature was searched for details of these cases. Data that were extracted included demographic details on victims and perpetrators, scene and method of homicide, presence of psychiatric diagnoses and prior treatment, and disposition of the perpetrators. Results: Results obtained for mental health workers has been published pre-viously1. Thirty-three homicides of mental health workers were found and examined. Young women caseworkers who were unaccompanied during visits to residential treatment facilities were the most common victims. Men with a diagnosis of schizophrenia were the most common perpetrators. The most likely method of homicide was gunshot. Perpetrators often had a prior history of violence, criminal charges, involuntary hospitalization and nonadherence to medications. Thirty cases of homicides of physicians were found and examined. Psychiatry was the single most likely specialty of the victims (37%). Most homicides occurred in physician offices (33%). The most common psychiatric diagnosis of the perpetrators was schizophrenia (17%), but many other diagnoses were identified, and 33% of perpetrators could not be assigned a diagnosis. The most common method of homicide was again by gunshot. Discussion: Homicides of mental health workers, and of physicians generally, are rare events that emerge from a background of common aggression and violence in healthcare settings. Many of these homicides may have been preventable. Strategies to identify violence risk and to train acute care staff in possible prevention measures, as well as some policy and training measures will be discussed.

University of Ottawa Faculty of Medicine
Background: Under the current ethical and legal standards physicians are expected to breach confidentiality when a third party is at risk. However, the law has mainly focused on risk of bodily harm and there is no legal guidance on physicians' responsibilty when it comes to risk of psychological harm to a potential targeted victim Methods: This case report illustrates a clinical dilemma on duty to warn for mental health professionals. Results: N/A Discussion: This case report illustrates an unconventional perspective on a psychiatrist's duty to warn: consideration of risk of psychological harm to the potential target of their patient. Psychological trauma can have a potential negative impact on victims, affecting their mental health and well being as well as their physical health. The ethicolegal dilemma discussed in this case has implications for policies related to the care of psychiatric patients.

F142. THE USE OF NEUROIMAGING MARKERS IN STRATIFIED DIAGNOSIS AND THERAPY OF SCHIZOPHRENIC AND AFFECTIVE DISORDERS
Oliver Gruber* ,1 1 University Clinic Heidelberg Background: Neuroimaging techniques have been developed as important tools to investigate brain dysfunctions that underlie mental disorders. In particular, modern functional magnetic resonance imaging (fMRI) holds the promise to provide neurofunctional biomarkers for improved diagnosis, prognosis, and optimized treatment of schizophrenic and affective disorders. Methods: Neurofunctional connectivity MRI using advanced experimental paradigms permits targeted investigation of the functional integrity of brain systems involved in the pathomechanisms of schizophrenic and affective disorders. From these investigations, pathophysiologically relevant neuroimaging biomarkers can be derived for differential diagnosis and tailored treatment selection. Results: Possible neuroimaging biomarkers will be presented for the prediction of development and clinical course of schizophrenic and affective disorders as well as for the prediction of individual treatment responses. Further, recent neuroimaging findings on possible pathophysiological subtypes of schizophrenic and affective disorders will be discussed.

. Kline Institute for Psychiatric Research; 2 New York University; 3 Teachers College Columbia University
Background: Schizophrenia is a severe and chronic mental illness characterized by continual relapses that may require hospitalization, changes in medications, arrests, emergency room hospitalizations, self-harm or suicidal behavior. Research has shown that costs associated with treatment received following relapse may constitute the largest share of treatment costs psychiatric illnesses. Although, demographic and clinical characteristics associated with relapse have been examined in previous research, information about potential predictors of relapse are limited. The aim of this study was to evaluate the effect of patient and disease characteristics, cognitive, functioning, and COMT gene polymorphism (rs4680) on relapse during 2-year following completion of an inpatient rehabilitation and cognitive treatment.
Methods: Data were taken from a COMT genotype and response to cognitive remediation study of schizophrenia in the United States conducted between 07/2005 and 10/2015 for inpatients with schizophrenia who were also participating in psychiatric rehabilitation. Patients with and without relapse 2 years following completion of the study were compared on clinical, demographic, cognitive, functional and COMT genotype characteristics. The COMT gene rs4680 polymorphism was genotyped using a DNA sequence detection system. Relapse or events identified as treatment failures include: arrest, psychiatric re-hospitalization, suicide, discontinuation of antipsychotic treatment due to inadequate efficacy, treatment supplementation with another antipsychotic due to inadequate efficacy, discontinuation of antipsychotic treatment due to safety or tolerability, or increase in the level of psychiatric services. Baseline (end of study, start of 2-year follow-up) predictors of subsequent relapse were also assessed. Univariate Analsyis and Cox's regression was used to examine the effect of potential predictors on outcome. Results: Of 140 subjects with eligible data, 91 (65.00%) relapsed during the 2-year follow-up period. Patients who relapsed were younger (< 45 years), higher number of previous hospitalizations, shorter chronicity of illness (< 10 years), PANSS baseline score of >4 on the core PANSS items (conceptual disorganization, hallucinatory behavior, suspiciousness, unusual thought content), higher negative symptom factor, substance use, PSP score of < 60 and lower MCCB composite T score (> 2 SD below the mean). Univariate analysis shows that COMT rs4680 gene variants were different between relapse and stable groups. The COMT rs4680 gene had an interaction with PANSS baseline core item scores and MCCB composite score. Number of previous antipsychotic trials did not predict relapse. Discussion: There is a high relapse rate within 2 years in chronic schizophrenia. Behavioral symptoms, aided by genetic and environmental factors common to this population (homelessness, unemployment, and social isolation) frequently lead to treatment failure. Knowing potential triggers of relapse can help in developing resources for this population to reduce treatment failures and associated costs.

F144. MUSCARINIC M1 RECEPTOR SIGNALLING UNDERLYING COGNITION IN PSYCHOTIC DISORDERS
Therese van Amelsvoort* ,1 , Geor Bakker 1 , Claudia Vingerhoets 1 , Barbara J. Sahakian 2 , Oswald Bloemen 3 , Matthan Caan 4 , Jan Booij 4 1 Maastricht University; 2 University of Cambridge; 3 GGz Centraal, Maastricht University; 4 Academic Medical Centre Background: Antipsychotic treatment has failed to improve cognitive deficits associated with psychotic disorders. This has led to an increased interest to revisit earlier implications from post-mortem studies that lowered muscarinic M1 receptor signaling may underlie these symptoms. This receptor is highly expressed in important regions for cognition such as the dorsolateral prefrontal cortex (DLPFC) and hippocampus, and administration of anti-muscarinic agents gives induce cognitive deficits in healthy volunteers. Administration of xanomeline, a M1/4 agonist in patients with schizophrenia resulted in improved learning and memory scores and decreased psychotic symptom severity. Therefore, the current study sought to examine alterations in muscarinic M1 receptor signaling in relation to cognitive functioning in medication free subjects with psychotic disorders and matched controls. Methods: Muscarinic M1 binding potential (BPND) was measured using single photon emission computed tomography (SPECT) with the M1 selective radiopharmaceutical 123I-iododexetimide in the DLPFC and hippocampus in the psychotic group. Pharmacological functional magnetic resonance imaging (phMRI) with the M1 antagonist biperiden was used to assess differences in functional response on