Effect of social class at birth on risk and presentation of schizophrenia: case-control study

OBJECTIVES

To examine if low parental social class increases children's risk of subsequently developing schizophrenia or modifies the presentation.

DESIGN

Case-control study with historical controls.

SETTING

Geographically defined region in south Dublin.

PARTICIPANTS

352 patients with first presentation of schizophrenia matched with the next registered same sex birth from the same birth registration district.

MAIN OUTCOME MEASURES

Social class at birth. Age at presentation to psychiatric services, admission to hospital, and diagnosis of schizophrenia.

RESULTS

Risk of schizophrenia was not increased in people from lower social classes. There was a slight excess risk among people in highest social classes (odds ratio 0.59, 95% confidence interval 0.40 to 0.85). However, the mean age at presentation was 24.8 years for patients whose parents were in the highest social class compared with 33.1 years for those in the lowest social class at birth.

CONCLUSIONS

Although social class of origin does not seem to be an important risk factor for schizophrenia, it partially determines the age at which patients receive treatment. The relation between low social class at birth and poor outcome may be at least partially mediated through treatment delay.

Is reduced dermatoglyphic a-b ridge count a reliable marker of developmental impairment in schizophrenia?

BACKGROUND

Finger and hand prints are formed during the late first and second trimester of foetal development, after which they remain unchanged. Their expression may be influenced by both genetic and environmental factors. Some studies have suggested that a reduced total finger ridge count (TFRC) and, in particular, a reduce total a-b ridge count (TABRC), may be associated with schizophrenia.

AIM

To study these two variables in a large, ethnically homogenous sample and to compare our findings with those of other recent studies.

METHOD

Finger and hand prints of 150 people with DSM-III-R schizophrenia were compared with those of 92 healthy controls.

RESULTS

Patients had a reduced mean TABRC (P = 0.03) compared with controls. There was a significant (P=0.02) linear trend for lower TABRC and increasing incidence of schizophrenia (ORlineartrend = 1.3; 95%CI1.1-1.7), implying a continuous increase in the risk for schizophrenia with reduction in TABRC. No significant difference between groups was observed for TFRC.

CONCLUSION

These results provide further evidence that dermatoglyphic abnormalities exist in at least some patients with schizophrenia and that the a-b ridge count may be a marker of disruption, probably environmental, that occurs when the developing brain may also be particularly vulnerable to such insult. These findings support the concept that some cases of schizophrenia may be due to adverse intrauterine events.

Dermatoglyphic fluctuating asymmetry and atypical handedness in schizophrenia

Atypical handedness and dermatoglyphic abnormalities are hypothesized to reflect a neurodevelopmental disturbance in schizophrenia. Developmental instability, indexed by dermatoglyphic fluctuating asymmetry (FA), reflects the degree to which an individual's ontogenetic program is maintained and provides a useful framework in which to consider atypical handedness in schizophrenia. Thirty patients diagnosed with schizophrenia were compared with 37 matched healthy controls on levels of dermatoglyphic FA, a demonstration task determining hand preference and a test of relative hand skill. Multivariate analyses established that patients demonstrated greater FA and more atypical hand skill compared with controls. In patients, but not in controls, there was a strong positive association between a measure of FA and a measure of atypical hand skill, suggesting that these markers of neurodevelopmental disturbance are related in schizophrenia. On a measure of hand preference, patients were more likely than controls to be classified as mixed handed than either right or left handed. Results from the present study support the conjecture of greater developmental instability in schizophrenia affecting neurodevelopmental processes, including those conferring manual dominance.

Determinants of neurological dysfunction in first episode schizophrenia

BACKGROUND

Although it is well recognized that individuals with schizophrenia display evidence of subtle neurological impairment, its aetiopathological and clinical significance continues to be unclear.

METHODS

Patients presenting with a first episode of schizophrenia or schizophreniform psychosis (DSM-IV criteria) were examined using two previously validated neurological examinations. The majority (N = 35) were examined prior to their 'first ever' dose of neuroleptic while the remaining patients (N = 21) had been medicated for less than one month. The manner in which neurological functioning is influenced by symptomatology and handedness was ascertained.

RESULTS

The majority of patients who were examined neuroleptic-naive displayed evidence of neurodysfunction. A combination of relative hand preference and symptomatology explained a significant proportion of the variance in neurological functioning. Mixed handedness among adults at the time of first presentation with schizophrenia was associated with more severe neurological impairment and a history of poorer scholastic attainment and pre-morbid social adjustment.

CONCLUSIONS

Neurological soft signs are an intrinsic part of schizophrenia rather than a direct consequence of treatment. Early developmental processes are associated with the level of subsequent neurological impairment in first episode schizophrenia. However, symptomatology appears to have an influence on the apparent severity of neurological impairment.

The prevalence of comorbid substance misuse and its influence on suicidal ideation among in-patients with schizophrenia

OBJECTIVE

To estimate the prevalence, and identify the clinical correlates of comorbid substance misuse (abuse or dependence) among readmissions with schizophrenia, particularly to establish whether comorbid substance misuse is associated with higher rates of depressive symptoms and suicidal ideation.

METHOD

Over 12 months, consecutive readmissions from a catchment area psychiatric service with DSM-IV schizophrenia/schizoaffective disorder were assessed using clinical assessments of symptomatology including depression, insight and compliance. Comorbid substance misuse was diagnosed using DSM-IV criteria.

RESULTS

Of 102 readmissions 40% had lifetime, while 20% had current comorbid substance misuse and were predominately young males. Comorbid substance misuse had no statistically significant impact on positive, negative or depressive symptomatology. However, those currently misusing substances reported more suicidal ideation compared with past or non-substance misusers.

CONCLUSION

Readmissions with comorbid substance misuse were more likely to report suicidal ideation, and may represent a group of individuals who are at higher risk of suicide.

Determinants of quality of life at first presentation with schizophrenia

BACKGROUND

Quality of life (QOL) has gained importance as a global measure of social and clinical outcome in schizophrenia.

AIMS

To identify the clinical correlates of QOL at the time of first presentation with schizophrenia.

METHOD

Over two years, consecutive first-episode psychosis patients presenting to a catchment area psychiatric service underwent validated clinical assessments of premorbid adjustment, illness duration, symptoms and QOL.

RESULTS

At presentation, subjects already had a diminished QOL. Although independent of gender and age at onset of psychosis, QOL was influenced by premorbid adjustment, duration of untreated psychosis and symptoms.

CONCLUSIONS

Reducing the duration of untreated psychosis may have a beneficial effect on the subsequent QOL of patients presenting with schizophrenia. First-episode patients with a protracted duration of untreated psychosis or impaired premorbid adjustment may warrant specific treatment interventions to prevent the development of secondary handicaps.

Early cerebro-craniofacial dysmorphogenesis in schizophrenia: a lifetime trajectory model from neurodevelopmental basis to 'neuroprogressive' process

Understanding the temporal origin(s) of schizophrenia, through specifying the earliest identifiable pathology, might indicate when to look for etiological factor(s), what their nature might be, and how course of illness might evolve from these origins. From this premise, earlier formulations are elaborated to offer a rigorously data-driven model that roots schizophrenia in cerebro-craniofacial dysmorphogenesis, particularly along the mid-line but involving other structures, over weeks 9/10 through 14/15 of gestation. However, a brain that has been compromised very early in fetal life is still subject to the normal endogenous programme of developmental, maturational and involutional processes on which a variety of exogenous biological insults and psychosocial stressors can impact adversely over later pregnancy, through infancy and childhood, to maturation and into old age, to sculpt brain structure and function; it should be emphasised that the effects of such endogenous programmes and exogenous insults on such an already developmentally-compromised brain may be different from their effects on a brain whose early fetal origins were unremarkable. From these early origins, a lifetime trajectory model for schizophrenia from developmental basis to 'neuroprogressive' process is constructed. Thereafter, consideration is given to what the model can explain, including cerebral asymmetry and homogeneity, what it cannot explain, what empirical findings would challenge or disprove the model, what cellular and molecular mechanisms might underpin the model, and what are its implications.

Dysphoric subjective response to neuroleptics in schizophrenia: relationship to extrapyramidal side effects and symptomatology

OBJECTIVE

Subjective reports of dysphoric responses to neuroleptic medication are common in clinical practice. However, cognitive and affective side effects of neuroleptic medications are difficult to differentiate from the symptoms of schizophrenia. We sought to elucidate the relative contribution of extrapyramidal side effects and symptomatology to dysphoric response.

METHOD

Fifty clinically stable outpatients with schizophrenia attending a rehabilitation centre were assessed for extrapyramidal side effects and symptomatology before completing the drug attitude inventory (DAI).

RESULTS

Presence of extrapyramidal side effects, found in 28 patients (Z = -1.99, p = 0.05), and severity of negative symptoms (r = -0.47, p = 0.001) were independently associated with dysphoric response, explaining a significant proportion of the variance (R = 0. 53, R(2) = 25.2%, F = 9.27, df = 2, p = 0.0004).

CONCLUSIONS

Patients who report a dysphoric response which they associate with neuroleptic medications have more extrapyramidal side effects and more severe negative symptoms. While these responses may be part of the negative symptoms of the illness or due to other factors such as depression, we raise the possibility that they may be clinically indistinguishable from, and be a subjective measure of, the so-called 'neuroleptic-induced deficit syndrome'.

Seasonal influences on admissions for affective disorder and schizophrenia in Ireland: a comparison of first and readmissions

Although genetic and environmental factors operating before or around the time of birth have been demonstrated to be relevant to the aetiology of the major psychoses, a seasonal variation in the rates of admission of such patients has long been recognised. Few studies have compared first and readmissions. This study examined for seasonal variation of admission in the major psychoses, and compared diagnostic categories by admission status. Patients admitted to Irish psychiatric inpatient facilities between 1989 and 1994 with an ICD-9/10 diagnosis of schizophrenia or affective disorder were identified from the National Psychiatric Inpatient Reporting System (NPIRS). The data were analysed using a hierarchical log linear model, the chi-square test, a Kolmogorov-Smirnov (KS) type statistic, and the method of Walter and Elwood. The hierarchical log linear model demonstrated significant interactions between the month of admission and admission order (change in scaled deviance 28.77, df = 11, P < 0.003). Both first admissions with mania, and readmissions with bipolar affective disorder exhibited significant seasonality. In contrast, only first admissions with schizophrenia showed significant seasonal effects. Although first admissions with mania and readmissions with bipolar disorder both show seasonality, seasonal influences appear to be more relevant to onset of schizophrenia than subsequent relapse.

The neurodevelopmental basis of schizophrenia: clinical clues from cerebro-craniofacial dysmorphogenesis, and the roots of a lifetime trajectory of disease

A "read-back" analysis of schizophrenia, from chronic illness, through the first psychotic episode, to psychosocial and neurointegrative abnormalities of childhood and infancy, leads to the intrauterine period as a primary focus for etiological events. Evidence for a characteristic topography of cerebro-craniofacial dysmorphology in schizophrenia is reviewed, and interpreted to estimate: (i) the timing of dysmorphic event(s); (ii) the nature of early cellular and molecular mechanisms which might determine that topography of dysmorphogenesis; and (iii) the population homogeneity of these processes. It is argued that early cerebro-craniofacial dysmorphogenesis in schizophrenia should be conceptualized as a first stage not in a static but rather in a dynamic, lifetime trajectory of disease.

Subjective and external assessments of quality of life in schizophrenia: relationship to insight

OBJECTIVE

This study assessed the manner in which insight influenced schizophrenic patients' evaluation of their objective life conditions and the concurrent validity between patients' and clinicians' assessments of patients' global quality of life.

METHOD

Forty out-patients who fulfilled DSM-III-R criteria for schizophrenia were independently interviewed using the Lancashire Quality of Life Profile and the Standard of Living Interview. Insight was assessed using a self-report questionnaire, the Insight Scale.

RESULTS

For insightful patients there was a significant but modest correlation between objective and subjective indicators of quality of life. Likewise, a significant correlation between subjective and external evaluations of global quality of life was limited to those individuals who had good insight.

CONCLUSION

Diminished insight may limit the usefulness of the self-report methodology for assessing quality of life for some individuals with schizophrenia.

Evaluation of accuracy and repeatability of identification of food-borne pathogens by automated bacterial identification systems

The performances of five automated microbial identification systems, relative to that of a reference identification system, for their ability to accurately and repeatedly identify six common food-borne pathogens were assessed. The systems assessed were the MicroLog system (Biolog Inc., Hayward, Calif.), the Microbial Identification System (MIS; MIDI Inc., Newark, Del.), the VITEK system (bioMérieux Vitek, Hazelwood, Mo.), the MicroScan WalkAway 40 system (Dade-MicroScan International, West Sacramento, Calif.), and the Replianalyzer system (Oxoid Inc., Nepean, Ontario, Canada). The sensitivities and specificities of these systems for the identification of food-borne isolates of Bacillus cereus, Campylobacter jejuni, Listeria monocytogenes, Staphylococcus aureus, Salmonella spp., and verotoxigenic Escherichia coli were determined with 40 reference positive isolates and 40 reference negative isolates for each pathogen. The sensitivities of these systems for the identification of these pathogens ranged from 42.5 to 100%, and the specificities of these systems for the identification of these pathogens ranged from 32.5 to 100%. Some of the systems had difficulty correctly identifying the reference isolates when the results were compared to those from the reference identification tests. The sensitivity of MIS for the identification of S. aureus, B. cereus, E. coli, and C. jejuni, for example, ranged from 47.5 to 72. 5%. The sensitivity of the Microlog system for the identification of E. coli was 72.5%, and the sensitivity of the VITEK system for the identification of B. cereus was 42.5%. The specificities of four of the five systems for the identification of all of the species tested with the available databases were greater than or equal to 97.5%; the exception was MIS for the identification of C. jejuni, which displayed a specificity of 32.5% when it was tested with reference negative isolates including Campylobacter coli and other Campylobacter species. All systems had >80% sensitivities for the identification of Salmonella species and Listeria species at the genus level. The repeatability of these systems for the identification of test isolates ranged from 30 to 100%. Not all systems included all six pathogens in their databases; thus, some species could not be tested with all systems. The choice of automated microbial identification system for the identification of a food-borne pathogen would depend on the availability of identification libraries within the systems and the performance of the systems for the identification of the pathogen.

Seasonal influences on admissions in schizophrenia and affective disorder in Ireland

Although the seasonal patterns of admissions of affective disorder have been extensively studied, less attention has been given to the seasonal admission patterns of schizophrenia. The traditional method of aggregating the data over a study period, rather than analysing by year of admission may obscure potentially relevant fluctuations in the seasonal pattern. We examined the year-to-year variation in the admission patterns of schizophrenia and affective disorder in Ireland. Using the National Psychiatric Inpatient Reporting System (NPIRS), individuals admitted with an ICD-9/10 diagnosis of a first episode of schizophrenia or affective disorder during the 6-year period 1989-1994 were identified. Seasonal variations in their admission patterns were examined statistically and graphically. There was a significant seasonal variation in the monthly admission patterns of both schizophrenia and affective disorder. This pattern was more marked for individuals with affective disorder. However, the seasonal pattern was not constant from year to year, particularly for schizophrenia.

Evaluation of universal preenrichment broth for the recovery of foodborne pathogens from milk and cheese

The use of universal preenrichment broth for the recovery of verotoxigenic Escherichia coli, Salmonella spp., and Listeria monocytogenes from milk and cheese was examined. Universal preenrichment broth supported the growth of low inoculum levels (10 cfu/ml) of these organisms in pure cultures and in mixed cultures containing higher levels of other pathogens or bacterial flora from raw milk. This medium also supported the recovery and growth of heat-injured Salmonella spp., L. monocytogenes, and verotoxigenic E. coli at inoculum levels of 10(2) cfu/ml to yield cell levels of 10(8) cfu/ml in pure cultures and at least 10(5) cfu/ml in the presence of high levels of known competitive pathogens or microflora of cheese samples after 24 h of incubation. Universal preenrichment broth performed better than Listeria enrichment broth in supporting the recovery and growth of heat-injured L. monocytogenes and equally as well as buffered peptone water or trypticase soy broth in supporting the growth of uninjured L. monocytogenes, Salmonella spp., and verotoxigenic E. coli. Coenrichment of these pathogens in universal preenrichment broth reduced the quantity of milk or cheese samples that were required for analysis and also reduced the cost and labor involved in preparing and processing separate preenrichment media.

Spontaneous abnormal involuntary movements in first-episode schizophrenia and schizophreniform disorder: baseline rate in a group of patients from an Irish catchment area

OBJECTIVE

This study investigated the rate of spontaneous abnormal involuntary movements in a group of patients presenting with a first episode of schizophrenia or schizophreniform psychosis.

METHOD

Seventy-nine patients with a first episode of schizophrenia or schizophreniform psychosis who presented to a catchment area psychiatric service over a 3-year period, and who were neuroleptic-naive or had been medicated for less than 1 month, were examined for the presence of involuntary movements with use of the Abnormal Involuntary Movement Scale.

RESULTS

Six patients (7.6%) had spontaneous dyskinesia as defined by the criteria of Schooler and Kane, and nine other patients had mild orofacial involuntary movements. The patients with spontaneous dyskinesia had completed significantly fewer years of education than the patients without dyskinesia. Spontaneous involuntary movements were unrelated to age at presentation for treatment.

CONCLUSIONS

Spontaneous abnormal involuntary movements were evident among a proportion of patients with first-episode schizophrenia or schizophreniform psychosis at baseline presentation and were associated with reduced educational attainment. This finding supports previous suggestions that abnormal involuntary movements in schizophrenia may be related to the pathophysiology of the illness and therefore cannot be attributed entirely to the adverse effects of neuroleptic medication.

Compliance with neuroleptic medication in outpatients with schizophrenia; relationship to subjective response to neuroleptics; attitudes to medication and insight

The relationship between compliance, subjective response to neuroleptics, attitudes to medication, and insight was assessed in a selected group of individuals with schizophrenia who were attending a catchment area outpatient psychiatric service. Regular compliers with medication reported a significantly better subjective response to neuroleptics and were more frequently prescribed depot medication compared with individuals who were irregularly compliant. There was no difference between regular and irregular compliers in terms of attitudes to medication or level of insight. There was a significant correlation between the measures of insight obtained using a self-report questionnaire (the Insight Scale [IS]) and a semistructured interview (the Scale for Assessment of Insight [SAI]).

Course of psychopathology, cognition and neurobiological abnormality in schizophrenia: developmental origins and amelioration by antipsychotics?

It is argued that schizophrenia has origins in events occurring during the first or early second trimester that are reflected in minor physical anomalies and which may at least in part predispose to later obstetric complications. This neurodevelopmental basis underlies certain neuromotor and psychosocial abnormalities of infancy and childhood, which are the early manifestations of what will be reconceptualised later as negative symptoms and (particularly frontal) cognitive dysfunction, but gives rise to positive symptoms only on the maturation of other systems necessary for their expression. This later emergence of psychosis may reflect an active morbid process that is associated with increased accrual of negative symptoms and of general (but not frontal) cognitive impairment that may be ameliorated by effective antipsychotic treatment. The psychological or biological basis of this heuristic process is poorly understood. Contemporary re-appraisal of any impact of antipsychotics on the long-term course of schizophrenia must take into account what is known of the origins of the disease process with which such drugs might interact. Much recent work continues to indicate that very early events, during the embryonic/fetal period, are important in, if not fundamental to, the genesis of schizophrenia; i.e. that there is a neurodevelopmental basis to the disorder. The present article seeks to establish a time-line relating early intrauterine adversity and dysmorphogenesis, through the onset of psychosis, to the chronic phase of the illness over adulthood; from this time-line, a schema is elaborated for a beneficial impact of antipsychotics on the course of psychopathology, cognition and, less clearly, neurobiological abnormality.

Neurodevelopmental and neuroprogressive processes in schizophrenia. Antithetical or complementary, over a lifetime trajectory of disease?

The neurodevelopmental model of schizophrenia maintains ascendancy among current etiopathologic perspectives on schizophrenia. However, inconsistencies across studies and the absence thus far of pathognomic brain changes suggest the need for complex conceptualization of neurodevelopmental arrest, including some reconciliation with the competing neurodegenerative model of schizophrenia. This article critically reviews the preponderance of evidence for each model and provides an account of how these may interact or synergize to produce the characteristic clinical expression of schizophrenia.

The octreotide suppression test and [111In-DTPA-D-Phe1]-octreotide scintigraphy in neuroendocrine tumours correlate with responsiveness to somatostatin analogue treatment

OBJECTIVE

The somatostatin analogue octreotide (Sandostatin, Novartis, Basie) significantly improves the syndromes suffered by most patients with neuroendocrine tumours (NETs). The use of [111In-DTPA-D-Phe1]-octreotide scintigraphy ([111In]-pentetreotide) to predict the response to octreotide treatment has been described. Short-term hormone inhibition by a single injection of octreotide has also been reported. This study aimed to compare the effects of the suppression test with the response to long-term somatostatin analogue treatment, and to seek a correlation between the short-term suppression test, [11In]-pentetreotide observations and long-term somatostatin analogue treatment.

DESIGN AND MEASUREMENTS

Short octreotide suppression test and octreotide scintigraphy. Blood samples were collected before (0900, 0930 h), at (1000 h), and after (1030, 1100, 1200, 1300 h) the injection of 50 micrograms octreotide subcutaneously. Plasma hormones relevant to the syndrome were analysed by radioimmunoassay. The short suppression effects, the [111In]-pentetreotide observations and the response to long-term treatment with somatostatin analogue were evaluated and compared.

PATIENTS

Twenty-six patients with metastatic NETs were evaluated, including 14 carcinoid tumours, 10 pancreatic endocrine tumours and 2 medullary carcinomas of thyroid (MCTs). Twelve patients had received octreotide treatment before the study, another 4 patients were treated subsequently with somatostatin analogue.

RESULTS

During the short suppression test, hormones relevant to the syndromes were suppressed in 24 patients (those with carcinoids and pancreatic endocrine tumours). There was no suppression in the 2 patients with MCT. [111In]-pentetreotide observations closely correlated with the short suppression response to octreotide. Fourteen patients were treated with somatostatin analogue, and responded clinically; they had a positive short inhibition test and positive tumour uptake. Two patients with MCT did not respond to the treatment and had a negative suppression test and a negative [111In]-pentetreotide.

CONCLUSION

Our results suggest that a consistent relationship exists between the short suppression test and the response to somatostatin analogue treatment in the majority of the patients with neuroendocrine tumours. The octreotide suppression test and octreotide scintigraphy together will be helpful in selecting appropriate patients for clinical treatment with somatostatin analogues.

Quality of life in schizophrenia: insight and subjective response to neuroleptics

The relationship between quality of life, insight, and subjective response to neuroleptics was assessed in a selected group of clinically stable outpatients with schizophrenia. A significant portion of the variance in these individuals' quality of life was explained by a combination of protracted illness duration and the presence of a dysphoric response to neuroleptics. However, there was no significant relationship between quality of life and the level of insight these individuals had into the nature of their illness. The development of treatment strategies to alleviate neuroleptic-induced dysphoria may enable outpatients with schizophrenia to benefit from rehabilitation programs devised to improve quality of life.

The Unlinked Anonymous HIV Prevalence Monitoring Programme in N. Ireland 1992-1995

Previous evidence has suggested that Northern Ireland is a low seroprevalence area for HIV infection. The Unlinked Anonymous HIV Prevalence Monitoring Programme initiated in England and Wales in 1990 was extended to Northern Ireland in 1992. Patients attending the Genitourinary Medicine Clinic at the Royal Victoria Hospital have, with informed consent, been tested anonymously for HIV infection since that time. The results of the survey between 1992 and 1995 have shown an overall seroprevalence rate 3.01% for homosexual/bisexual men, 0.08% for heterosexual men, and 0.05% for heterosexual women. These results confirm the previous impression of low HIV seroprevalence in Northern Ireland and the survey provides an excellent longitudinal study by which changes may be monitored.