Structural brain abnormalities specific to childhood-onset schizophrenia identified by neuroimaging techniques

This review discusses functional and structural brain abnormalities in childhood-onset schizophrenia identified by neuroimaging techniques. Published literature regarding both morphological and functional neuroimaging is discussed, regarding also the diversity of neuroimaging findings which partly reduces their reliability. The findings in early onset schizophrenia are compared with those of adult patients. The results of long-term investigations of structural abnormalities in early onset schizophrenia are given particular attention. The most consistent findings are ventricular enlargement and reduced total brain volume. Further, volumetric changes in the temporal and frontal cortex, thalamus, basal ganglia and limbic system are reported, as are hemispheric asymmetries and, conversely, reduction of normal differences. Findings regarding the corpus callosum and cerebellum are less consistent. In patients whose schizophrenia commenced in early childhood, the differences were generally more marked than in adolescence- or adult-onset schizophrenia. Atrophy of total brain volume was progressive throughout the course of the disorder. It is probable that neuroanatomical cerebral abnormalities present prior to disease onset play an etiopathogenic role in the development of schizophrenia.

[Personality disorders and psychiatric comorbidity in obsessive-compulsive disorder and anorexia nervosa]

The aim of this prospective longitudinal study was to examine the course of adolescent anorexia nervosa and obsessive-compulsive disorder (OCD) (fulfilling DSM-III-R criteria) to compare psychiatric comorbidity and personality disorders of both groups. Because anorexia nervosa patients are mainly female, we compared them only with female OCD patients. Ten years after discharge the whole sample (32 female patients; 100%) of a group of 39 (32 female; 7 male) anorexia nervosa patients could be reexamined personally. 25 (61%) female patients of a group of 116 patients (41 female; 75 male) with obsessive-compulsive disorder were also reexamined. The anorexia nervosa patients were interviewed using the Structured Interview for Anorexia and Bulimia nervosa (SIAB [39]) to assess eating disorder symptomatology. To examine comorbid psychiatric disorders we used the Composite International Diagnostic Interview, WHO [44] and SCID-II [45] for personality disorders. One fourth of the patients with anorexia nervosa (AN) and 20% of the patients with obsessive-compulsive disorder had a personality disorder according to DSM-III-R. Most of them were "Cluster C"-personality disorders (AN: 28%; OCD: 20%). In the group of the female OCD patients 8% schizoid, 4% schizotype and 12% paranoid personality disorders were observed. The most prevalent psychiatric disorders were anxiety (AN: 28%; OCD: 20%) and affective disorders (AN: 16%; OCD: 16%). Our results support the view that in the course of anorexia nervosa and in obsessive-compulsive disorder there is a high prevalence of psychiatric comorbidity and "Cluster C"-personality disorders according to DSM-III-R. These results might confirm a model of a high vulnerability of the serotonergic neurotransmitter system in patients with anorexia nervosa or OCD.

Changes of the brain electrical fields during the continuous performance test in attention-deficit hyperactivity disorder-boys depending on methylphenidate medication

OBJECTIVE

The continuous performance test (CPT) is successfully applied to evaluate attentional performance in attention-deficit hyperactivity disorder (ADHD)-children. The aim of the present study was to investigate the changes of the topographic P300-features in relation to methylphenidate-medication and to different attentional processes in primer- and distractor-conditions.

METHODS

Twenty-one-channel-ERPs of 17 ADHD-boys were analyzed with reference-independent methods. Four quasi stable microstates within the time frames of conventional P100, P200, P3a and P3b components were identified by means of a data-driven segmentation procedure.

RESULTS

In segment 3 topographical assessment yielded a significant occipital and right-shift of the positive centroid, longer centroid distance and higher amplitudes in primer- than in distractor conditions. MPH increased the amplitude and distance in primer and distractor-condition, without changing the topography. In segment 4 the electric field strength of distractor-conditions collapsed, whereas the primer condition showed a strong fronto-parietally oriented potential-field. There was a tendency to higher amplitudes due to MPH-medication.

CONCLUSIONS

These results indicate a robust neurophysiologic differentiation of cognitive processes. MPH activates an early (P3a) covert attention process indicated by increased amplitudes and centroid. No effects were seen in later processes. Based on these effects, we propose to use the amplitude- and distance-increase in microstate 3 as an indicator of MPH efficacy in ADHD-boys.

Olanzapine in children and adolescents with chronic anorexia nervosa. A study of five cases

Psychopathology in severely anorexic patients often seems to be of compulsive and delusional quality rendering therapeutic approaches extremely difficult. With conventional therapeutic regimes failing, administration of the novel antipsychotic olanzapine induced remarkable improvement in five cases reported here. Paranoid ideation concerning body image or weight gain decreased and sedative effects helped to reduce inner tensions and phobia with respect to food intake. Olanzapine, therefore, might represent an important therapeutic tool in anorexic patients who present the following characteristics: long-term history of anorexia nervosa mostly with several hospitalisations, missing perception of their severe state of illness, refusal of therapy, delusional quality of anorexic thinking, risk of discontinuation of therapy with life-threatening consequences.

Unterschiede zwischen jugendlichen Patientinnen mit Anorexia und Bulimia nervosa im Hinblick auf psychologische und psychosoziale Merkmale

Zusammenfassung: Fragestellung: Die Studie widmet sich der Frage, inwieweit sich jugendliche Patientinnen mit Anorexia und Bulimia nervosa in psychologischen Merkmalen und Lebensverhältnissen unterscheiden. Methode: Die Krankengeschichten von 140 Patientinnen (110 mit Anorexia nervosa und 30 mit Bulimia nervosa), die in den Jahren 1982 bis 1992 in der Klinik für Kinder- und Jugendpsychiatrie der Universität Würzburg stationär behandelt wurden, wurden im Rahmen einer retrospektiven Studie ausgewertet. Alle Patientinnen erfüllen die Kriterien nach ICD-10 für Anorexia- oder Bulimia nervosa. Daten aus der Basis-Dokumentation und aus der multiaxialen Klassifikation (MAS) wurden herangezogen, standardisierte Verfahren wie der Anis-32, MMPI, BDI, HAWIK-R und HAWIE kamen zur Auswertung. Die Ergebnisse zeigen signifikante Unterschiede zwischen den beiden Stichproben. Das häufigste Alter bei erster stationärer Aufnahme war bei anorektischen Patientinnen 14,5 und bei bulimischen Patientinnen 16,5 Jahre. Die störungsspezifischen Symptome betreffend unterschieden sich die beiden Stichproben hinsichtlich ihres Essverhaltens im Faktor Bulimie des Anis-32. Beim Vergleich der Persönlichkeitsmerkmale beschrieben sich die anorektischen Patientinnen im MMPI weniger psychopathisch als die Bulimia nervosa Patientinnen. Im BDI war die depressive Symptomatik bei Anorexia nervosa als klinisch relevant einzustufen. Andere Charakteristika der anorektischen Patientinnen waren ein überdurchschnittlicher IQ, Überfürsorglichkeit innerhalb der familiären Beziehungen, vermehrte Trennungsängste und Kontaktstörungen in der Schule. Im Vergleich dazu zeigten die bulimischen Patientinnen häufiger Leistungs- und Disziplinierungsschwierigkeiten in der Schule, innerhalb der Familie wurde das Kontaktverhalten und die Kommunikation beeinträchtigter als bei Familien anorektischer Patientinnen erlebt.

Agranulozytose bei einem Kind mit Schizophrenie unter Clozapintherapie - klinisches Bild und Therapie, eine Kasuistik

Zusammenfassung: Fragestellung: Clozapin ist aufgrund des 1- bis 3%igen Risikos medikamentös induzierter Agranulozytose besonderen Verordnungsrichtlinien unterworfen. Bislang gibt es keine Falldarstellung, dass unter der Behandlung einer Schizophrenie im Kindesalter unter Clozapintherapie eine Agranulozytose auftrat. Die kasuistische Darstellung widmet sich der Frage, wie das klinische Bild sich darstellen kann und welche Behandlungsschritte zu ergreifen sind. Methodik: Dargelegt wird die Kasuistik eines bei Behandlungsbeginn 12-jährigen Kindes mit schizophrener Psychose. Beschrieben wird die psychotische Symptomatik vor Behandlungsbeginn und im Behandlungsverlauf. Dargelegt werden die notwendigen diagnostischen Schritte zur Feststellung der Agranulozytose und die einzelnen Schritte zur Therapie. Schlussfolgerung: Unter Clozapinmedikation kann auch beim Kind mit schizophrener Psychose eine Agranulozytose ausgelöst werden. So sind auch im Kindesalter die von der Herstellerfirma vorgegebenen Kontrolluntersuchungen unbedingt einzuhalten. Eine Agranulozytose kann auch erst nach 15 Wochen der Clozapinmedikation auftreten. Die Behandlung mit granulozytenstimulierendem Faktor unterstützt entscheidend Erholung und Normalisierung des Blutbildes.

[Differences between adolescent patients with anorexia and bulimia nervosa with reference to psychological and psychosocial markers]

OBJECTIVES

We present a retrospective study of 140 patients (110 with anorexia nervosa, 30 with bulimia nervosa), hospitalized between 1982-1992 at the Department of Child and Adolescent Psychiatry at the University of Wuerzburg, Germany.

METHODS

All patients met the ICD-10 criteria for anorexia nervosa or bulimia nervosa. We collected data from basic documentation and the multiaxial classification (MAS), using a variety of standard instruments such as Anis 32, MMPI, BDI, HAWIK-R and HAWIE.

RESULTS

Our findings show significant differences between the two populations. At the time of their first admission anorectic patients were somewhat younger than their bulimic counterparts (14.5 years vs. 16.5 years, respectively). With regard to the typical symptoms of either disorder, the two populations differ in their eating behavior on the factor bulimia described by Anis-32. A comparison of personality features reveals that anorectic patients scored lower than bulimic patients on the MMPI scales, especially on psychopathology, but higher on depression in the BDI. Other characteristics of anorectic patients include a higher-than-average IQ, more enmeshment and overprotectiveness in family relations, more separation anxiety and insufficient communication skills at school. By contrast, bulimic patients demonstrated poorer scholastic performance and more discipline problems at school, while communication among family members was impaired.

[Agranulocytosis in a child with schizophrenia treated with clozapine--clinical findings and therapy, a case report]

OBJECTIVES

The indication of clozapine therapy is governed by special guidelines due to a 1%-3% risk of clozapine-induced agranulocytosis. Up to now there has never been a report of such a case in a child with schizophrenia. The case report presented here is concerned with the clinical features and the treatment of clozapine-induced agranulocytosis in childhood schizophrenia.

METHODS

It deals with the treatment of a 12-yearold boy with a schizophrenic psychosis. The psychotic symptoms before treatment and during inpatient treatment are described. The procedures for the diagnosis and treatment of the clozapine-induced agranulocytosis are presented.

RESULTS

Clozapine medication may induce agranulocytosis in the treatment of a child with a schizophrenic psychosis. The highly specific guidelines governing its use must be followed as well in the treatment of very early onset schizophrenia. An agranulocytosis may result following 15 weeks of clozapine medication. The treatment with granulocyte colony-stimulating factor seems to support normalization of the blood picture.

[Long-term course of childhood or adolescence onset obsessive-compulsive disorder: psychosocial adaptation in adulthood]

OBJECTIVE

The aim of the study was to investigate the long-term course of obsessive-compulsive disorder (OCD) with onset in childhood or adolescence. This presentation focuses on the social adjustment of the former patients in adulthood.

METHODS

Fifty-five out of 116 patients with childhood OCD classified according to DSM-IV criteria were interviewed personally using structured interviews. Mean age at onset of OCD was 12.5 years, and mean follow-up time was 11.2 years.

RESULTS

Despite the evident burden of mental disorder at the time of the follow-up, 76% led their own lives without being overly dependent upon their parents. 84% had no problems that impaired either school or their occupation. 73% were rated as maintaining satisfying social contacts, but only 54% were in a relationship at follow-up.

CONCLUSIONS

In agreement with other studies we found an association between the level of psychosocial adjustment and the course of obsessive-compulsive symptoms. Summing up, social adjustment and psychosexual functioning seem to be more impaired than occupational functioning. The relatively good adjustment of our sample indicates that most patients have found a way of managing their lives, albeit still suffering from mental disorders.

Long-term outcome and prognosis of obsessive-compulsive disorder with onset in childhood or adolescence

The aim of the catch-up follow-up study is to describe the long-term outcome of obsessive-compulsive disorder (OCD) with onset in childhood and adolescence. The psychiatric morbidity in adulthood including personality disorders was assessed and predictors in childhood for the course of obsessive-compulsive symptoms were examined. The total study group consisted of the entire patient population treated for OCD at our departments for child and adolescent psychiatry between 1980 and 1991. We reassessed 55 patients personally by way of structured interviews. The mean age of onset of OCD was 12.5 years and the mean follow-up time was 11.2 years. At the follow-up investigation 71% of the patients met the criteria for some form of psychiatric disorder, while 36% were still suffering from OCD. Of the patients with a present diagnosis of OCD 70% had at least one further clinical disorder (especially anxiety and affective disorders). The most frequent personality disorders diagnosed were obsessive-compulsive (25.5%), avoidant (21.8%), and paranoid (12.7%) personality disorders. In-patient treatment, terminating treatment against advice and tics in childhood or adolescence significantly correlated with more severe OC symptoms in adulthood.

[Long-term course of childhood or adolescence onset obsessive-compulsive disorder: psychosocial adaptation in adulthood]

OBJECTIVE

The aim of the study was to investigate the long-term course of obsessive-compulsive disorder (OCD) with onset in childhood or adolescence. This presentation focuses on the social adjustment of the former patients in adulthood.

METHODS

Fifty-five out of 116 patients with childhood OCD classified according to DSM-IV criteria were interviewed personally using structured interviews. Mean age at onset of OCD was 12.5 years, and mean follow-up time was 11.2 years.

RESULTS

Despite the evident burden of mental disorder at the time of the follow-up, 76% led their own lives without being overly dependent upon their parents. 84% had no problems that impaired either school or their occupation. 73% were rated as maintaining satisfying social contacts, but only 54% were in a relationship at follow-up.

CONCLUSIONS

In agreement with other studies we found an association between the level of psychosocial adjustment and the course of obsessive-compulsive symptoms. Summing up, social adjustment and psychosexual functioning seem to be more impaired than occupational functioning. The relatively good adjustment of our sample indicates that most patients have found a way of managing their lives, albeit still suffering from mental disorders.

Contingent Negative Variation (CNV) bei Kindern mit hyperkinetischem Syndrom - eine experimentelle Untersuchung mittels des Continuous Performance Test (CPT)

Zusammenfassung Fragestellung: Gibt es neurophysiologische Korrelate der Aufmerksamkeitsstörung beim hyperkinetischen Syndrom (HKS) und welche Bedeutung haben diese für die Ätiologie der Störung. Methodik: Selektive Aufmerksamkeitsprozesse wurden anhand des zweistufigen Continuous Performance Test (CPT) bei 18 Jungen mit hyperkinetischem Syndrom (HKS) untersucht und mit einer nach dem Alter parallelisierten Kontrollgruppe von 21 Jungen verglichen. Die Altersspanne der Stichprobe betrug 6 bis 12 Jahre. Parallel dazu wurden ereigniskorrelierte Potentiale (EKP) während des Tests an den Elektrodenpositionen Fz, Cz, Pz und Oz mit Referenz zu verbundenen Ohren abgeleitet. Ergebnisse: Im EKP nach dem präparatorischen Stimulus konnten zwei Komponenten der Contingent Negative Variation (CNV) mit unterschiedlicher topographischer Verteilung identifiziert werden (CNV-1: 600 bis 1100 ms und CNV-2: 1000 bis 1500 ms nach Stimulus). Die Stichproben unterschieden sich nicht auf der Verhaltensebene (Fehlerrate und Reaktionszeit). Signifikante Gruppenunterschiede ergaben sich hinsichtlich der Topographie der beiden CNV-Komponenten. Kinder mit HKS zeigten im Vergleich zu Kontrollkindern eine signifikant niedrigere CNV-1 über der frontalen und eine Tendenz zu stärkerer Negativierung (CNV-1 und CNV-2) über der occipitalen Elektrode. Schlussfolgerungen: Die Ergebnisse unterstützen die Hypothese einer Unterfunktion frontaler inhibitorischer Prozesse bei Kindern mit HKS.

[Contingent negative variation (CNV) in children with hyperkinetic syndrome--an experimental study using the Continuous Performance Test (CPT)]

OBJECTIVES

Evaluation of event-related potentials for selective attention in attention deficit/hyperactivity disordered children.

METHODS

Selective attention processes were examined in a group of 18 boys aged 6 to 12 years with attention deficit/hyperactivity disorder and compared with the data of a control group of 21 age and sex matched boys. Parallel thereto the event-related potentials (ERP) were derived during the test at the electrode positions Fz, Cz, Pz, and Oz with reference to the linked ears.

RESULTS

Two components of the contingent negative variation (CNV) with different topography were identified in the ERP following a preparatory stimulus (CNV-1: 600 to 1100 ms and CNV-2: 1000 to 1500 ms after the stimulus). There were no group differences at the behavioural level (number of correct detected targets, number of errors). Significant group differences resulted with regard to the topography of the two CNV components. Children with ADD showed an attenuated frontal CNV-1 amplitude and a trend towards increased CNV-1 and CNV-2 occipital amplitudes.

CONCLUSIONS

The results support the hypothesis of impaired frontal inhibitory processes in children with ADD.

Testdiagnostische Verfahren zur Überprüfung der Fertigkeiten im Lesen, Rechtschreiben und Rechnen. Eine kritische Übersicht

Zusammenfassung: Fragestellung: Die Diagnose einer umschriebenen Entwicklungsstörung schulischer Fertigkeiten kann nur auf der Grundlage individuell angewendeter standardisierter Testverfahren zur Prüfung von Schulleistungen und IQ erfolgen. Um dem Untersucher die Auswahl geeigneter Verfahren zu erleichtern, soll eine kritische Übersicht deutschsprachiger Verfahren zur Erfassung von Rechtschreib-, Lese- und Rechenfertigkeiten gegeben werden.Methodik: Testintention und Gütekriterien der Schulleistungstests werden zusammenfassend dargestellt. Die Verfahren werden hinsichtlich ihrer Brauchbarkeit zur Legasthenie- und Dyskalkuliediagnostik bewertet. Ergänzend werden Vorschläge zur klinischen Prüfung gegeben. Ergebnis: Zusammenfassend stehen jenseits des Grundschulbereichs nicht ausreichend aktuell normierte und den gängigen Gütekriterien genügende Verfahren zur Verfügung. Insbesondere zur Prüfung von Rechenfertigkeiten muss jenseits der 4. Klasse auf Verfahren zurückgegriffen werden, deren curriculare Gültigkeit zweifelhaft ist. Die letzten Klassenstufen der Haupt- und Realschule sind dann wieder besser abgedeckt. Schlussfolgerungen: Es kann ein deutlicher Bedarf an Neukonstruktionen bzw. Aktualisierungen publizierter Schulleistungstests festgestellt werden.

[Diagnostic testing methods for skill assessment in reading, writing, and arithmetic. A critical review]

OBJECTIVES

The diagnosis of a specific developmental disorder of reading, writing and arithmetic can be made based upon individually applied standardized methods for testing scholastic achievement and IQ. To make the choice of suitable methods easier for the administrator of the test, a critical survey of German-language methods for assessing skills in reading, writing and arithmetic is presented.

METHODS

Test intention and psychometric properties for scholastic achievement are summarized. The methods are assessed with regard to their utility in the diagnosis of congenital alexia and dyscalculia. Supplementary suggestions for clinical assessment are given.

RESULTS

In summary, beyond the primary school area there is a lack of current standardized methods that meet the current standards of quality. Particularly the assessment of arithmetic skills above those of the 4th grade level require resorting to methods of dubious curricular validity. Coverage is once again better for the upper elementary and middle school levels.

CONCLUSIONS

There is a need for new constructions, respectively a need to update published scholastic achievement tests.

Reading and spelling disorders: clinical features and causes

Developmental dyslexia (specific reading and specific spelling disorder) is thought to stem from specific features in cognitive processing strongly related to biological maturation of the central nervous system which interact with non-biological learning conditions. The specific learning disorder should not be accounted for by mental age, gross neurological deficits, emotional disturbances or inadequate schooling. As a clinical guideline, the child's level in reading and spelling must be significantly below that expected for the population of children of the same mental age. The persistence rate is high and dyslexia is often associated with psychiatric problems. The etiology is not known. From the biological point of view, dyslexia is supposed to have a neurological basis. Neuroanatomical, neurophysiological, and neuropsychological correlates have been studied by means of autopsy, brain imaging, neurophysiological and neuropsychological methods. There is good evidence that dyslexia is determined by heritable cognitive components of reading and spelling processing. Experimental research focuses on characteristics of brain structure and cognitive skills related to the central nervous systems of auditory-phonological and visual information processing.