Age-dependence of Schneiderian psychotic symptoms in bipolar patients

Psychotic symptoms frequently occur in bipolar disorder, especially in younger patients. However, whether the association with younger age also extends to psychotic symptoms that have traditionally been associated with schizophrenia, such as Schneiderian first-rank symptoms (FRSs), is unclear. This study examined FRSs in bipolar I patients and their relationship to age and gender. The sample comprised 103 consecutive inpatients who met DSM IV criteria for bipolar disorder, manic or mixed. FRSs were rated with the Scale for the Assessment of Positive Symptoms (SAPS). Interaction between FRSs and gender and FRSs and age was assessed using logistic regression. A high rate of FRSs in manic and mixed patients was found with a higher frequency in men (31%) than in women (14%; P=0.038). A monotonic increase in the association between FRSs and younger age was apparent (odds ratios (OR) over five levels: 1.42; 1.00-2.01). These results confirm previous findings that FRSs are not specific to schizophrenia and suggest in addition that a dimension of nuclear psychotic experiences of developmental origin extends across categorically defined psychotic disorders.

Self-reported psychotic experiences in the general population: a valid screening tool for DSM-III-R psychotic disorders?

OBJECTIVE

To examine the diagnostic value of self-reported psychotic-like experiences for DSM-III-R psychotic disorders.

METHOD

A general population sample of 7076 subjects aged 18-64 years was interviewed with the Composite International Diagnostic Interview (CIDI) and, if there was evidence of psychotic experiences, the Structured Clinical Interview for DSM-III-R.

RESULTS

The probability of having a psychotic disorder increased in a dose-response fashion with the level of self-reported psychotic experiences, but individual CIDI psychotic experience ratings had relatively low post-test probabilities (PPs) (range: 5.1-26.5%). However, limiting the sample to individuals who had been in contact with mental health services substantially improved PPs (range: 13.3-43.1%).

CONCLUSION

Screening for psychosis in the population carries a high risk of stigmatization in false-positive cases and violation of the right 'not to know' in true-positive cases. However, in mental health care users, self-reported psychotic experiences may be a useful screening tool in individuals who have already developed help-seeking.

Can cognitive deficits explain differential sensitivity to life events in psychosis?

BACKGROUND

Life events (LE) have been found to influence the onset and course of psychotic disorders. It has been suggested that LE have their effect by increasing underlying sensitivity to daily life stress, a reported vulnerability marker for psychosis. As increased stress-sensitivity and cognitive impairments have been shown to be negatively associated with each other in patient populations, it is attractive to hypothesise that the impact of LE on sensitivity to daily stress is modified by the degree of cognitive impairment, higher levels of cognitive impairment giving rise to reduced impact of LE on daily life stress-sensitivity.

METHODS

Patients with psychotic illness (n = 42) were studied with a) a standard battery of neuropsychological tests to assess cognitive functioning, b) the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess (i) appraised subjective stress related to daily events and activities, and (ii) emotional reactivity conceptualised as changes in both negative affect (NA) and positive affect (PA), and c) the Brown and Harris Life Event and Difficulties Schedule to assess LE over the last year.

RESULTS

Multilevel regression analyses showed that a prior history of LE increased the sensitivity for daily life stress in subjects with the best performance on the cognitive tests.

CONCLUSIONS

Subjects with cognitive impairments, who already were shown to have lower levels of sensitivity to daily life stress (Myin Germeys et al. 2002), may additionally be less reactive to prior exposure to LE. This result fits with the notion of separate affective and cognitive pathways of symptom formation in psychosis, the cognitive pathway being characterised by severe cognitive deficits and the affective pathway by increased levels of stress-sensitivity associated with prior exposure to LE.

How psychotic are individuals with non-psychotic disorders?

BACKGROUND

The objective of this study was to compare, using a self-report questionnaire, the dimensions of psychosis across different patient groups in a community mental health service (CMHS) and in non-patients in the general population.

METHODS

The Community Assessment of Psychic Experiences (CAPE) is a 40-item self-report instrument with positive, negative and depressive symptom dimensions. Seven hundred and sixty-two patients and 647 subjects in the general population filled in the CAPE. In 555 of the 762 patients, a DSM-IV diagnosis was made. The following DSM-IV categories were used in the analyses: 1. Schizophrenia and Other Psychotic Disorders (n = 72), 2. Mood Disorders (n = 214), 3. Anxiety Disorders (n = 129). The patient and non-patient groups were compared on the three dimensions of the CAPE using multivariate regression analysis.

RESULTS

The patient groups scored significantly higher on the positive, negative and depressive dimensions than the non-patients. Patients with psychotic disorders had the greatest difference in positive psychosis items compared to non-patients (beta = 0.94, 95 % CI: 0.7-1.18), whereas patients with mood and anxiety disorders had the highest depressive symptom scores, and positive symptom scores that were intermediate to that of non-patients and patients with psychotic disorders (mood disorders: beta = 0.53, 95 % CI: 0.39-0.68; anxiety disorders: beta = 0.22, 95 % CI: 0.04-0.39). The CAPE distress score adjusted for the corresponding frequency score was not significantly different between the patient groups, but compared to the general population, patient status did contribute significantly to the level of distress.

DISCUSSION

Patients with anxiety and mood disorders had elevated scores on positive psychosis items, indicating that expression of psychosis in non-psychotic disorders is common. The finding of elevated scores of the patient groups on all three dimensions compared to non-patients suggests that the psychopathology associated with psychotic disorders varies quantitatively across DSM-IV categories.

Cerebral tissue alterations and daily life stress experience in psychosis

OBJECTIVE

To examine whether the total volumes of cerebrospinal fluid (CSF), cerebral grey matter and white matter were correlated with the experience of environmental stress in daily life situations.

METHOD

Twenty-seven patients with psychosis underwent magnetic resonance imaging scanning and a random time-sampling self-assessment technique (Experience Sampling Method) to determine subjective daily life stress experiences. Total cerebral tissue volumes were derived from an automated segmentation procedure.

RESULTS

CSF volume was positively associated with daily life event-related stress (beta=0.016, P=0.002), while the association with total white matter was negative (beta=-0.013, P=0.005). The effects were independent of each other and of total cerebral volume and other confounders. No large or significant association was found with grey matter volume.

CONCLUSION

Subjective stress experience in daily life is associated with increased CSF and reduced white matter volumes in patients with psychosis, suggesting functional significance of these cerebral measures.

Discrimination and delusional ideation

BACKGROUND

In the UK and The Netherlands, people with high rates of psychosis are chronically exposed to discrimination.

AIMS

To test whether perceived discrimination is associated longitudinally with onset of psychosis.

METHOD

A 3-year prospective study of cohorts with no history of psychosis and differential rates of reported discrimination on the basis of age, gender, disability, appearance, skin colour or ethnicity and sexual orientation was conducted in the Dutch general population (n=4076). The main outcome was onset of psychotic symptoms (delusions and hallucinations).

RESULTS

The rate of delusional ideation was 0.5% (n=19) in those who did not report discrimination, 0.9% (n=4) in those who reported discrimination in one domain, and 2.7% (n=3) in those who reported discrimination in more than one domain (exact P=0.027). This association remained after adjustment for possible confounders. No association was found between baseline discrimination and onset of hallucinatory experiences.

CONCLUSIONS

Perceived discrimination may induce delusional ideation and thus contribute to the high observed rates of psychotic disorder in exposed minority populations.

2-COM: an instrument to facilitate patient-professional communication in routine clinical practice

OBJECTIVE

A simple patient-completed self-report instrument may facilitate patient-professional carer communication.

METHOD

A 19-item self-report needs schedule was used in a sample of 243 out-patients with non-affective psychosis. Patients and professional carers commented on the usefulness of the instrument. In a subgroup of 95 patient-carer dyads, the professional carer was asked to rate the needs in addition to the patient.

RESULTS

Patients scored their needs reliably and lower than the professionals (OR = 0.9, 95% CI: 0.9, 0.97). Concordance between patients and professional carers on individual needs was very low. More than 50% of the professional carers and more than 80% of the patients found 2-COM useful. The higher the number of needs indicated by the patient, the greater the discrepancy between patients and professional carers with regard to the usefulness of the schedule.

CONCLUSION

2-COM is a useful instrument to expose, and subsequently bridge, patient-professional carer discordance on patient needs.

Child psychopathology and lower cognitive ability: a general population twin study of the causes of association

Previous work has demonstrated associations between lower cognitive ability and childhood and adult non-psychotic psychopathology. As both cognitive ability (CA) and child psychopathology (CP) are influenced by genetic factors, one explanation for the association is that they are the pleiotropic manifestations of the same underlying genetic factors. The present paper examines three possible causes of the association: additive genetic factors, common environmental factors and individual-specific environmental factors. Three hundred and seventy-six twin pairs from the East Flanders Prospective Twin Survey were examined with the Child Behaviour Checklist and the Wechsler Intelligence Scale for Children-Revised. The cross-twin within-variable, within-twin cross-variable and cross-twin cross-variable correlations were calculated. Using structural equation modelling, bivariate models were fitted. The best fitting model was chosen, based on likelihood and parsimony. The observed phenotypic correlation between CP and CA was -0.19 (95% CI: -0.09, -0.27), with genetic factors accounting for about 84% of the observed correlation. Bivariate model fitting quantified the genetic correlation between CP and CA at -0.27 (95% CI: -0.12, -0.42) and the individual-specific environmental correlation at -0.17 (95% CI: -0.03, -0.31). In children, three different genetic factors may exist: one that solely affects the liability to CP, one that has only an effect on CA and one that influences both CP and CA. While individual-specific environmental factors can influence the liability to both traits, our results suggest that most of the environmental factors that increase the risk of CP do not influence CA and vice versa.

Cannabis use and psychosis: a longitudinal population-based study

Cannabis use may increase the risk of psychotic disorders and result in a poor prognosis for those with an established vulnerability to psychosis. A 3-year follow-up (1997-1999) is reported of a general population of 4,045 psychosis-free persons and of 59 subjects in the Netherlands with a baseline diagnosis of psychotic disorder. Substance use was assessed at baseline, 1-year follow-up, and 3-year follow-up. Baseline cannabis use predicted the presence at follow-up of any level of psychotic symptoms (adjusted odds ratio (OR) = 2.76, 95% confidence interval (CI): 1.18, 6.47), as well as a severe level of psychotic symptoms (OR = 24.17, 95% CI: 5.44, 107.46), and clinician assessment of the need for care for psychotic symptoms (OR = 12.01, 95% CI: 2.24, 64.34). The effect of baseline cannabis use was stronger than the effect at 1-year and 3-year follow-up, and more than 50% of the psychosis diagnoses could be attributed to cannabis use. On the additive scale, the effect of cannabis use was much stronger in those with a baseline diagnosis of psychotic disorder (risk difference, 54.7%) than in those without (risk difference, 2.2%; p for interaction = 0.001). Results confirm previous suggestions that cannabis use increases the risk of both the incidence of psychosis in psychosis-free persons and a poor prognosis for those with an established vulnerability to psychotic disorder.

Clinical correlates of depression following myocardial infarction

OBJECTIVE

Post-MI depression increases mortality, especially in the first 18 months after MI. Identifying patients at risk for post-MI depression is therefore important. In the present study we investigated possible correlates for post-MI depression on an a priori basis.

METHOD

Based on the literature, four clinically easily attainable variables were selected as possible correlates for post-MI depression. These were prescription of benzodiazepines during acute hospitalization, cardiac complications during acute hospitalization, history of depression, and not being able to stop smoking within six months after MI. A consecutive cohort of 173 first-MI patients was screened with the SCL-90 depression scale and DSM-III-R criteria for major depression. Of this cohort 35 depressed patients were compared with 35 non-depressed post-MI patients, matched for gender, age, and severity of MI.

RESULTS

In univariate analyses, complications during hospitalisation (OR = 2.14; CI = 0.89-5.14), prescription of benzodiazepines (OR = 3.67; CI = 1.11-12.1), history of depression (OR = 3.0; CI = 0.87-10.4), and not being able to stop smoking (OR = 4.5; CI = 1.11-18.2) were clinical correlates for post-MI depression. Multivariate analyses showed that none of these variables were independent of the others in predicting depression.

CONCLUSIONS

A number of easily measurable patient characteristics identify those MI-patients at risk of post-MI depression. Further investigations should focus on the predictive value of these factors in relation to post-MI depression.

Neuropsychological performance of psychotic patients in community care: results from the UK700 study

OBJECTIVE

To compare cognitive performance in chronic schizophrenic and affective psychotic patients maintained in community care.

METHOD

We studied a sample of community-based patients (n = 707) with chronic psychotic disorders. Neuropsychological assessment was completed using the National Adult Reading Test (NART) and the Trail Making Test (TMT).

RESULTS

Affective psychotic patients had higher premorbid IQ than schizophrenic patients before adjustment for confounding factors (P=0.03); however, after adjustment for ethnic group and social class this became non-significant (P=0.19). There were no significant differences between groups on the TMT, parts A or B.

CONCLUSION

Unlike studies suggesting that schizophrenic patients are more cognitively impaired than affective psychotic patients, our study suggests a degree of cognitive homogeneity between those patients who develop a chronic illness. Measures of premorbid IQ suggest that this cognitive homogeneity exists prior to the onset of illness.

Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment

OBJECTIVE

To determine whether the incidence of schizophrenia among people from non-white ethnic minorities is greater in neighbourhoods where they constitute a smaller proportion of the total population.

DESIGN

Ecological design including retrospective study of case records to calculate the incidence of schizophrenia in the ethnic minority population across electoral wards and multi-level analysis to examine interaction between individuals and environment.

SETTING

15 electoral wards in Camberwell, South London.

PARTICIPANTS

All people aged 16 years and over who had contact with psychiatric services during 1988-97.

MAIN OUTCOME MEASURE

Incidence rates of schizophrenia according to Research Diagnostic Criteria.

RESULTS

The incidence of schizophrenia in non-white ethnic minorities increased significantly as the proportion of such minorities in the local population fell. The incidence rate ratio varied in a dose-response fashion from 2.38 (95% confidence interval 1.49 to 3.79) in the third of wards where non-white ethnic minorities formed the largest proportion (28-57%) of the local population to 4.4 (2.49 to 7.75) in the third of wards where they formed the smallest proportion (8-22%).

CONCLUSION

The incidence of schizophrenia in non-white ethnic minorities in London is greater when they comprise a smaller proportion of the local population.

Does socioeconomic status predict course and outcome in patients with psychosis?

BACKGROUND

We examined the relationship between socioeconomic status (SES) and course and outcome of patients with psychosis. Two hypotheses were examined: a) patients with higher best-ever SES will have better course and outcome than those with lower best-ever SES, and b) patients with greater downward drift in SES will have poorer course and outcome than those with less downward drift.

METHOD

Data were drawn from the baseline and 2-year follow-up assessments of the UK700 Case Management Trial of 708 patients with severe psychosis. The indicators of SES used were occupational status and educational achievement. Drift in SES was defined as change from best-ever occupation to occupation at baseline.

RESULTS

For the baseline data highly significant differences were found between best-ever groups and negative symptoms (non-manual vs. unemployed--coef -10.5, p=0.000, 95% CIs 5.1-15.8), functioning (non-manual vs. unemployed--coef -0.6, p=0.000, 95% CIs 0.3 to -0.8) and unmet needs (manual vs. unemployed - coef 0.5, p=0.004, 95% CIs 0.2-0.9). No significant differences between best-ever groups were found for days in hospital, symptoms, perceived quality of life and dissatisfaction with services. Significant differences for clinical and social variables were found between drift and non-drift SES groups. There were no significant findings between educational groups and clinical and social variables.

CONCLUSIONS

Best-ever occupation, but not educational qualifications, appeared to predict prognosis in patients with severe psychosis. Downward drift in occupational status did not result in poorer illness course and outcome.

Emotional reactivity to daily life stress in psychosis

BACKGROUND

The vulnerability-stress model of psychotic disorders describes, in essence, an interaction between personal vulnerability and environmental stressors. The present study investigated this interaction and studied emotional reactivity to daily life stress as a vulnerability marker for psychotic illness.

METHODS

Patients with psychotic illness (n = 42), their first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experience Sampling Method (a structured diary technique assessing thoughts, current context, and mood in daily life) to assess (1) appraised subjective stress of daily events and smaller disturbances in daily life and (2) emotional reactivity conceptualized as changes in both negative affect and positive affect.

RESULTS

Multilevel regression analyses showed that an increase in subjective stress was associated with an increase in negative affect and a decrease in positive affect in all groups. However, the groups differed quantitatively in their pattern of reactions to stress. Patients with psychotic illness reacted with more intense emotions to subjective appraisals of stress in daily life than control subjects. The decrease in positive affect in the relatives was similar to that of the patients, while the increase in negative affect in this group was intermediary to that of patients and control subjects.

CONCLUSIONS

Higher levels of familial risk for psychosis were associated with higher levels of emotional reactivity to daily life stress in a dose-response fashion. Subtle alterations in the way persons interact with their environment may constitute part of the vulnerability for psychotic illness.

Stroke and mental health care: a record linkage study

BACKGROUND

Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients.

METHOD

A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area.

RESULTS

Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04-2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower.

CONCLUSION

Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke.

Ethical issues in European psychiatry

European psychiatrists and psychiatric service planners are confronting new ethical dilemmas as a direct or indirect result of European integration. These dilemmas present themselves at a variety of levels, ranging from the individual doctor-patient relationship to national and international legislations. We review some of the areas in which ethical questions may arise as a result of increasing European unity. Some of the issues may seem minor but are likely to have some impact on any psychiatrist exposed to transcultural practice in the European Union. Other examples have been selected not because they are common but because of their massive ethical ramifications. Attempts, by psychiatrists, to address these issues pro-actively are few and far apart.

The continuity of psychotic experiences in the general population

Schizophrenia is a severe mental illness that affects 1% of the population. The diagnosis is made according to current diagnostic systems of DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Association, 1992) on the basis of characteristic 'positive' and 'negative' symptoms. The traditional medical model assumes a categorical view of the schizophrenia syndrome and its core symptoms, in which differences between psychotic symptoms and their normal counterparts are considered to be qualitative. An alternative, dimensional approach assumes that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. This paper reviews evidence for the continuity of psychotic symptoms with normal experiences, focusing on the symptoms of hallucinations and delusions. It concludes by discussing the theoretical and treatment implications of such a continuum.

High expressed emotion: marker for a caring family?

"Expressed emotion" (EE) is considered a marker of dysfunctional family interaction in patients with schizophrenia. An alternative hypothesis, however, is that at least some of the different elements of EE really represent attempts on the part of carers to cope with and care for a relative with a psychiatric disorder. EE (criticism and emotional overinvolvement) was measured in relatives (n = 31) of patients with psychotic illness using the Five-Minute Speech Sample (FMSS). Level of EE was examined in relation to (1) patient-reported family involvement in care over the previous 2 years as indicated by medication monitoring, involvement in treatment decisions, and providing a substitute for institutional care; and (2) symptom severity and number of psychotic episodes. Presence of EE in the relative was strongly associated with the degree of family involvement in care (odds ratio [OR] over three levels: 3.2; 95% confidence interval [CI], 1.1 to 9.0). In addition, presence of high EE was associated with number of psychotic episodes in the previous 5 years in the proband (OR over 0, 1, or 2 episodes: 6.2; 95% CI, 1.2 to 31.9). The association with family involvement was confined to emotional overinvolvement (OR = 9.1; 95% CI, 2.0 to 42.2), whereas the association with previous psychotic episodes was confined to criticism (OR = 20.6; 95% CI, 2.8 to 149.3). Emotional overinvolvement may be a state marker for attempts on the part of relatives to be partners in the care for patients with psychotic illness. High level of criticism may be a trait marker in relatives associated with poor prognosis, but could also develop in reaction to a frequently relapsing illness.

A prospective twin study of birth weight discordance and child problem behavior

BACKGROUND

We investigated whether low birth weight constitutes a causal risk factor for child problem behavior, using a variation of the co-twin control method.

METHODS

In a representative sample of 745 twin pairs (monozygotic: 324 pairs), birth weight was recorded at birth and child problem behavior at mean age 10 years was measured with the Child Behaviour Checklist (CBCL).

RESULTS

Lower birth weight was a continuous risk factor for later child problem behavior (adjusted regression coefficient over units of 500 g: beta = -.15, p =.046), and greater levels of within-pair CBCL discordance did not result in a reduced effect size. Greater within-pair birth weight discordance was associated with greater within-pair CBCL score discordance (beta =.35, p <.001). This latter effect was similar in monozygotic (beta =.34, p =.005) and dizygotic twins (beta =.37, p =.003).

CONCLUSIONS

The fact that (1) the effect size of the association between low birth weight and child problem behavior was not reduced in pairs with greater levels of CBCL discordance, and (2) similar effect sizes were found in monozygotic and dizygotic twins for the within-pair association between birth weight discordance and CBCL score discordance, suggests that the observed relationship between low birth weight and child problem behavior is not due to a shared environmental or genetic variable that influences both characteristics. Lower birth weight is a causal risk factor for child problem behavior, the effects of which may well extend into adulthood.

Associations between nonshared environment and child problem behaviour

BACKGROUND

Twin studies suggest that environmental effects on the development of child psychopathology largely involve nonshared environmental processes. However, the influence of the nonshared environment may have been overestimated, as the relationship between environment and behaviour may be genetically mediated. A direct measure of the nonshared environment (using the Sibling Inventory of Differential Experience - SIDE) was investigated in relation to child psychopathology, and tested for possible genetic mediation.

METHOD

Parent-rated versions of the Child Behaviour Checklist (CBCL) and the SIDE were collected in 760 twin pairs aged 6-17 years. Multilevel regression analysis was used to assess the influence of SIDE scores on CBCL total problem scores, internalising symptoms, externalising symptoms and depressive symptom scores. Genetic mediation was assessed by examining interaction with zygosity in the association between SIDE scores and differences in CBCL scores (absence of interaction indicating no genetic mediation).

RESULTS

The results revealed significant associations between SIDE dimensions on the one hand, and degree of internalising, externalising, depression and total symptom scores on the other. However, the effects were non-linear, and especially apparent for the extremes of differential environmental experience within twin pairs. Overall, there was no strong evidence for genetic mediation of associations between nonshared environment and symptoms.

CONCLUSIONS

Direct, genetically unconfounded but skewed relationships may exist between nonshared environment on the one hand and behavioural differences on the other, although longitudinal data are necessary to determine the direction of effects.

Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison

BACKGROUND

Urban and rural populations have different rates of psychotic illness. If psychosis exists as a continuous phenotype in nature, urban-rural population differences in the rate of psychotic disorder should be accompanied by similar differences in the rate of abnormal mental states characterized by psychotic or psychosislike symptoms.

METHODS

A random sample of 7076 individuals aged 18 to 64 years were interviewed by trained lay interviewers with the Composite International Diagnostic Interview. Approximately half of those with evidence of psychosis according to the Composite International Diagnostic Interview were additionally interviewed by clinicians. We investigated associations between a 5-level urbanicity rating and (1) any DSM-III-R diagnosis of psychotic disorder (sample prevalence, 1.5%), (2) any rating of hallucinations and/or delusions (sample prevalence, 4.2%), and (3) any rating of psychotic or psychosislike symptoms (sample prevalence, 17.5%).

RESULTS

Level of urbanicity was associated not only with DSM-III-R psychotic disorder (adjusted odds ratio [OR] over 5 levels, 1.47; 95% confidence interval [CI], 1.25-1.72), but also, independently, with any rating of delusion and/or hallucination (adjusted OR, 1.28; 95% CI, 1.17-1.40; clinician-assessed psychotic symptoms only: OR, 1.30; 95% CI, 1.03-1.64) and any rating of psychosislike symptom (adjusted OR, 1.18; 95% CI, 1.13-1.24). Psychotic symptoms were strongly and independently associated with psychotic disorder, regardless of the level of urbanization.

CONCLUSIONS

Community level of psychotic and psychosislike symptoms may be inextricably linked to the prevalence of psychotic disorder. The prevalence of abnormal mental states that facilitate development to overt psychotic illness increases progressively with level of urbanization.

MACS-II: does coping enhance subjective control over psychotic symptoms?

OBJECTIVE

Associations between subjective experience of control and the use of self-initiated coping strategies were examined in patients with psychotic symptoms.

METHOD

Twenty-three patients were interviewed to assess (i) the subjective experience of distress with and control over symptoms and (ii) the coping strategies used.

RESULTS

There was a positive association between coping type and control (OR = 1.07, 95% CI: 1.03-1.12). Active coping strategies had the strongest association with experience of control (active problem-solving: OR = 1.41 95% CI: 1.18-1.68; active problem-avoiding: OR = 1.45 95% CI: 1.18-1.68). Symptomatic coping was negatively associated with control (OR = 0.40, 95% CI: 0.30-0.55), but was the most frequently used strategy. Depressive symptoms were associated with the highest number of coping strategies.

CONCLUSION

Coping strategies differ in the degree and direction of associated subjective control, and symptoms differ in the degree with which coping is mobilized. Assessment of coping strategies may be useful as a prelude to psychological therapy.

Maastricht Assessment of Coping Strategies (MACS-I): a brief instrument to assess coping with psychotic symptoms

OBJECTIVE

To examine the reliability of a brief instrument to assess coping with symptoms by patients with psychotic illness.

METHOD

A semi-structured interview (MACS) was developed to assess the amounts of distress, control and coping in relation to psychotic symptoms. Two raters interviewed 23 symptomatic but stable patients with a diagnosis of chronic schizophrenia on two separate occasions. Case managers were also interviewed.

RESULTS

Both the number of coping strategies used for different groups of symptoms, and the amount of coping used in different domains of coping strategies could be assessed reliably between interviewers (intraclass correlation coefficients range: 0.90-0.97) and between interview sessions (ICCs range: 0.75-0.80). Reliability with case managers, however, was low.

CONCLUSION

The MACS may be a reliable and useful instrument to assess coping in relation to subjective experience of distress by and control over psychotic symptoms.

Predictors and outcome characteristics associated with suicidal behaviour in early psychosis: a two-year follow-up of first-admitted subjects

OBJECTIVE

To assess the baseline characteristics associated with a greater risk of suicidal behaviour (suicide and parasuicide) over the 2 years following a first admission for psychosis, and the associations between suicidality and outcome.

METHOD

First-admitted subjects with psychosis (n=65) were assessed at 6-monthly intervals over a 2-year follow-up period.

RESULTS

Over this period, 11.3% of the patients displayed suicidal behaviour. Baseline predictors of suicidal behaviour were a lifetime history of parasuicide before first admission (OR=5.9, 95% CI 1.5-23.4), lower Positive And Negative Symptom Scale positive subscores (OR=0.8, 95% CI 0.6-0.97) and a longer duration of first admission (OR=1.1, 95% CI 1-1.2). Subjects with suicidal behaviour presented with a longer duration of psychotic symptoms (OR=1.1, 95% CI 1.02-1.2) and a greater risk of being readmitted (OR=4.6, 95%CI 1.1-19.1). Subjects with substance misuse over the follow-up period were seven times (95%CI 1.3-39) more likely to engage in suicidal behaviour.

CONCLUSION

Subjects with a previous history of parasuicide, with a deteriorating clinical course, or with substance misuse are at increased risk of suicidal behaviour in the 2 years after the onset of a first psychotic episode.

Is the association between duration of untreated psychosis and outcome confounded? A two year follow-up study of first-admitted patients

OBJECTIVE

To assess whether a long duration of untreated psychosis (DUP) before first admission predicts poor clinical and social outcome, and whether this association, if any, is confounded by premorbid and clinical characteristics.

METHOD

A population-based sample of first-admitted subjects with psychosis (n = 65) was assessed at six monthly intervals over a two year follow-up using multiple sources of information.

RESULTS

Most subjects (87%) with a life-chart 'continuous' course of psychotic symptoms had a history of a 'long' delay between onset of psychotic symptoms and first admission (> or = 3 months, median split), compared with 55% of subjects with a course of 'neither episodic nor continuous', 42% of subjects with an 'episodic' course, and 33% of subjects with 'no psychotic symptoms' during the follow-up period (RR = 9; 95%CI 1.5-54.8, P = 0.02). The strength of association between DUP and continuous course of psychosis was strongly reduced (63%) after adjustment for premorbid functioning, and to a lesser extent for the severity of illness and for the intensity of negative symptoms at first admission.

CONCLUSIONS

The association between DUP and poor outcome may be spurious, confounded by the fact that poor premorbid functioning is independently associated with both DUP and poor outcome, with no direct causal link between these two latter variables. DUP may also be on the causal pathway between poor premorbid functioning and poor outcome, poor adjustment delaying access to care, and subsequently increasing the risk of presenting with a non-remitting course of illness. The links between premorbid functioning, DUP and outcome have to be further explored to clarify the directions of the associations between these variables.

Neighbourhood level and individual level SES effects on child problem behaviour: a multilevel analysis

OBJECTIVE

This study examined whether neighbourhood level socioeconomic variables have an independent effect on reported child behaviour problems over and above the effect of individual level measures of socioeconomic status.

DESIGN AND SETTING

Multilevel analysis of cross sectional survey data relating individual level child behavioural problems and parental measures of socioeconomic status with neighbourhood level measures of socioeconomic deprivation in the city of Maastricht, the Netherlands.

PARTICIPANTS

Children born in the years 1990-1991 attending the second grade of normal kindergarten schools in the city of Maastricht, the Netherlands. Out of 1417 eligible 5-7 year olds, the parents of 734 children (51.8%) agreed to participate.

MAIN RESULTS

Child behaviour problems were more frequent in families of low parental occupation and education (F=14.51, df 3, 721, p<0.001; F=12.20, df 3, 721, p<0.001, respectively) and in families living in deprived neighbourhoods (F=13.26, df 2, 722, p<0.001). Multilevel random effects regression analysis showed that the effect of neighbourhood level deprivation remained after adjustment for individual level socioeconomic status (B over three levels of deprivation: 1.36; 95%CI=0.28, 2.45).

CONCLUSIONS

Living in a more deprived neighbourhood is associated with higher levels of child problem behaviour, irrespective of individual level socioeconomic status. The additional effect of the neighbourhood may be attributable to contextual variables such as the level of social cohesion among residents.

Neuroticism, life events and mental health: evidence for person-environment correlation

BACKGROUND

There is some evidence that genetic effects on the likelihood of experiencing stressful life events (SLEs) are mediated by heritable traits such as cognitive ability (CA) and neuroticism (N).

AIMS

To examine whether the association between CA, N and mental ill-health is driven in part by a predisposition to experience depressogenic SLEs.

METHOD

Childhood measures of N and CA were available in a birth cohort of 5362 individuals. At ages 36 and 43 years, mental state and occurrence of SLEs in the previous year were assessed. Using a path-analytic approach, models with and without a hypothesised influence of N and CA on the occurrence of SLEs were compared.

RESULTS

The fit of the model with childhood N having a direct influence on SLEs was good with chi 2 = 5.72, d.f. = 4, P = 0.22 at age 36 years and chi 2 = 3.50, d.f. = 5, P = 0.62 at age 43. The fit of the model was significantly worse without this path at both ages (36 years: chi 2 = 42.5, d.f. = 1, P < 0.001; 43 years chi 2 = 15.3, d.f. = 1, P < 0.001). No consistent differences were seen in comparisons of models with CA.

CONCLUSIONS

The results are congruent with the suggestion that genetic effects on SLEs are mediated by personal characteristics. Part of the well-established association between N and minor psychiatric disorder may be mediated by an indirect effect of N on the likelihood of experiencing SLEs.

Single or multiple familial cognitive risk factors in schizophrenia?

The fact that relatives of patients with schizophrenia display subtle cognitive abnormalities suggests genetic transmission of an underlying cognitive endophenotype. It was examined to what extent the cognitive abnormalities that discriminate patients and relatives from controls do so independently of each other, and independent of IQ. Neuropsychological measures were assessed in 50 patients with schizophrenia, 50 first-degree relatives of patients with schizophrenia, and 50 healthy controls. The assessment focused on episodic memory, attentional span, simple and complex speed of information, and semantic memory. Factor analysis of the cognitive test results yielded four factors reflecting speed, episodic memory, working memory, and semantic fluency. Performance of the relatives was intermediate to that of the patients and the controls after adjustment for age, sex, educational level, and IQ. For both patients and relatives, speed of information processing, working memory, and episodic memory independently discriminated from control performance, with a similar pattern in the order of the size of the effects. The results suggest the existence of more than one familial cognitive risk factor for schizophrenia. Independent familial cognitive risk factors may represent separate causal influences or separate indicators of risk related to the same genetic mechanism.

Strauss (1969) revisited: a psychosis continuum in the general population?

Although dichotomously defined for clinical purposes, psychosis may exist as a continuous phenotype in nature. A random sample of 7076 men and women aged 18-64years were interviewed by trained lay interviewers with the Composite International Diagnostic Interview (CIDI). Those with evidence of psychosis according to the CIDI were additionally interviewed by psychiatrists. For the 17 CIDI core psychosis items, we compared a psychiatrist's rating of hallucinations and/or delusions (Clinical Psychosis; sample prevalence 4.2%) with three other possible positive CIDI ratings of the same items: (i) symptom present, but not clinically relevant (NCR Symptom; sample prevalence 12.9%); (ii) symptom present, but the result of drugs or somatic disorder (Secondary Symptom; sample prevalence 0.6%); (iii) symptom appears present, but there is a plausible explanation (Plausible Symptom; sample prevalence 4.0%). Of the 1237 individuals with any type of positive psychosis rating (sample prevalence 17.5%), only 26 (2.1%) had a DSM-III-R diagnosis of non-affective psychosis. All the different types of psychosis ratings were strongly associated with the presence of psychiatrist-rated Clinical Psychosis (NCR Symptom: OR=3.4; 95% CI: 2.9-3.9; Secondary Symptom: OR=4.5; 95% CI: 2.7-7.7; Plausible Symptom: OR=5.8; 95% CI: 4.7-7.1). Associations with lower age, single marital status, urban dwelling, lower level of education, lower quality of life, depressive symptoms and blunting of affect did not differ qualitatively as a function of type of rating of the psychotic symptom, were similar in individuals with and without any CIDI lifetime diagnosis, and closely resembled those previously reported for schizophrenia. Presence of any rating of hallucinations was strongly associated with any rating of delusions (OR=6.7; 95% CI: 5.6-8.1), regardless of presence of any CIDI lifetime diagnosis. The observation by Strauss (1969. Hallucinations and delusions as points on continua function. Arch. Gen. Psychiatry 21, 581-586) that dichotomously diagnosed psychotic symptoms in clinical samples are, in fact, part of a continuum of experiences, may also apply to the general population. The boundaries of the psychosis phenotype may extend beyond the clinical concept of schizophrenia.

Medication adherence in psychosis: predictors and impact on outcome. A 2-year follow-up of first-admitted subjects

OBJECTIVE

To assess the baseline characteristics predicting poor medication adherence following a first admission for psychosis, and the impact of poor medication adherence on outcome.

METHOD

First-admitted subjects with psychosis (n = 65) were assessed at 6-month intervals over a 2-year follow-up. Medication adherence was assessed using multiple sources of information.

RESULTS

Baseline lower occupational status, alcohol misuse and the intensity of delusional symptoms and suspiciousness predicted poor medication adherence during the 2-year follow-up. Over this period, subjects with poor medication adherence presented more frequently with an episodic course of illness and were more frequently readmitted, especially with regard to involuntary readmission.

CONCLUSION

In naturalistic conditions one out of two subjects with psychosis interrupts his/her treatment in the months following his/her first discharge from hospital. Therapeutic programmes aimed at improving medication adherence should be implemented early in the course of psychosis to reduce the deleterious consequences of poor medication adherence on clinical outcome.

Congenital dermatoglyphic malformations and psychosis: a twin study

OBJECTIVE

In a previous twin study, congenital dermatoglyphic abnormalities, such as ridge dissociations and abnormalities of palmar flexion creases, were more prevalent in twins with psychotic and related disorders than in comparison twins. This study was an attempt to replicate that finding in an independent study group.

METHOD

Ridge dissociations and abnormal palmar flexion creases were assessed in monozygotic pairs concordant (19 pairs) and discordant (31 pairs) for psychosis and related disorders.

RESULTS

The presence of either ridge dissociations or abnormal palmar flexion creases was higher in the combined group of affected concordant and discordant twins (37.7%), than in the nonaffected discordant twins (20.0%; odds ratio=2.4). In the discordant pairs, the presence of either abnormality was strongly associated with psychotic disorder (odds ratio=3.0).

CONCLUSIONS

Factors affecting early fetal development may increase the risk for psychotic disorder. Differential exposure to such early risk factors may contribute to twin discordance for psychotic disorder.

Association between cerebral structural abnormalities and dermatoglyphic ridge counts in schizophrenia

Dermatoglyphic ridge counts (1) reflect ontogenic processes during the second trimester of pregnancy and (2) can be influenced by some of the factors that also affect cerebral development. Therefore, the demonstration of an association between dermatoglyphic and cerebral structural measures in patients with schizophrenia would give credence to the view that the structural brain abnormalities associated with this disorder have their origin early in development. Twenty-eight male subjects with schizophrenia and 19 male controls underwent magnetic resonance imaging (MRI) and dermatoglyphic analysis. The pattern of association between the ab-ridge count and nine MRI features was dissimilar in cases and controls for two measures. Associations between dermatoglyphic features, on the one hand, and the frontal CSF (r = .54, P = .004) and fourth ventricular volume (r = .38, P = .05), on the other, were larger in the cases versus the controls (test for interaction, P = .08 and P = .06, respectively). These findings, while in need of replication, support the view that the cerebral structural abnormalities found in patients with schizophrenia are the result of an early pathologic process affecting the development of fetal ectodermal structures.

Diagnostic value of the DSM and ICD categories of psychosis: an evidence-based approach. UK700 Group

BACKGROUND

It is generally assumed that the distinction between affective and non-affective psychosis occasioned by modern diagnostic criteria provides a useful symptomatic contrast.

METHOD

In a sample of 708 patients with chronic psychosis, the distinction of lifetime DSM-III-R and ICD-10 diagnoses of affective versus non-affective psychosis was used as a diagnostic test to detect lifetime presence of depressive, manic, positive, negative and disorganisation symptoms.

RESULTS

A manic or depressive affective diagnosis was a perfect test to diagnose the presence of manic and depressive symptoms, as evidenced by very high diagnostic likelihood ratios. However, this test result was based solely on the inclusion criterion that patients with affective psychosis must have affective symptoms (guaranteeing high specificity and high likelihood ratios), and ignored the fact that patients with non-affective psychosis also had high affective symptom scores (low sensitivity). Furthermore, a non-affective psychotic diagnosis was a very poor test to diagnose correctly the presence of positive, negative and disorganisation symptoms in comparison with an affective psychotic diagnosis. In general, the DSM-III-R categories performed somewhat better as a diagnostic test than those of ICD-10.

CONCLUSION

The evidence for true diagnostic value of the distinction between affective and non-affective psychotic diagnoses is weak. Rather, the distinction appears to obscure natural overlap between the symptom dimensions of the different diagnostic categories.

Developmental instability and schizotypy

INTRODUCTION

It has been suggested that evidence of developmental disturbance of cognition and lateralisation in schizophrenia can be best understood from the perspective of developmental stability (DS), an indicator of the extent to which an individual develops according to a specified ontogenic programme in the presence of environmental noise. Higher levels of fluctuating asymmetry (FA; the difference between right and left side of a quantitative morphological trait such as dermatoglyphics) are thought to reflect less DS. We examined this issue for dimensions of schizotypy.

METHODS

Associations between FA, measures of laterality and cognitive function on the one hand, and negative and positive dimensions of schizotypy on the other, were examined in a sample of 260 healthy adolescents aged 11.9-15.6years. FA was measured as a-b ridge count right-left differences. Neuropsychological measures yielded a general cognitive ability score and a frontal function score. Laterality was assessed with the Annett scale.

RESULTS

Measures of psychosis proneness were normally distributed. Negative schizotypy was associated with more FA and lower general cognitive ability in a dose-response fashion. The association with FA was more apparent in boys. No associations existed with laterality or frontal function.

CONCLUSION

The negative dimension of schizotypy may be associated with early developmental instability, resembling the pattern seen in the negative symptom dimension of schizophrenia. Measures of fluctuating asymmetry may be more sensitive with regard to the schizotypy phenotype than measures of laterality.

Changes in negative symptoms and the risk of tardive dyskinesia: a longitudinal study. UK700 Group

OBJECTIVE

To examine whether the development of tardive dyskinesia (TD) is accompanied by a parallel process of worsening negative symptoms in a longitudinal study.

METHOD

A sample of 708 psychotic patients were followed over a period of 2 years, using the Abnormal Involuntary Movement Scale and the Scale for the Assessment of Negative Symptoms (SANS).

RESULTS

Of 361 individuals with no prior evidence of dyskinesia, 46 (13%) developed TD by year 2. Independent of the effects of male sex (odds ratio (OR)=2.18, 95% confidence interval: 1.00-4.74), age (OR per quartile group = 1.39, 95% CI: 1.01-1.90), duration of exposure to antipsychotic medication (OR = 2.35 per 8 months, 95% CI: 1.17-4.72) and average SANS score (OR per quartile group = 1.38, 95% CI: 0.99-1.93), worsening of negative symptoms over the 2 previous years was associated with TD onset (OR per quartile group = 1.46, 95% CI: 1.07-2.00).

CONCLUSION

The development of TD is linked, independent of the effect of antipsychotics and older age, to an illness-related pathological process, characterized by worsening negative symptoms.

Neighbourhood variation in incidence of schizophrenia. Evidence for person-environment interaction

BACKGROUND

Neighbourhood characteristics may influence the risk of psychosis, independently of their individual-level equivalents.

AIMS

To examine these issues in a multi-level model of schizophrenia incidence.

METHOD

Cases of schizophrenia, incident between 1986 and 1997, were identified from the Maastricht Mental Health Case Register. A multi-level analysis was conducted to examine the independent effects of individual-level and neighbourhood-level variables in 35 neighbourhoods.

RESULTS

Independent of individual-level single and divorced marital status, an effect of the proportion of single persons and proportion of divorced persons in a neighbourhood was apparent (per 1% increase respectively: RR = 1.02; 95% CI 1.00-1.03; and RR = 1.12, 95% CI 1.04-1.21). Single marital status interacted with the neighbourhood proportion of single persons, the effect being stronger in neighbourhoods with fewer single-person households.

CONCLUSIONS

The neighbourhood environment modifies the individual risk for schizophrenia. Premorbid vulnerability resulting in single marital status may be more likely to progress to overt disease in an environment with a higher perceived level of social isolation.