How do relatives cope with eating disorders? Results from an Italian multicentre study

OBJECTIVE

This paper aims to: (1) describe coping strategies in relatives of patients with eating disorders (EDs); (2) analyze coping strategies according to the different EDs; (3) identify correlations between patients' clinical characteristics, relatives' socio-demographic characteristics and coping strategies.

METHODS

Patients and their relatives consecutively attending three outpatient units for EDs at the Universities of Naples SUN, Salerno and Catanzaro were recruited. Coping strategies were assessed through the Family Coping Questionnaire for Eating Disorders (FCQ-ED). It consists of 32 items, grouped into two factors: problem-oriented ("seek for information", "positive communication") and emotion-focused ("avoidance," "collusion," "coercion") strategies, plus one item on seeking for spiritual help.

RESULTS

Seventy-two patients and 127 relatives were recruited. The most frequently reported coping strategies by relatives were seeking for information, positive communication, seeking for spiritual help; the first two coping strategies were positively correlated with the level of education of both patients and relatives. Mothers reported avoidance less frequently than other relatives. Relatives of patients with BN reported collusion and coercion more frequently compared to relatives of patients with AN.

DISCUSSION

This report represents an initial attempt to understand the complex relationship among clinical, social and personal variables involved in the development of coping strategies. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:587-592).

Are coping strategies really different among family members of patients with eating disorders?

Introduction

Family members of patients with Eating Disorders(EDs)–in dealing with the relatives’ disease–report negative feelings such as self-blame and criticism, but little is known regarding their coping strategies.

Objectives

To describe coping strategies in a sample of relatives of patients with EDs using the Family Coping Questionnaire–Eating Disorder version (FCQ-ED).

Aims (1) To evaluate coping strategies in relatives of patients with EDs; (2) to describe differences in coping strategies according to type of kinship with the patient; (3) to identify correlations among socio-demographic characteristics, patients’ clinical characteristic, and type of coping strategies.

Methods

Relatives’ coping strategies were evaluated using the FCQ-ED, a self-administered questionnaire, consisting of 32 items, grouped in 5 subscales: coercion; positive communication; collusion; seeking for information; avoidance, plus one item on seeking for spiritual help.

Results

Seventy-two patients and 127 relatives were recruited. The most frequently adopted coping strategies were seeking for information, positive communication, seeking for spiritual help; the former were positively correlated with the level of education of both patients and relatives. Mothers avoided the patients less frequently than other relatives.

Discussion

This is one of the first studies focused on coping strategies in families of patients with EDs showing that problem-oriented ones are used quite often. Socio-demographic characteristics and type of kinship can have an impact on the adoption of coping strategies, but further longitudinal studies are needed in order to identify other possible factors implied in their development.

Conclusions

This represents an initial attempt to understand how clinical, social and personal variables can have an impact on the development of coping strategies.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

SM-5, ICD-11, RDoC and the Future of Psychiatric Classification

The publication of the DSM-III in 1980 was intended to be a reaction to the evidence of the embarrassingly low reliability of psychiatric diagnoses, which was perceived as a major threat to the credibility of the psychiatric profession. The aims of the DSM-III project were actually two. First, the reliable definition of the diagnostic categories was expected to lead to the collection of research data that would validate those diagnostic entities and in particular elucidate their etiopathogenetic underpinnings. Second, there was an expectation that, by increasing reliability, communication among clinicians would be improved and clinical decisions made more rational. Today, one could say that the first aim of the project has not been achieved, while the fulfilment of the second aim has never been tested appropriately. The crisis of confidence in the DSM paradigm, clearly emerging from the debate following the publication of the DSM-5, has led on the one hand to a renewed emphasis on clinical utility, which is featuring prominently in the ongoing process of development of the ICD-11. On the other hand, it has led to a radical attempt to reform psychiatric nosology starting from neurobiological and behavioural phenotypes. This attempt does have its weaknesses, but may also represent a stimulus to reconceptualize some psychopathological constructs, especially in the area of psychoses, in order to reduce the gap between the level of neuroscience and that of clinical phenomenology.

Disclosure of interest

The author has not supplied his declaration of competing interest.

The Impact of Premorbid Functioning on Outcome Indices in a Large Sample of Italian Patients with Schizophrenia

Introduction

An impairment of premorbid adjustment (PA) has been regarded among poor prognostic indicators of schizophrenia. Some discrepancies in the literature suggest the usefulness of further characterizations of its impact on different aspects of the disease.

Aims

The present study aimed to investigate the association of poor PA with psychopathology, neurocognition and real-life functioning in patients with schizophrenia recruited within the multicenter study of the Italian network for research on psychoses. functioning during childhood and adolescence (early adjustment) was assessed also in a group of healthy controls (HC) and one of unaffected relatives of patients (UR).

Methods

Group comparisons were performed between patients with poor and those with good PA. Differences in frequency of poor early adjustment were investigated among patients, HC and UR.

Results

Patients with poor PA, as compared to those with good PA, showed earlier age of onset, more severe negative symptoms and disorganization, greater impairment on all cognitive domains with the exception of attention/vigilance and worse real-life functioning in the considered areas (interpersonal relationships, community activities and work abilities). The pattern of poor early adjustment was more frequent in patients with respect to UR and HC and, to a less degree, in UR with respect to HC.

Conclusions

Our findings confirm that poor PA in schizophrenia is associated with poorer illness outcome, and offer a further characterization of PA impact on different psychopathological and cognitive domains. They also suggest that poor early adjustment is a candidate endophenotype of schizophrenia, occurring in patients and their unaffected relatives.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychiatry 2017: Acknowledging Complexity While Avoiding Defeatism

In the past few years, it has become a sort of cliché to state that psychiatry is in a crisis. In particular, it has been repeatedly argued that: (a) psychiatric diagnoses are invalid; (b) psychiatric research has not progressed significantly (in particular, it has not been able to identify “the cause” of schizophrenia, depression or bipolar disorder); (c) psychiatric treatments are of limited value, and their widespread use has not been able to reduce the incidence of mental disorders. This perception of crisis has been at least in part generated by an identification of mainstream psychiatry with the neo-kraepelinian paradigm, so that the crisis of confidence in that paradigm has expanded into a crisis of confidence in the psychiatric discipline. According to Kuhn, the crisis of confidence in a paradigm is accompanied by a period of “extraordinary science”, marked by a proliferation of competing methodologies, the proposition of a variety of divergent solutions for the problem defining the crisis, and the recourse to philosophy and to debate over fundamentals of the discipline. The crisis of confidence in the neo-kraepelinian paradigm has generated such a period, in which we are all now immersed. In this presentation, I will summarize the main components of the neo-kraepelinian paradigm; I will illustrate why that paradigm has failed, or at least has lost people's confidence; and will summarize the main elements which are emerging in the current period of “extraordinary science”.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Autistic Traits in Patients with Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder: A Pilot Study

Introduction

Previous data showed higher autistic traits in individuals with anorexia nervosa (AN) compared to healthy controls (CTL). It is not known, however, whether this characteristic is shared by other feeding and eating disorders (FEDs) or it is uniquely associated to AN.

Objectives

To compare autistic traits among individuals with AN, bulimia nervosa (BN), binge eating disorder (BED) and CTL and to investigate which specific dimensions differentiate one group from another.

Methods

A total of 241 FED patients (53 AN, 41 BN, 42 BED) and 105 CTL were administered the autism-spectrum quotient (AQ), the adult autism subthreshold spectrum (AdAS Spectrum), the Ritvo autism and Asperger diagnostic scale 14-item (RAADS-14 Screen).

Results

FED subjects reported higher AQ, AdAS spectrum and RAADS-14 total and subscales scores compared to CTL (all P < .001). No differences were found amongst AN, BN and BED subjects in questionnaires’ total scores. BN group scored higher than AN in the hyper-/hyporeactivity to sensory input domain of the AdAS spectrum (P < .001); AN group scored higher than BED in the attention switching domain of the AQ (P < .001), and BED group scored lower than both AN and BN in the mentalizing deficit domain of the RAADS-14 (all P < .001).

Conclusions

We reported for the first time that not only AN but also BN and BED patients show greater autistic traits compared to CTL. Longitudinal studies are needed to confirm this preliminary report and to elucidate whether autistic traits either precede, co-occur or follow FEDs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adult Autism Subthreshold Spectrum (AdAS Spectrum): Validation of a questionnaire investigating subthreshold autism spectrum

AIM

Increasing literature has shown the usefulness of a dimensional approach to autism. The present study aimed to determine the psychometric properties of the Adult Autism Subthreshold Spectrum (AdAS Spectrum), a new questionnaire specifically tailored to assess subthreshold forms of autism spectrum disorder (ASD) in adulthood.

METHODS

102 adults endorsing at least one DSM-5 symptom criterion for ASD (ASDc), 143 adults diagnosed with a feeding and eating disorder (FED), and 160 subjects with no mental disorders (CTL), were recruited from 7 Italian University Departments of Psychiatry and administered the following: SCID-5, Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale 14-item version (RAADS-14), and AdAS Spectrum.

RESULTS

The AdAS Spectrum demonstrated excellent internal consistency for the total score (Kuder-Richardson's coefficient=.964) as well as for five out of seven domains (all coefficients>.80) and sound test-retest reliability (ICC=.976). The total and domain AdAS Spectrum scores showed a moderate to strong (>.50) positive correlation with one another and with the AQ and RAADS-14 total scores. ASDc subjects reported significantly higher AdAS Spectrum total scores than both FED (p<.001) and CTL (p<.001), and significantly higher scores on the Childhood/adolescence, Verbal communication, Empathy, Inflexibility and adherence to routine, and Restricted interests and rumination domains (all p<.001) than FED, while on all domains compared to CTL. CTL displayed significantly lower total and domain scores than FED (all p<.001). A significant effect of gender emerged for the Hyper- and hyporeactivity to sensory input domain, with women showing higher scores than men (p=.003). A Diagnosis* Gender interaction was also found for the Verbal communication (p=.019) and Empathy (p=.023) domains. When splitting the ASDc in subjects with one symptom criterion (ASD₁) and those with a ASD, and the FED in subjects with no ASD symptom criteria (FED₀) and those with one ASD symptom criterion (FED₁)_, a gradient of severity in AdAS Spectrum scores from CTL subjects to ASD patients, across FED₀, ASD₁, FED₁ was shown.

CONCLUSIONS

The AdAS Spectrum showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of ASD. The questionnaire performed differently among the three diagnostic groups and enlightened some significant effects of gender in the expression of autistic traits.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio-environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual-focused, health system-focused, and community level and policy-focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

Interhemispheric functional connectivity in anorexia and bulimia nervosa

The functional interplay between hemispheres is fundamental for behavioral, cognitive, and emotional control. Anorexia nervosa (AN) and bulimia nervosa (BN) have been largely studied with brain magnetic resonance imaging (MRI) in relation to the functional mechanisms of high-level processing, but not in terms of possible inter-hemispheric functional connectivity anomalies. Using resting-state functional MRI (fMRI), voxel-mirrored homotopic connectivity (VMHC) and regional inter-hemispheric spectral coherence (IHSC) were studied in 15 AN and 13 BN patients and 16 healthy controls (HC). Using T1-weighted and diffusion tensor imaging MRI scans, regional VMHC values were correlated with the left-right asymmetry of corresponding homotopic gray matter volumes and with the white matter callosal fractional anisotropy (FA). Compared to HC, AN patients exhibited reduced VMHC in cerebellum, insula, and precuneus, while BN patients showed reduced VMHC in dorso-lateral prefrontal and orbito-frontal cortices. The regional IHSC analysis highlighted that the inter-hemispheric functional connectivity was higher in the 'Slow-5' band in all regions except the insula. No group differences in left-right structural asymmetries and in VMHC vs. callosal FA correlations were significant in the comparisons between cohorts. These anomalies, not explained by structural changes, indicate that AN and BN, at least in their acute phase, are associated with a loss of inter-hemispheric connectivity in regions implicated in self-referential, cognitive control and reward processing. These findings may thus gather novel functional markers to explore aberrant features of these eating disorders.

The Classification of Anxiety and Fear-Related Disorders in the ICD-11

Anxiety disorders are highly prevalent worldwide and engender substantial economic costs and disability. The World Health Organization is currently developing the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), which represents the first opportunity to improve the validity, clinical utility, and global applicability of the classification in more than 25 years. This article describes changes in the organization and diagnostic guidelines for anxiety and fear-related disorders proposed by the ICD-11 Working Group on the Classification of Mood and Anxiety Disorders and the rationale and evidence base for the proposals. In ICD-11, anxiety and fear-related disorders that manifest across the lifespan are brought together under a new grouping, and are partly distinguished by their focus of apprehension. The focus of apprehension is the stimulus or situation that triggers the fear or anxiety and may be highly specific as in specific phobia or relate to a broader class of situations as in social anxiety disorder. The guidelines also clarify the relationship between panic disorder and agoraphobia and a qualifier is provided for panic attacks in the context of other disorders. A standardized format emphasizing essential features of anxiety disorders is intended to improve clinical utility. Guidelines will be further refined based on findings from two types of field studies: those using a case-controlled vignette methodology disseminated via the Internet to practitioners worldwide (http://gcp.network) and clinic-based field trials implemented globally at participating field study centers.

From Asperger's Autistischen Psychopathen to DSM-5 Autism Spectrum Disorder and Beyond: A Subthreshold Autism Spectrum Model

Growing interest has recently been devoted to partial forms of autism, lying at the diagnostic boundaries of those conditions previously diagnosed as Asperger's Disorder. This latter includes an important retrieval of the European classical psychopathological concepts of adult autism to which Hans Asperger referred in his work. Based on the review of Asperger's Autistische Psychopathie, from first descriptions through the DSM-IV Asperger's Disorder and up to the recent DSM-5 Autism Spectrum Disorder, the paper aims to propose a Subthreshold Autism Spectrum Model that encompasses not only threshold-level manifestations but also mild/atypical symptoms, gender-specific features, behavioral manifestations and personality traits associated with Autism Spectrum Disorder. This model includes, but is not limited to, the so-called broad autism phenotype spanning across the general population that does not fully meet Autism Spectrum Disorder criteria. From this perspective, we propose a subthreshold autism as a unique psychological/behavioral model for research that could help to understand the neurodevelopmental trajectories leading from autistic traits to a broad range of mental disorders.

Social cognition in people with schizophrenia: a cluster-analytic approach

BACKGROUND

The study aimed to subtype patients with schizophrenia on the basis of social cognition (SC), and to identify cut-offs that best discriminate among subtypes in 809 out-patients recruited in the context of the Italian Network for Research on Psychoses.

METHOD

A two-step cluster analysis of The Awareness of Social Inference Test (TASIT), the Facial Emotion Identification Test and Mayer-Salovey-Caruso Emotional Intelligence Test scores was performed. Classification and regression tree analysis was used to identify the cut-offs of variables that best discriminated among clusters.

RESULTS

We identified three clusters, characterized by unimpaired (42%), impaired (50.4%) and very impaired (7.5%) SC. Three theory-of-mind domains were more important for the cluster definition as compared with emotion perception and emotional intelligence. Patients more able to understand simple sarcasm (⩾14 for TASIT-SS) were very likely to belong to the unimpaired SC cluster. Compared with patients in the impaired SC cluster, those in the very impaired SC cluster performed significantly worse in lie scenes (TASIT-LI <10), but not in simple sarcasm. Moreover, functioning, neurocognition, disorganization and SC had a linear relationship across the three clusters, while positive symptoms were significantly lower in patients with unimpaired SC as compared with patients with impaired and very impaired SC. On the other hand, negative symptoms were highest in patients with impaired levels of SC.

CONCLUSIONS

If replicated, the identification of such subtypes in clinical practice may help in tailoring rehabilitation efforts to the person's strengths to gain more benefit to the person.

The "Insight Paradox" in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression

The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.

Pathways to functional outcome in subjects with schizophrenia living in the community and their unaffected first-degree relatives

RATIONALE

Variables influencing real-life functioning have repeatedly been modeled in schizophrenia subjects but not systematically investigated in their unaffected first-degree relatives (SRs), in whom milder forms of deficits reported in schizophrenia have been observed, but confounders of clinical cohorts are not in play. Demonstrating that pathways to functional outcome are similar between patients and SRs would validate structural models developed in schizophrenia subjects. The present multicenter study aimed to explore whether variables associated with real-life functioning are similar in schizophrenia patients and their unaffected relatives.

METHODS

The study sample included 921 schizophrenia patients, 379 SRs and 780 healthy controls. Structural Equation Models (SEMs) were used in patients and SRs to test associations of psychopathological dimensions, neurocognition, social cognition, resilience, perceived stigma and functional capacity with real-life functioning domains, impaired in both patients and SRs.

RESULTS

Interpersonal Relationships and Work Skills were the only functional domains impaired in both patients and SRs. For both domains, functional impairment in patients was found to predict impairment in unaffected relatives, suggesting the involvement of similar illness-related vulnerability factors. In both groups variables significantly associated with Interpersonal Relationships included Social Cognition, Neurocognition, Avolition, Resilience, Disorganization, Perceived Stigma and Gender, and those significantly associated with Work Skills included Social Cognition, Neurocognition and Disorganization.

CONCLUSIONS

Pathways to functional outcome for Interpersonal relationships and Work skills are similar between schizophrenia patients and their unaffected first-degree relatives. These findings validate, in the absence of confounders of clinical cohorts, structural models of determinants of functional outcome in people with schizophrenia.

Genome-wide association study of 40,000 individuals identifies two novel loci associated with bipolar disorder

Bipolar disorder (BD) is a genetically complex mental illness characterized by severe oscillations of mood and behaviour. Genome-wide association studies (GWAS) have identified several risk loci that together account for a small portion of the heritability. To identify additional risk loci, we performed a two-stage meta-analysis of >9 million genetic variants in 9,784 bipolar disorder patients and 30,471 controls, the largest GWAS of BD to date. In this study, to increase power we used ∼2,000 lithium-treated cases with a long-term diagnosis of BD from the Consortium on Lithium Genetics, excess controls, and analytic methods optimized for markers on the X-chromosome. In addition to four known loci, results revealed genome-wide significant associations at two novel loci: an intergenic region on 9p21.3 (rs12553324, P =  5.87 × 10 -  9; odds ratio (OR) = 1.12) and markers within ERBB2 (rs2517959, P =  4.53 × 10 -  9; OR = 1.13). No significant X-chromosome associations were detected and X-linked markers explained very little BD heritability. The results add to a growing list of common autosomal variants involved in BD and illustrate the power of comparing well-characterized cases to an excess of controls in GWAS.

Underweight subjects with anorexia nervosa have an enhanced salivary cortisol response not seen in weight restored subjects with anorexia nervosa

The cortisol response to awakening (CAR) has been reported to be enhanced in symptomatic patients with anorexia nervosa (AN). However, it has been not established whether the dysregulation of CAR was a primary phenomenon or a change secondary to malnutrition. Therefore, we aimed to explore the salivary CAR in both underweight and weigh-restored women with AN. Fifty-nine women volunteered for the study. They were 18 underweight AN women, 15 weight-restored AN women and 26 normal-weight healthy women. Saliva samples were collected in the morning, immediately on awakening and after 15, 30 and 60min to measure saliva levels of cortisol. Participants' anxiety levels in the morning of sampling were measured by the State-Trait Anxiety Inventory. As compared to control women, underweight AN patients showed an enhanced CAR whereas weight-restored patients had a normal CAR. These results could be not explained by group differences in body mass index or levels of anxiety. These findings show, for the first time, that the enhanced CAR occurring in the acute phase of AN is not seen in weight-recovered patients, suggesting that the dysregulated activity of the hypothalamus-pituitary-adrenal axis of symptomatic AN patients is a state-dependent phenomenon.

Olanzapine Is Faster than Haloperidol in Inducing Metabolic Abnormalities in Schizophrenic and Bipolar Patients

The effects of olanzapine and haloperidol on metabolic parameters in bipolar patients have been evaluated much less comprehensively than in schizophrenic patients. Therefore, in this study, medical records of 343 schizophrenic and bipolar patients treated with haloperidol or olanzapine for 1 year were retrospectively reviewed and metabolic outcomes were evaluated. After 12 months of follow-up, 25.9% of patients showed ≥3 metabolic abnormalities with a point prevalence of 27.2% in the bipolar and 24.9% in the schizophrenic group: 22.0% of the schizophrenic patients treated with haloperidol and 29.8% of those treated with olanzapine achieved ≥3 metabolic alterations; in bipolar patients, these percentages were 15.8% of those treated with haloperidol and 37.8% of those treated with olanzapine (p < 0.0001). Significant changes were reported over time in fasting glucose, triglycerides and cholesterol blood levels, systolic and diastolic blood pressure, body weight, and BMI. Overall, a significant number of schizophrenic and bipolar patients treated with olanzapine showed ≥3 metabolic alterations in the first month of treatment when compared to those treated with haloperidol. Moreover, the number of olanzapine-treated patients developing metabolic changes in the first month was significantly higher in both diagnostic groups when compared to those who reached metabolic abnormal values in the subsequent 11 months. These data suggest that both antipsychotics could increase the metabolic risk in schizophrenic and bipolar patients with a higher prevalence in olanzapine-treated patients. On the other hand, olanzapine-treated patients seem to achieve metabolic abnormalities faster than haloperidol-treated subjects in both diagnostic groups.

Investigation of the Endogenous Stress Response System in Patients with Chronic Schizophrenia

OBJECTIVE

Cardiophysiological and neuroendocrine studies suggest that the two components of the endogenous stress response system, the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis, are dysregulated in patients with schizophrenia. However, cardiophysiological measures are influenced by several confounding factors and the secretion of α-amylase in saliva is believed to represent a more reliable index of SNS activity. Therefore, to characterize the functional status of the SNS and HPA axis in schizophrenia we explored the concomitant salivary secretion of cortisol and α-amylase.

METHODS

Saliva cortisol and α-amylase levels were measured after awakening in 30 patients with chronic schizophrenia and 22 healthy subjects.

RESULTS

After awakening, saliva cortisol increased in a similar way in both patients and healthy controls, while saliva α-amylase concentrations showed a clear-cut decrease in healthy subjects but not in patients with schizophrenia. No significant correlation emerged between biochemical measures and patients' demographic or psychopathological characteristics.

CONCLUSIONS

These findings demonstrate normal activity of the HPA axis with an enhanced SNS tone, which suggests a functional dissociation of the two components of the endogenous stress response system in patients with chronic schizophrenia. The pathophysiological significance of such dysregulation needs further studies to be clarified.

Characterization of premorbid functioning during childhood in patients with deficit vs. non-deficit schizophrenia and in their healthy siblings

Impaired premorbid adjustment has been reported in patients with schizophrenia, generally in association with unfavorable aspects of the illness (e.g., poor outcome and severe negative symptoms). Several studies attempted to define the domains of premorbid dysfunction associated with negative symptoms and poor outcome; however, most of them assessed broadly defined negative symptoms. The present study was aimed to characterize premorbid functioning in a group of patients with deficit schizophrenia (DS), characterized by the presence of at least two primary and persistent negative symptoms (PPNS), and one of patients with a diagnosis of schizophrenia who did not meet criteria for DS (NDS). The presence of emotional/behavioral problems during childhood was investigated using the Childhood Behavior Checklist (CBCL) in both patient groups and in their respective healthy siblings. The Premorbid Adjustment Scale (PAS) was also used to assess premorbid functioning during childhood in the two patient groups. PPNS were also treated as a continuous variable and correlated with the indices of premorbid functioning regardless the DS/NDS categorization. DS patients, as compared to NDS, showed higher scores on the CBCL subscale "Withdrawn". Both DS and NDS patients showed, as compared to their healthy siblings, a greater impairment on almost all CBCL subscales. PAS findings revealed that DS patients had poorer premorbid adjustment than NDS. No significant correlation between premorbid functioning and PPNS was observed. These findings support the hypothesis that DS has a different developmental trajectory with respect to NDS, and that premorbid adjustment is one of the essential aspects of its characterization.