Diagnostic stability of first-episode psychosis. Comparison of ICD-10 and DSM-III-R systems

Diagnostic stability in patients with first-episode psychosis

OBJECTIVE

To examine the short-term stability of Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) and International Classification of Diseases (10th revision; ICD-10) diagnoses in a group of patients with first-episode psychosis.

METHOD

Sixty patients with first-episode psychosis admitted consecutively to Roozbeh Hospital, Tehran, were sampled; their illnesses could not be attributed to any medical or substance-induced conditions. Patients were assessed at the time of discharge from the hospital, and at 3, 6 and 12 month intervals following admission. At each visit, two psychiatrists made consensus DSM-IV and ICD-10 diagnoses, based on all available information. Stability was discerned as the consistency between diagnoses at the time of discharge and at 12 month follow up.

RESULTS

Forty-eight patients completed follow up. Affective psychotic disorders and schizophrenia in both classification systems were highly stable. In addition, all patients with DSM-IV brief psychotic disorder and ICD-10 acute and transient psychotic disorders remained the same at follow up.

CONCLUSIONS

Affective psychoses and schizophrenia, in line with previous findings, remained stable. Diagnoses of brief psychoses were highly stable as well; this could reflect a non-relapsing course of acute brief psychoses, especially in developing countries.

Stability of the diagnosis of first-episode psychosis made in an emergency setting

OBJECTIVE

This study aimed at evaluating the stability of the first psychotic episode diagnosis in the emergency context.

METHODS

Fifty-nine patients were selected during a 15-month period and were followed for an average of 19.35 +/- 6.12 months. The admission and discharge emergency diagnosis were compared with the longitudinal diagnosis, obtained by the application of Structured Clinical Interview for DSM-IV Axis I Disorders--clinical version at the end of the follow-up. Severity rating scales (Brief Psychiatric Rating Scale, Young Mania Rating Scale and Hamilton Rating Scale for Depression) were applied in the emergency assessment.

RESULTS

Agreement between admission emergency diagnosis and longitudinal diagnosis was unsatisfactory (k=0.25), whereas that between emergency discharge and longitudinal diagnosis was satisfactory (k=0.57). Brief psychotic disorder diagnosis presented higher sensitivity rates but low specificity, comprising several false positives. Bipolar disorder had the highest rates of specificity.

CONCLUSION

Brief psychotic disorder may not be a useful concept in the emergency assessment. A short period of observation can improve emergency psychiatric diagnosis.

Diagnostic stability in bipolar disorder in clinical practise as according to ICD-10

BACKGROUND

The diagnostic stability of the ICD-10 diagnosis of mania/bipolar disorder has not been investigated in clinical practice.

METHODS

All patients who got a diagnosis of mania/bipolar disorder at least once in a period from 1994 to 2002 at outpatient treatment or at discharge from psychiatric hospitalisation in Denmark were identified in a nationwide register.

RESULTS

Totally, 4116 patients got a diagnosis of mania/bipolar disorder at least once; among these, 2315 patients (56.2%) got the diagnosis at the first contact, whereas the remaining patients (43.8%) got the diagnosis at later contacts. Approximately 30% of patients with an initial diagnosis of mania/bipolar disorder eventually changed diagnosis during follow-up. A substantial proportion of patients initially presented with prodromal syndromes such as transient psychosis, reaction to stress/adjustment disorder or mental and behavioural disorder due to psychoactive substance use and got a diagnosis of bipolar disorder later on. Especially younger but also female patients were at increased risk of delay of the diagnosis of bipolar disorder.

LIMITATIONS

Only patients from psychiatric settings were included.

CONCLUSIONS

Clinicians should, especially in younger and female patients, be more observant on manic symptoms in patients who as first glance presents with transient psychosis, reaction to stress/adjustment disorder or with psychoactive substance abuse and follow these patients more closely over time identifying putable hypomanic and manic symptoms as early as possible.

Diagnostic stability in depressive disorder as according to ICD-10 in clinical practice

BACKGROUND

The diagnostic stability of the ICD-10 diagnosis of depressive disorder has not been investigated in clinical practice.

SAMPLING AND METHODS

All patients who were diagnosed with depressive disorder at least once in a period from 1994 to 2002 in psychiatric out- or inpatient settings in Denmark were identified in a nationwide register.

RESULTS

A total of 39,741 patients were diagnosed with depressive disorder at least once; among these, 81% were diagnosed at the first contact. In approximately 56% of patients, the initial diagnosis of depressive disorder eventually changed during follow-up mainly to the schizophrenic spectrum (16%), but also to personality disorders (9%), neurotic, stress-related and somatoform disorders (8%) and to bipolar disorder (8%). Among the 18% of patients who were later diagnosed with depressive disorder, 23% initially had a diagnosis of adjustment disorder.

CONCLUSIONS

When the ICD-10 diagnoses are used in clinical practice, the diagnosis of depressive disorder has a low stability over time. These findings emphasize the need for a longitudinally based diagnostic process in the diagnostic systems.

Diagnostic stability in a Dutch psychosis incidence cohort

BACKGROUND

No study outside the UK has examined the diagnostic stability of psychotic disorders in a population-based sample.

AIMS

To determine diagnostic stability in a Dutch population-based psychosis incidence cohort, to examine the frequencies of diagnostic shifts to and from schizophrenic disorders and to report the revised relative risks of schizophrenic disorders for immigrants.

METHOD

A 30-month follow-up study assessed the cohort (n=181) by means of face-to-face diagnostic interviews.

RESULTS

Diagnostic stability of schizophrenic disorders was high (91%), but lower for other psychotic disorders. At follow-up, the initial diagnosis was adjusted to schizophrenic disorder more often than that the reverse occurred. Almost half (49%) of the patients who were not initially diagnosed as having a schizophrenic disorder received this diagnosis at follow-up. The relative risks for most immigrant groups were stable.

CONCLUSIONS

Schizophrenic disorders are underdiagnosed, rather than overdiagnosed, at first presentation.

Acute and transient psychotic disorders: precursors, epidemiology, course and outcome

BACKGROUND

ICD-10 has introduced the diagnostic group acute and transient psychotic disorders (ATPDs; F23).

AIMS

To validate the nosological distinctiveness of ICD-10 ATPDs by following up an inception cohort with first-episode psychosis.

METHOD

All patients with first-episode psychosis identified in Nottingham between 1992 and 1994 and diagnosed using ICD-10 criteria were reassessed 3 years later. ATPD outcomes were compared with schizophrenia and affective psychosis. Multivariate analyses were conducted to determine whether acute onset and early remission predicted favourable 3-year outcome in first-episode psychosis.

RESULTS

Of 168 cases of first-episode psychosis, 32 (19%) received an intake diagnosis of ATPD. The diagnosis of ATPD was stable in women over 3 years, but not in men. Outcomes in ATPD were better than in schizophrenia and similar to affective psychosis. In non-affective psychoses, favourable outcomes were a function of gender and premorbid functioning rather than acute onset and early remission.

CONCLUSIONS

The ICD-10 criteria for ATPDs identify a diagnostically unstable group of disorders. Acute onset and early remission do not independently predict favourable outcome over 3 years in first-episode psychosis.

Cognitive functioning in young people with first episode psychosis: relationship to diagnosis and clinical characteristics

OBJECTIVE

To examine the extent and nature of neuropsychological deficits in adolescents and young people with first episode psychosis (FEP), and to determine whether the pattern and extent of neuropsychological deficits varied according to diagnosis.

METHOD

A total of 83 FEP subjects aged 13-25 years, and 31 healthy controls completed a comprehensive battery of neuropsychological tests, grouped into 10 cognitive domains. First episode psychosis subjects were stratified into three diagnostic groups (schizophrenia, affective disorders, substance-induced psychosis) and differences in cognitive profiles were examined. The contribution of demographic and clinical characteristics to cognitive performance was also explored.

RESULTS

The schizophrenia group demonstrated significantly worse performance on tasks of verbal learning and memory than the affective disorders group. Compared to healthy controls, the schizophrenia group also demonstrated global impairment across the majority of cognitive domains. The substance-induced group's performance lay between that of the schizophrenia and affective disorders groups. Analyses of differential deficits revealed that verbal learning, verbal memory and current intellectual functioning were selectively impaired in the schizophrenia group, whereas the affective disorders group demonstrated a selective deficit in speeded processing. Premorbid intellectual functioning, negative symptomatology and medication levels were the strongest predictors of cognitive performance in FEP subjects.

CONCLUSIONS

Verbal memory deficits differentiate individuals with schizophrenia from those with psychotic affective disorders. Although significant cognitive deficits are evident across all diagnostic FEP groups, individuals with schizophrenia appear to have more generalized impairment across a broad array of cognitive functions than other psychotic diagnoses. Lower premorbid intellectual functioning does not appear to contribute to greater cognitive deterioration following onset of psychosis, but severity of illness may be a more important factor than levels of mood disturbance.

Pituitary volume in psychosis

BACKGROUND

Patients with psychosis have activation of the hypothalamic-pituitary-adrenal (HPA) axis during the acute phase of the psychosis. Whether this has any morphological consequences for the pituitary gland is currently unknown.

AIMS

To examine pituitary volume variation in people at different stages of psychotic disorder.

METHOD

Pituitary volume was measured using 1.5 mm, coronal magnetic resonance images in 24 people with first-episode psychosis, 51 with established schizophrenia and 59 healthy controls.

RESULTS

Compared with the control group, the people with first-episode psychosis had pituitary volumes that were 10% larger, whereas those with established schizophrenia had pituitary volumes that were 17% smaller. In both of the groups with psychosis, there was no difference in pituitary volume between those receiving typical antipsychotic drugs and those receiving atypical antipsychotics.

CONCLUSIONS

The first episode of a psychosis is associated with a larger pituitary volume, which we suggest is due to activation of the HPA axis. The smaller pituitary volume in the group with established schizophrenia could be the consequence of repeated episodes of HPA axis hyperactivity.

Effects of low-dose risperidone and low-dose zuclopenthixol on cognitive functions in first-episode drug-naive schizophrenic patients

BACKGROUND

Studies on the effects of antipsychotics on cognitive deficits in schizophrenia mostly suggest a superior effect of atypical over typical compounds, although findings are inconsistent and effect sizes small. Several methodological issues, such as heterogeneous patient samples, incomparable drug doses, effects of prior medication, construct validity, and retest effects on neuropsychological tasks, confound most results and the comparability between studies. Consequently, the conclusion concerning effects of antipsychotics on cognition is still equivocal.

OBJECTIVE

The present randomized clinical trial examined the effects on cognition of comparatively low doses of a typical antipsychotic (zuclopenthixol) and an atypical antipsychotic (risperidone) in a homogeneous group of drug-naive first-episode schizophrenic patients in a longitudinal setting.

METHODS

First-episode schizophrenic patients who had never previously been exposed to antipsychotic treatment (N=25) were randomly allocated to treatment with flexible doses of zuclopenthixol or risperidone in an open-label design. Cognitive functions were examined both when patients were drug-naive, and after 13 weeks of treatment. A comprehensive neuropsychological battery was used in order to optimize construct validity, and principal components of cognitive functions were extrapolated in order to reduce type I errors. A healthy control group was tested at baseline and after 13 weeks, in order to examine retest effects. The cognitive domains studied were executive functions, selective attention, and reaction time.

RESULTS

The patients showed considerable cognitive deficits when drug-naive. There were few differential effects of risperidone and zuclopenthixol on cognitive deficits, except for a differential significance, respectively, tendency towards improved reaction and movement times in the risperidone group, and a lack of such in the zuclopenthixol group. These differences were no longer significant after covarying for extrapyramidal side effects and anticholinergic medication that were more prevalent in the zuclopenthixol group and the increases after medication were comparable with retest effects in controls.

CONCLUSION

The study underscores the importance of examining impact of factors, such as clinical improvement, extrapyramidal side effects, anticholinergic medication and retest effects in longitudinal efficacy studies. This study does not support efficacy of either risperidone or zuclopenthixol on cognitive functions in drug-naive schizophrenia patients after 3 months of medication, because neither could be distinguished from retest effects of the healthy control group.

Symptom and demographic profiles in first-episode schizophrenia

First-episode schizophrenia (FE-SZP) presents a diagnostic challenge because of symptomatic overlap between the various causes of psychosis. An early and accurate diagnosis is important for the implementation of appropriate treatment, for determining prognosis and for identifying research participants. In an effort to facilitate early diagnosis, we followed a group of first-episode psychosis patients with a presumptive diagnosis of schizophrenia who were subsequently diagnosed at 6-month follow-up with either schizophrenia (n=104) or other psychiatric diagnoses (n=19). The two groups-first-episode schizophrenia and first-episode non-schizophrenia-were compared on measures of demographics, symptoms, quality of life, premorbid adjustment and lateral dominance. Odds ratios were calculated for each variable and all significant variables were entered into a multivariate prediction model. The model showed that higher levels of anhedonia and hallucinations increased the odds of a final diagnosis of schizophrenia. This predictive model was validated in a smaller group of patients.

Reliability and stability of a semistructured DSM-IV interview designed for family studies

OBJECTIVE

To determine the interrater reliability and stability of diagnoses, and to compare the results of in-person versus telephone administration of the Missouri Assessment of Genetics Interview for Children (the MAGIC), a new, semistructured, glossary-based diagnostic interview for children and adolescents.

METHOD

The interview was developed for a large-scale epidemiological family genetics study. For reliability measures, parent report on offspring, child self-report, and adolescent self-report interviews were independently scored by two different raters on a population-based sample of respondents. The stability of diagnoses was assessed by comparing repeat interviews of parents, children, and adolescents, separated on average by 13 months. Frequencies of parent and adolescent report of disorders were determined for telephone and in-person interviews.

RESULTS

High interrater reliabilities were achieved for individual DSM-IV symptoms and diagnoses and for individual characteristics of diagnostic domains, including number, clustering, duration, and impairment of symptoms. The stability of diagnoses was also high for parents and adolescents. No significant differences in the prevalence of attention-deficit/hyperactivity disorder and major depressive disorder were found for interviews administered in person or by telephone.

CONCLUSIONS

The MAGIC demonstrates high interrater reliability and stability for DSM-IV symptoms and diagnoses.

A critique of the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) chapter on non-affective psychotic disorders

BACKGROUND

There has been a longstanding interest in the study of psychotic disorders in adults with intellectual disability. The DC-LD chapter for non-affective psychotic disorders provides operationalised criteria for use with this population.

METHODS

A detailed, structured review of the literature was carried out. Relevant papers were reviewed to provide a framework for a critique of the DC-LD criteria.

RESULTS

Most of the research literature focuses on psychotic disorders in adults with mild intellectural disability and suggests that this group experience clinical symptoms similar to those experienced by adults with average abilities. Although the DC-LD criteria for non-affective psychotic disorders are derived from the ICD-10 equivalent categories they are broader than other classification systems, which may affect their reliability, validity and utility.

CONCLUSIONS

At this stage, it is important that the DC-LD criteria are used alongside established systems to gather information about their use for clinical and research purposes.

Acute and transient psychotic disorders: comparison with schizophrenia

Concept and nosologic status of acute and transient psychotic disorders, as they appear in the tenth edition of the International Classification of Disease, have seen review from the standpoint of validation and delineation from schizophrenia and affective disorders. Current research, particularly on the epidemiology, course, and outcome, and family genetic studies indicate that these disorders are common among women in developing countries, as well as among lower socioeconomic status and rural subjects. These patients have greater frequency of exposure to stress before childbirth, a family history of acute and transient psychotic disorder (and not of schizophrenia), and a course and outcome that is different from that of schizophrenia. The findings so far support the argument that acute and transient psychotic disorders are different from schizophrenia.

Pharmacological Management of First-Episode Schizophrenia and Related Nonaffective Psychoses

Schizophrenia is a severe mental illness characterised by abnormalities of thought and perception that affects 1-2% of the population. Patients who experience a first episode of schizophrenia should be treated early and optimally with antipsychotic agents to lessen the morbidity of the initial episode and possibly improve the course of the illness. Positive psychotic symptoms remit in the majority of patients who are treated with adequate trials of antipsychotic medications, but most relapse within 1 year. Non-adherence is strongly related to the likelihood of recurrence of symptoms. Innovative programmes that integrate early intervention, psychosocial treatments and atypical antipsychotic pharmacotherapy show promise in improving outcomes. The available research supports the use of antipsychotic medications early in the first-episode of schizophrenia and for at least 1 year after remission of positive symptoms. Antidepressants, benzodiazepines and mood stabilisers have roles in the acute and maintenance phases of treatment for some patients. Atypical antipsychotics represent a great advance in the treatment of first-episode schizophrenia with strong evidence for greater tolerability with equal or better therapeutic efficacy. Future research will further define their roles in treatment and hopefully identify targets for prevention of first-episode schizophrenia.

Electroconvulsive therapy in adolescents: similarities to and differences from adults

OBJECTIVE

Information on the indications, technique, and effectiveness of electroconvulsive therapy (ECT) in adolescent patients is scarce. The recommendations for the use of ECT in this age group are similar to those in adults. This study compares the experience with ECT in the two age groups in the same community psychiatric institution, which adheres to the accepted protocols for diagnosis and treatment.

METHOD

The files of 24 consecutive adolescent patients treated in an ECT unit located in the center of Israel in the years 1991-1995 were retrospectively examined, and the findings were compared with those in 33 adult patients who started their ECT course on the same day. The technique for applying ECT was essentially the same in the two age groups.

RESULTS

ECT was equally effective for adolescents and adults (58% in each group achieved remission). The main difference was the diagnosis for which patients were referred: most of the adolescents were in the "psychotic spectrum, whereas most of the adults were in the "affective spectrum."

CONCLUSIONS

The findings support the current medical recommendations for the use of ECT in adolescents. Possible explanations for the differences in diagnosis between the two age groups are discussed.

Aggressive incidents in first-episode psychosis

BACKGROUND

Recent research has reported increased risk of aggressive incidents by individuals with psychotic illness.

AIMS

To examine acts of aggression in first-episode psychosis.

METHOD

Subjects with a first-episode psychosis were ascertained from a defined catchment area (Nottingham, UK) and reassessed at 3 years (n=166) using clinical interview, informants, health care and forensic records.

RESULTS

Of the subjects, 9.6% demonstrated at least one act of serious aggression (defined as weapon use, sexual assault or victim injury) during at least one psychotic episode and 23.5% demonstrated lesser acts of aggression (defined as all other acts of aggression). For all aggressive subjects (33.1%), unemployment (OR=3.6, 95% C11.6-8.0), comorbid substance misuse (OR=3.1, C1 1.1-8.8) and symptoms of overactivity at service contact (OR=6.9,C1 2.7-17.8) had independent effects on risk of aggression.

CONCLUSIONS

We confirmed some previously reported demographic and clinical associations with aggression in first-episode psychosis but no relationship with specific psychotic symptoms or diagnostic groups was observed.

The nature of schizophrenia: signposts to prevention

OBJECTIVE

To describe the characteristics of schizophrenia relevant to conducting indicated preventive interventions.

METHOD

A systematic review of the literature informed by experiences at the Personal Assistance and Crisis Evaluation (PACE) clinic.

RESULTS

Primary prevention requires a sophisticated knowledge of key causal risk factors relevant to the expression of a disorder. The causal risk factors most useful from an intervention standpoint may turn out to be somewhat removed from the neurobiology of the disorder and may even be relatively non-specific, so that tackling them could reduce the risks for a range of mental disorders. The frontier for more specific prevention in schizophrenia and related psychosis is currently represented by indicated preventive interventions for subthreshold symptoms. Again, these may be relatively broad spectrum early in the prepsychotic phase but more proximal to onset, greater treatment specificity can be explored. However, this can be viewed more as preventively orientated treatment rather than primary prevention per se. Early detection of first episode psychosis and optimal intensive treatment of first episodes and the critical early years after diagnosis also represent increasingly attractive preventive foci in psychotic disorders.

CONCLUSION

As evidence accumulates, implementation of evidence-based practice in real work settings is a major challenge as it is throughout the mental health service system. The momentum of preventively orientated treatment must be maintained through the 2nd National Mental Health Strategy and in the face of recent misleading polemic regarding the treatability of psychotic disorders, especially schizophrenia. The evidence demonstrates that schizophrenia and related disorders have never been more treatable.

Three-year outcome of first-episode psychoses in an established community psychiatric service

BACKGROUND

Changes in service provision, secular trends in substance misuse and changing social structures might affect outcome in psychosis.

AIMS

To assess the three-year outcome of an inception cohort of first-episode psychoses treated in a modern, community-oriented service; to compare outcomes with an earlier cohort treated in hospital-based care; and to examine the predictive validity of ICD-10 diagnostic criteria.

METHOD

Three-year follow-up (1995-1997) of an inception cohort of first-episode psychoses and comparison with two-year follow-up (1980-1982) of the Determinants of Outcome of Severe Mental Disorders (DOSMED) Nottingham cohort.

RESULTS

On most outcome measures, non-affective psychoses had a worse outcome than affective psychoses. Affective psychoses had better outcome than previously reported. Substance-related psychoses had very poor occupational outcome. Similar proportions of the current and DOSMED cohort were in remission but the former were rated as having greater disability.

CONCLUSIONS

In a modern community service, 30-60% of patients with first-episode psychoses experience a good three-year outcome. The ICD-10 criteria have good predictive validity.