A prospective longitudinal 10-year study of schizophrenia's three major factors and depression

The Relationship Between Depressive Symptoms and Psychological Variables in Patients With Schizophrenia

INTRODUCTION

Depressive symptoms are common in schizophrenia and can be seen at any stage of the disease. Although various models have been proposed to explain the development of depression in schizophrenia, studies investigating related psychological factors are scarce and the studies that have been done usually focus on only a small number of possible factors.

OBJECTIVE

The goal of this study was to investigate the predictability of some psychological factors on depression in patients with schizophrenia. For this purpose, patients with high and low depression scores were compared.

METHODS

Two groups of individuals with schizophrenia, with (n=29) and without (n=31) depression, as determined by scores on the Calgary Depression Scale in Schizophrenia, were compared using a sociodemographic data form, the Positive and Negative Syndrome Scale (PANSS), the Beck Anxiety Inventory, the Rotter Internal-External Locus 2024 of Control Scale, the Multidimensional Scale of Perceived Social Support, and the Stress Coping Styles Scale.

RESULTS

No differences were found between the 2 groups in terms of sociodemographic and clinical characteristics, social support scores, and coping styles. Statistically significant differences were found between the groups on the PANSS positive, negative, and general psychopathology subscales, in PANSS total scores, in anxiety scores, and in locus of control scores.

CONCLUSIONS

This study showed that high levels of negative, positive, and general psychopathological symptoms, external locus of control, and high anxiety scores may be predictive of depression in individuals with schizophrenia. Studies that examine psychological factors in larger patient groups may provide the opportunity to detect and target these factors earlier in the course of schizophrenia, thereby reducing morbidity and mortality.

'An experience of meaning': A 20-year prospective analysis of delusional realities in schizophrenia and affective psychoses

Delusions are transdiagnostic and heterogeneous phenomena with varying degrees of intensity, stability, and dimensional attributes where the boundaries between everyday beliefs and delusional beliefs can be experienced as clearly demarcated, fuzzy, or indistinguishable. This highlights the difficulty in defining delusional realities. All individuals in the current study were evaluated at index and at least one of six subsequential follow-ups over 20 years in the Chicago Longitudinal Study. We assessed 16 distinct delusions categorized as thought or thematic delusions. We also examined the probability of recurrence and the relationships between delusions and hallucinations, depression, anxiety, and negative symptoms. The sample consisted of 262 individuals with schizophrenia vs. affective psychosis. Thought delusions were significantly different between groups at all follow-up evaluations except the 20-year timepoint. Thematic delusions were more common than thought delusions and show a significant decreasing pattern. In general, delusional content varied over time. Referential, persecutory, and thought dissemination delusions show the highest probability of recurrence. Hallucinations were the strongest indicator for thought, thematic, and overall delusions. The formation and maintenance of delusions were conceptualized as a multimodal construct consisting of sensory, perceptual, emotional, social, and somatic embodiment of an "experience of meanings". Given the significant associations between delusions and hallucinations, future work incorporating participatory research is needed to better define and align subjective and objective perspectives. Our research also points to the need for future clinical interventions that specifically evaluate and target the coexistence and entanglement of delusions and hallucinations.

Predictors of unrecognised comorbid depression in patients with schizophrenia at Amanuel mental specialized hospital, Ethiopia: a cross-sectional study

BACKGROUND

The occurrence of depression in patients with schizophrenia (PWS) increases the risk of relapse, frequency and duration of hospitalisation, and decreases social and occupational functioning.

OBJECTIVE

This study aimed to assess prevalence of unrecognised comorbid depression and its determinants in PWS.

METHOD

A cross-sectional study was conducted from 1 to 30 March 2019 at Amanuel mental specialized hospital among 300 PWS. The 9-item Calgary Depression Scale for Schizophrenia was used to assess comorbid depression. Logistic regression was used to determine the association between outcome and explanatory variables. Statistical significance was declared at p value <0.05 with 95% CI.

RESULTS

The prevalence of unrecognised comorbid depression was found to be 30.3%. Living alone (adjusted OR (AOR)=3.49, 95% CI=0.45 to 8.36), having poor (AOR=4.43, 95% CI=1.45 to 13.58) and moderate (AOR=4.45, 95% CI=1.30 to 15.22) social support, non-adherence to medication (AOR=3.82, 95% CI=1.70 to 8.55), presenting with current negative symptoms such as asocialia (AOR=4.33, 95% CI=1.98 to 9.45) and loss of personal motivation (AOR=3.46, 95% CI=1.53 to 7.84), and having suicidal behaviour (AOR=6.83, 95% CI=3.24 to 14.41) were the significant predictors of comorbid depression in PWS.

CONCLUSION

This study revealed considerably a high prevalence of unrecognised comorbid depression among PWS. Therefore, clinicians consider timely screening and treating of comorbid depression in PWS.

Dissecting the neurobiology of linguistic disorganisation and impoverishment in schizophrenia

Schizophrenia provides a quintessential disease model of how disturbances in the molecular mechanisms of neurodevelopment lead to disruptions in the emergence of cognition. The central and often persistent feature of this illness is the disorganisation and impoverishment of language and related expressive behaviours. Though clinically more prominent, the periodic perceptual distortions characterised as psychosis are non-specific and often episodic. While several insights into psychosis have been gained based on study of the dopaminergic system, the mechanistic basis of linguistic disorganisation and impoverishment is still elusive. Key findings from cellular to systems-level studies highlight the role of ubiquitous, inhibitory processes in language production. Dysregulation of these processes at critical time periods, in key brain areas, provides a surprisingly parsimonious account of linguistic disorganisation and impoverishment in schizophrenia. This review links the notion of excitatory/inhibitory (E/I) imbalance at cortical microcircuits to the expression of language behaviour characteristic of schizophrenia, through the building blocks of neurochemistry, neurophysiology, and neurocognition.

Cognitive Functioning and Schizotypy: A Four-Years Study

Although there is ample evidence from cross-sectional studies indicating cognitive deficits in high schizotypal individuals that resemble the cognitive profile of schizophrenia-spectrum patients, there is still lack of evidence by longitudinal/follow-up studies. The present study included assessments of schizotypal traits and a wide range of cognitive functions at two time points (baseline and 4-years assessments) in order to examine (a) their stability over time, (b) the predictive value of baseline schizotypy on cognition at follow-up and (c) differences in cognition between the two time points in high negative schizotypal and control individuals. Only high negative schizotypal individuals were compared with controls due to the limited number of participants falling in the other schizotypal groups at follow-up. Seventy participants (mean age: 36.17; 70% females) were assessed at baseline and follow-up. Schizotypal traits were evaluated with the Schizotypal Personality Questionnaire. We found that schizotypal traits decreased over time, except in a sub-group of participants ("schizotypy congruent") that includes individuals who consistently meet normative criteria of inclusion in either a schizotypal or control group. In these individuals, negative schizotypy and aspects of cognitive-perceptual and disorganized schizotypy remained stable. The stability of cognitive functioning also varied over time: response inhibition, aspects of cued attention switching, set-shifting and phonemic/semantic verbal fluency improved at follow-up. High negative schizotypy at baseline predicted poorer response inhibition and semantic switching at follow-up while high disorganized schizotypy predicted poorer semantic processing and complex processing speed/set-shifting. The between-group analyses revealed that response inhibition, set-shifting and complex processing speed/set-shifting were poorer in negative schizotypals compared with controls at both time points, while maintaining set and semantic switching were poorer only at follow-up. Taken together, the findings show differential stability of the schizotypal traits over time and indicate that different aspects of schizotypy predict a different pattern of neuropsychological task performance during a 4-years time window. These results are of significant use in the formulation of targeted early-intervention strategies for high-risk populations.

Trajectories of depressive symptoms in the acute phase of psychosis: Implications for treatment

Depression is common in schizophrenia and associated with negative outcomes. Previous studies have identified heterogeneity in treatment response in schizophrenia. We aimed to investigate different trajectories of depression in patients suffering from psychosis and predictors of change in depressive symptoms during antipsychotic treatment. Two hundred and twenty-six patients >18 years acutely admitted due to psychosis were consecutively included and the follow-up was 27 weeks. The Calgary Depression Scale for Schizophrenia (CDSS) sum score was the primary outcome. Latent growth curve (LGCM) and Growth Mixture Models (GMM) were conducted. Predictors were the Positive sum score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Schizophrenia spectrum/non-spectrum psychoses, gender and being antipsychotic naive at inclusion. We found support for three depression-trajectories, including a high- (14.7%), a low depression-level (69.6%) class and a third depressed class quickly decreasing to a low level (15.7%). Change in CDSS was associated with change in PANSS positive score in all time intervals (4 weeks: b = 0.18, p < 0.001, 3 months: 0.21, p < 0.023, 6 months: 0.43, p < 0.001) and with a diagnosis within schizophrenia spectrum but not with antipsychotic naivety or gender. The schizophrenia-spectrum patients had less depressive symptoms at inclusion (-2.63, p < 0.001). In conclusion, an early responding and a treatment refractory group were identified. The treatment-refractory patients are candidates for enhanced anti-depressive treatment, for which current evidence is limited. The post-psychotic depression group was characterized by depressive symptoms in the acute phase as well. We could not identify differentiating characteristics of the depression trajectories.

Levels of Cognitive Control: A Functional Magnetic Resonance Imaging-Based Test of an RDoC Domain Across Bipolar Disorder and Schizophrenia

In recent years, the boundaries of psychopathology as defined by diagnostic categories have been criticized as inadequately 'carving nature at its joints' with respect to the neurobiology of major mental disorders. In 2010 the NIMH launched the Research Domain Criteria (RDoC) framework for understanding mental illnesses as brain circuit disorders that extend beyond DSM-defined diagnoses. In the present study we focus on cognitive dysfunction, a core feature of schizophrenia (SZ) and bipolar disorder (BPD), and use functional magnetic resonance imaging (fMRI) during a cognitive control (CC) task in recent onset patients to test the hypothesis that at a behavioral and underlying neural circuitry level these deficits exist on a continuum (as opposed to showing categorical differences) across the two disorders. In total, 53 healthy controls, 24 recent (<1 y) onset patients with BPD Type I with psychotic features, and 70 recent onset patients with SZ performed the AX-Continuous Performance Task while undergoing event-related fMRI at 1.5 T. In addition to behavior task-associated response was examined in frontoparietal regions-of-interest. In an a priori contrast-based analysis, significant deficits across patient groups (vs controls) were observed on CC-associated performance as well as frontoparietal response. These analyses further revealed a continuum of deficits in which BPD showed intermediate levels of CC relative to controls and SZ. Poor CC was associated with poverty and disorganization symptoms across patient groups. These results support the hypothesis that CC dysfunction in BPD and SZ reflects a continuum of deficits that cuts across traditional, DSM-based classification. Implications for the neurobiology of these diseases are discussed.

The mediator effect of personality traits on the relationship between childhood abuse and depressive symptoms in schizophrenia

Previous studies indicated that personality traits have a mediator effect on the relationship between childhood abuse and depressive symptoms in major depressive disorder and nonclinical general adult subjects. In the present study, we aimed to test the hypothesis that personality traits mediate the relationship between childhood abuse and depressive symptoms in schizophrenia. We used the following questionnaires to evaluate 255 outpatients with schizophrenia: the Child Abuse and Trauma Scale, temperament and character inventory, and Patients Health Questionnire-9. Univariate analysis, multiple regression analysis, and structured equation modeling (SEM) were used to analyze the data. The relationship between neglect and sexual abuse and the severity of depressive symptoms was mostly mediated by the personality traits of high harm avoidance, low self-directedness, and low cooperativeness. This finding was supported by the results of stepwise multiple regression analysis and the acceptable fit indices of SEM. Thus, our results suggest that personality traits mediate the relationship between childhood abuse and depressive symptoms in schizophrenia. The present study and our previous studies also suggest that this mediator effect could occur independent of the presence or type of mental disorder. Clinicians should routinely assess childhood abuse history, personality traits, and their effects in schizophrenia.

Association of the Jumping to Conclusions and Evidence Integration Biases With Delusions in Psychosis: A Detailed Meta-analysis

We completed a meta-analysis to investigate the relationship between delusions in psychosis and 4 cognitive biases: "jumping to conclusions" (JTC), the "bias against disconfirmatory evidence" (BADE), the "bias against confirmatory evidence" (BACE), and "liberal acceptance" (LA). Building on recent meta-analyses we compared more narrowly defined groups. We identified 35 JTC, 8 BADE, 7 BACE, and 6 LA studies for inclusion. Groups with schizophrenia who were currently experiencing delusions demonstrated greater JTC, BADE, BACE, and LA than groups with schizophrenia who were not currently experiencing delusions, who in turn demonstrated no more JTC than healthy control groups. Hence JTC, BADE, BACE, and LA co-vary with delusions in cross-sectional samples of people with schizophrenia. Groups who were experiencing delusions due to other psychiatric illnesses also demonstrated greater JTC than healthy controls, and equivalent JTC to groups with schizophrenia currently experiencing delusions. Hence JTC is associated with delusions across a range of diagnoses. Groups with other, non-delusional psychiatric illnesses demonstrated less JTC, BADE, BACE, and LA than groups with schizophrenia currently experiencing delusions, less JTC than groups experiencing delusions due to other diagnoses, and no more JTC, BADE, BACE, or LA than healthy control groups. Hence JTC, BADE, BACE, and LA were not associated with psychiatric illnesses in general. Our results indicate all 4 biases are associated with delusions specifically rather than merely with a diagnosis of schizophrenia or with being psychiatrically ill, consistent with the possibility that they contribute to delusional severity.

Twenty year multi-follow-up of different types of hallucinations in schizophrenia, schizoaffective disorder, bipolar disorder, and depression

Hallucinations are a salient feature of both psychotic and mood disorders. Currently there is a call for more research on the phenomenology of different forms of hallucinations, in a broader array of disorders, to further both theoretical knowledge and clinical utility. We investigated auditory, visual, and olfactory hallucinations at index hospitalization and auditory and visual hallucinations prospectively for 20years in 150 young patients, namely 51 schizophrenia, 25 schizoaffective, 28 bipolar, and 79 unipolar depression. For the index hospitalization, the data showed schizophrenia and schizoaffective patients had a greater rate of auditory and visual hallucinations than bipolar and depression patients. However, over the longitudinal trajectory of their illness, a greater percentage of schizophrenia patients had auditory and visual hallucinations than schizoaffective patients, as well as bipolar and depression patients. Also, in contrast to the initial period, schizoaffective patients did not differentiate themselves over the follow-up period from bipolar patients. Bipolar and depression patients did not significantly differ at index hospitalization or at follow-up. We found visual hallucinations differentiated the groups to a greater degree over the 20year course than did auditory hallucinations. These findings suggest the longitudinal course is more important for differentiating schizophrenia and schizoaffective disorder, whereas the initial years may be more useful to differentiate schizoaffective disorder from bipolar disorder. Furthermore, we found that the early presence of auditory hallucinations was associated with a reduced likelihood for a future period of recovery. No olfactory hallucinations were present at the index hospitalization in any patients. Over the course of 20years, a minority of schizophrenia patients presented with olfactory hallucinations, and very few schizoaffective and bipolar patients presented with olfactory hallucinations. This study underscores the importance of the longitudinal course of symptoms to understand the relationship between related disorders and recovery.

A Longitudinal Study of the Outcome and Associated Factors of Subsyndromal and Syndromal Depression in Community-Dwelling Older Adults with Schizophrenia Spectrum Disorder

OBJECTIVE

Studies examining depression in older adults with schizophrenia have been limited by cross-sectional data. This study examines longitudinal changes in depression, predictors of depression, and the impact of depression on clinical and psychosocial variables in this population.

METHODS

The sample consisted of 104 community-dwelling persons with schizophrenia spectrum disorder aged 55 and over who developed the disorder before age 45. Mean follow-up was 54 months (range: 12-116 months), mean age was 61 years, 55% were men, and 55% were white. Presence of subsyndromal or syndromal depression (SSSD) was defined as scoring >7 on the Center for Epidemiologic Studies-Depression Scale (CES-D).

RESULTS

There were no significant differences in SSSD rates between interviews (61% baseline; 54% follow-up); 44% of the sample had SSSD at both assessments, 30% did not have SSSD at either assessment, 16% went from SSSD to nondepression, and 10% went from nondepression to SSSD. Similarly, 20%, 27%, and 53% of the sample exhibited >0.5 effect size increase, decrease, or no change, respectively, in their CES-D scores between assessments. There were two significant time 1 predictors of SSSD at time 2: SSSD and greater number of psychotropic medications. SSSD at time 1 predicted having higher time 2 anxiety scores.

CONCLUSION

Persistent ("core") depression occurs in about two-fifths of persons, 30% remain persistently nondepressed, and one-fourth may fluctuate between depression and nondepression. No association was found between depression and most predictor variables. This study supports recent findings that schizophrenia in later life is not a quiescent state or one of affective withdrawal.

Individualized differential diagnosis of schizophrenia and mood disorders using neuroanatomical biomarkers

Magnetic resonance imaging-based markers of schizophrenia have been repeatedly shown to separate patients from healthy controls at the single-subject level, but it remains unclear whether these markers reliably distinguish schizophrenia from mood disorders across the life span and generalize to new patients as well as to early stages of these illnesses. The current study used structural MRI-based multivariate pattern classification to (i) identify and cross-validate a differential diagnostic signature separating patients with first-episode and recurrent stages of schizophrenia (n = 158) from patients with major depression (n = 104); and (ii) quantify the impact of major clinical variables, including disease stage, age of disease onset and accelerated brain ageing on the signature's classification performance. This diagnostic magnetic resonance imaging signature was then evaluated in an independent patient cohort from two different centres to test its generalizability to individuals with bipolar disorder (n = 35), first-episode psychosis (n = 23) and clinically defined at-risk mental states for psychosis (n = 89). Neuroanatomical diagnosis was correct in 80% and 72% of patients with major depression and schizophrenia, respectively, and involved a pattern of prefronto-temporo-limbic volume reductions and premotor, somatosensory and subcortical increments in schizophrenia versus major depression. Diagnostic performance was not influenced by the presence of depressive symptoms in schizophrenia or psychotic symptoms in major depression, but earlier disease onset and accelerated brain ageing promoted misclassification in major depression due to an increased neuroanatomical schizophrenia likeness of these patients. Furthermore, disease stage significantly moderated neuroanatomical diagnosis as recurrently-ill patients had higher misclassification rates (major depression: 23%; schizophrenia: 29%) than first-episode patients (major depression: 15%; schizophrenia: 12%). Finally, the trained biomarker assigned 74% of the bipolar patients to the major depression group, while 83% of the first-episode psychosis patients and 77% and 61% of the individuals with an ultra-high risk and low-risk state, respectively, were labelled with schizophrenia. Our findings suggest that neuroanatomical information may provide generalizable diagnostic tools distinguishing schizophrenia from mood disorders early in the course of psychosis. Disease course-related variables such as age of disease onset and disease stage as well alterations of structural brain maturation may strongly impact on the neuroanatomical separability of major depression and schizophrenia.

Individualized differential diagnosis of schizophrenia and mood disorders using neuroanatomical biomarkers

Magnetic resonance imaging-based markers of schizophrenia have been repeatedly shown to separate patients from healthy controls at the single-subject level, but it remains unclear whether these markers reliably distinguish schizophrenia from mood disorders across the life span and generalize to new patients as well as to early stages of these illnesses. The current study used structural MRI-based multivariate pattern classification to (i) identify and cross-validate a differential diagnostic signature separating patients with first-episode and recurrent stages of schizophrenia (n = 158) from patients with major depression (n = 104); and (ii) quantify the impact of major clinical variables, including disease stage, age of disease onset and accelerated brain ageing on the signature's classification performance. This diagnostic magnetic resonance imaging signature was then evaluated in an independent patient cohort from two different centres to test its generalizability to individuals with bipolar disorder (n = 35), first-episode psychosis (n = 23) and clinically defined at-risk mental states for psychosis (n = 89). Neuroanatomical diagnosis was correct in 80% and 72% of patients with major depression and schizophrenia, respectively, and involved a pattern of prefronto-temporo-limbic volume reductions and premotor, somatosensory and subcortical increments in schizophrenia versus major depression. Diagnostic performance was not influenced by the presence of depressive symptoms in schizophrenia or psychotic symptoms in major depression, but earlier disease onset and accelerated brain ageing promoted misclassification in major depression due to an increased neuroanatomical schizophrenia likeness of these patients. Furthermore, disease stage significantly moderated neuroanatomical diagnosis as recurrently-ill patients had higher misclassification rates (major depression: 23%; schizophrenia: 29%) than first-episode patients (major depression: 15%; schizophrenia: 12%). Finally, the trained biomarker assigned 74% of the bipolar patients to the major depression group, while 83% of the first-episode psychosis patients and 77% and 61% of the individuals with an ultra-high risk and low-risk state, respectively, were labelled with schizophrenia. Our findings suggest that neuroanatomical information may provide generalizable diagnostic tools distinguishing schizophrenia from mood disorders early in the course of psychosis. Disease course-related variables such as age of disease onset and disease stage as well alterations of structural brain maturation may strongly impact on the neuroanatomical separability of major depression and schizophrenia.

Does environmental confounding mask pleiotropic effects of a multiple sclerosis susceptibility variant on vitamin D in psychosis?

Background:

This work addresses the existing and emerging evidence of overlap within the environmental and genetic profiles of multiple sclerosis (MS) and schizophrenia.

Aims:

To investigate whether a genetic risk factor for MS (rs703842), whose variation is indicative of vitamin D status in the disorder, could also be a determinant of vitamin D status in chronic psychosis patients.

Methods:

A cohort of 224 chronic psychosis cases was phenotyped and biologically profiled. The relationship between rs703842 and physiological vitamin D status in the blood plasma was assessed by logistic regression. Deficiency was defined as a blood plasma concentration below 10 ng/µl. Potential environmental confounders of the vitamin D status were considered as part of the analysis.

Results:

We report suggestive evidence of an association with vitamin D status in established psychosis (ß_standardized=0.51, P=0.04). The logistic model fit significantly benefited from controlling for body mass index, depression and ethnicity (χ²=91.7; 2 degrees of freedom (df); P=1.2×10²⁰).

Conclusions:

The results suggest that, in addition to lifestyle changes that accompany the onset of illness, vitamin D dysregulation in psychosis has a genetic component that links into MS. Further, comprehensive studies are needed to evaluate this prospect.

Assessment of trait and state aspects of depression in schizophrenia

Depression and negative symptoms can be difficult to distinguish in schizophrenia. Assessments for negative symptoms usually account for the longitudinal nature of these symptoms, whereas instruments available to measure depression mainly assess current or recent symptoms. This construct difference may confound comparison of depressive and negative symptoms in schizophrenia because both domains may have trait-like aspects. We developed an instrument to measure both longitudinal "trait" as well as recent "state" symptoms of depression and tested this instrument (Maryland Trait and State Depression [MTSD] scale) in a sample of 98 individuals with schizophrenia or schizoaffective disorder and 115 community participants without psychotic illness. Exploratory factor analysis of the MTSD revealed 2 factors accounting for 73.4% of the variance; these 2 factors corresponded with "trait" and "state" depression inventory items. Neither MTSD-state nor MTSD-trait was correlated with negative symptoms as measured with the Brief Negative Symptom Scale (r = .07 and -.06, respectively) in schizophrenia patients. MTSD state and trait scores were significantly correlated with the Brief Psychiatric Rating Scale depression subscale (r = .58 and .53, respectively) as well as the Profile of Mood States depression subscale (r = .57 and .44). Persons with schizophrenia had significantly greater trait depressive symptoms than controls (P = .031). Individuals with schizoaffective disorder had significantly higher trait depression (P = .001), but not state depression (P = .146), compared with schizophrenia patients. Trait depressive symptoms are prominent in schizophrenia and are distinct from negative symptoms.

Repeated measurements of cerebral blood flow in the left superior temporal gyrus reveal tonic hyperactivity in patients with auditory verbal hallucinations: a possible trait marker

Background: The left superior temporal gyrus (STG) has been suggested to play a key role in auditory verbal hallucinations (AVH) in patients with schizophrenia.

Methods: Eleven medicated subjects with schizophrenia and medication-resistant AVH and 19 healthy controls underwent perfusion magnetic resonance (MR) imaging with arterial spin labeling (ASL). Three additional repeated measurements were conducted in the patients. Patients underwent a treatment with transcranial magnetic stimulation (TMS) between the first 2 measurements. The main outcome measure was the pooled cerebral blood flow (CBF), which consisted of the regional CBF measurement in the left STG and the global CBF measurement in the whole brain.

Results: Regional CBF in the left STG in patients was significantly higher compared to controls (p < 0.0001) and to the global CBF in patients (p < 0.004) at baseline. Regional CBF in the left STG remained significantly increased compared to the global CBF in patients across time (p < 0.0007), and it remained increased in patients after TMS compared to the baseline CBF in controls (p < 0.0001). After TMS, PANSS (p = 0.003) and PSYRATS (p = 0.01) scores decreased significantly in patients.

Conclusions: This study demonstrated tonically increased regional CBF in the left STG in patients with schizophrenia and auditory hallucinations despite a decrease in symptoms after TMS. These findings were consistent with what has previously been termed a trait marker of AVH in schizophrenia.

A 20-year multi-follow-up of hallucinations in schizophrenia, other psychotic, and mood disorders

BACKGROUND

Hallucinations are a major aspect of psychosis and a diagnostic feature of both psychotic and mood disorders. However, the field lacks information regarding the long-term course of hallucinations in these disorders. Our goals were to determine the percentage of patients with hallucinations and the relationship between hallucinations and recovery, and work attainment. Method The present study was a prospective evaluation of the 20-year trajectory of hallucinations in 150 young patients: 51 schizophrenia, 25 schizoaffective, 25 bipolar with psychosis, and 49 unipolar depression. The patients were studied at an index phase of hospitalization for hallucinations, and then reassessed longitudinally at six subsequent follow-ups over 20 years.

RESULTS

The longitudinal course of hallucinations clearly differentiated between schizophrenia and bipolar disorder with psychosis, and suggested some diagnostic similarities between schizophrenia and schizoaffective disorder, and between bipolar disorder and schizoaffective disorder and depression. Frequent or persistent hallucinatory activity over the 20-year period was a feature of 40-45% of schizophrenia patients. The early presence of hallucinations predicted the lack of future periods of recovery in all patients. Increased hallucinatory activity was associated with reduced work attainment in all patients.

CONCLUSIONS

This study provides data on the prospective longitudinal course of hallucinations, which were previously unavailable to the field, and are one of the key features of psychosis in major psychiatric disorders. This information on the clinical course of major psychiatric disorders can inform accurate classification and diagnosis.

Circulating levels of sTNFR1 as a marker of severe clinical course in schizophrenia

BACKGROUND

Schizophrenia (SZ) has been associated with an imbalance in the inflammatory cytokine TNF-α. The objectives of this study were to compare TNF-α and its soluble receptors' serum levels in individuals with SZ with the levels found in a group of healthy volunteers and to investigate the possible association between these biomarkers and the dimensions and severity of symptoms, clinical outcomes and response to treatment in patients with SZ.

METHODS

Fifty-four chronically medicated SZ outpatients and 118 healthy controls were included in the study. TNF-α levels were measured by Cytometric Bead Assay (CBA), and serum levels of soluble tumor necrosis factor receptor 1 (sTNFR1) and soluble tumor necrosis factor receptor 2 (sTNFR2) were measured by ELISA.

RESULTS

sTNFR1 and sTNFR2 were significantly elevated in patients with SZ as compared to the healthy control group. In the group of individuals with SZ, the levels of both types of soluble TNF receptors showed a negative correlation with global functioning. sTNFR1 levels were higher in the treatment-resistant patients as compared to the non-treatment-resistant patients and the controls. sTNFR1 levels were also heightened in patients with SZ and concomitant depression.

CONCLUSION

Our findings reinforce that SZ is associated with an inflammatory profile and suggest that sTNFR1 is a marker of a treatment-resistance and severe clinical course in SZ.

Consistency of symptomatic dimensions of schizophrenia over 20 years

Our goal was to analyze the consistency of the symptomatic dimensions of schizophrenia over the course of our 20-year prospective study. We investigated a sample of patients diagnosed with Diagnostic and Statistical Manual of Mental Disorders Third version (DSM III) schizophrenia and later re-diagnosed with Diagnostic and Statistical Manual of Mental Disorders Fourth version (DSM IV) at four intervals: three, seven, twelve and twenty years from their first hospitalization. The severity of symptoms was assessed using expanded version of Brief Psychiatric Rating Scale (BPRS - E). Exploratory factor analyses and then confirmatory factor analyses were conducted. A four-factor structure was found, with positive, negative, depressive and excitement factors. In the confirmatory factor analysis, the only symptomatic dimension confirmed at all follow-ups was the negative factor (emotional withdrawal, motor retardation, blunted affect and conceptual disorganization) as derived from the 20-year follow up in exploratory factor analysis. The positive syndrome derived from the three-year follow-up (hostility, suspiciousness, unusual thought content and hallucinations) was confirmed at the seven- and 20-year follow-ups. In the depressive syndrome the model from the 12-year follow-up (guilt, depression, suicidality, anxiety and somatic concern) was confirmed for the follow-ups after seven and 20 years. As regards the excitement syndrome, we confirmed the model from the three-year follow-up (motor hyperactivity, elated mood, conceptual disorganization, excitement) at the follow-ups at seven and 12 years.

Aging effects on regional brain structural changes in schizophrenia

BACKGROUND

Although mostly conceptualized as a neurodevelopmental disorder, there is an increasing interest in progressive changes of cognitive deficits and brain structure and function in schizophrenia across the life span.

METHODS

In this study, we investigated age-related changes in regional gray matter using voxel-based morphometry in a sample of 99 patients (age range 18-65 years) with Diagnostic and Statistical Manual of Mental Disorders-IV schizophrenia and 113 healthy controls (age range 19-59 years) using a cross-sectional design.

RESULTS

We found steeper age-related decline in gray matter in patients in a cluster comprising the left superior temporal cortex and adjacent inferior parietal lobule. We then divided the schizophrenia sample in 3 subgroups based on a 3-factor model of psychopathology ratings. Age-related changes were markedly different in each of the 3 subgroups (compared with healthy controls). While patients with predominantly paranoid symptoms showed stronger age-related progression in the left superior temporal cortex and right inferior frontal gyrus, those of the disorganized subgroup had stronger gray matter loss in the left lateral cerebellum, while the predominantly negative subgroup showed minor effects in the left superior temporal gyrus.

CONCLUSIONS

Our findings show that differences in brain structural changes associated with aging diverge between schizophrenia patients and healthy subjects and that different subgroups within a patient sample might be at higher risk of age-related regional gray matter loss.

Negative symptoms and their predictors in schizophrenia within the Northern Finland 1966 Birth Cohort

Negative symptoms are a major scientific and therapeutic challenge in schizophrenia. We report the occurrence and predicting factors of negative symptoms at two time points in a population-based birth cohort. The negative symptoms of subjects with Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) schizophrenia (n=46) were scrutinized at the first hospitalization due to psychosis from hospital records (first-episode psychosis) and with an interview approximately 10 years later (follow-up phase). Developmental and sociodemographic predictors of negative symptoms in first-episode psychosis, follow-up phase and at both measurements were analysed. Forty-one percent of the subjects had negative symptoms at the first episode, 39% in the follow-up phase, and in 24% the symptoms persisted at both measurements. Smoking at the age of 14, definite psychosocial stressor and not being married predicted more negative symptoms whereas good school performance and using less alcohol at age 14 predicted fewer persistent negative symptoms. These findings are new. However, we were not able to identify any major premorbid phenotype or endophenotype predicting negative symptoms which support the view that negative symptoms might mainly be a specific part of the illness.

A novel analytical framework for dissecting the genetic architecture of behavioral symptoms in neuropsychiatric disorders

BACKGROUND

For diagnosis of neuropsychiatric disorders, a categorical classification system is often utilized as a simple way for conceptualizing an often complex clinical picture. This approach provides an unsatisfactory model of mental illness, since in practice patients do not conform to these prototypical diagnostic categories. Family studies show notable familial co-aggregation between schizophrenia and bipolar illness and between schizoaffective disorders and both bipolar disorder and schizophrenia, revealing that mental illness does not conform to such categorical models and is likely to follow a continuum encompassing a spectrum of behavioral symptoms.

RESULTS AND METHODOLOGY

We introduce an analytic framework to dissect the phenotypic heterogeneity present in complex psychiatric disorders based on the conceptual paradigm of a continuum of psychosis. The approach identifies subgroups of behavioral symptoms that are likely to be phenotypically and genetically homogenous. We have evaluated this approach through analysis of simulated data with simulated behavioral traits and predisposing genetic factors. We also apply this approach to a psychiatric dataset of a genome scan for schizophrenia for which extensive behavioral information was collected for each individual patient and their families. With this approach, we identified significant evidence for linkage among depressed individuals with two distinct symptom profiles, that is individuals with sleep disturbance symptoms with linkage on chromosome 2q13 and also a mutually exclusive group of individuals with symptoms of concentration problems with linkage on chromosome 2q35. In addition we identified a subset of individuals with schizophrenia defined by language disturbances with linkage to chromosome 2p25.1 and a group of patients with a phenotype intermediate between those of schizophrenia and schizoaffective disorder with linkage to chromosome 2p21.

CONCLUSIONS

The findings presented are novel and demonstrate the efficacy of this approach in detection of genes underlying such complex human disorders as schizophrenia and depression.

How frequent is chronic multiyear delusional activity and recovery in schizophrenia: a 20-year multi-follow-up

To determine how frequent chronic multiyear delusional activity is in modern-day schizophrenia, we studied 200 patients over a 20-year period. We also studied the relation of delusions to hallucinations and thought disorder-disorganization, to work disability, and to later periods of global recovery and assessed several protective factors against delusional activity. The sample was assessed 6 times over 20 years and includes 43 patients with schizophrenia. Participants were evaluated at each follow-up for delusions, hallucinations, thought disorder-disorganization, work disability, and global recovery. Possible protective factors were assessed prospectively at index hospitalization. Twenty-six percent of the patients with schizophrenia were delusional at all follow-ups over the 20 years. Overall, 57% had frequently recurring or persistent delusions. A subgroup of over 25% of the schizophrenia patients had no delusional activity at any of the 6 follow-ups over 20 years. Schizophrenia patients with posthospital delusional activity had increased work disability (P < .05). Delusions that persisted after the acute phase in schizophrenia patients predicted a lower likelihood of future global recovery (P < .01). In conclusion, slightly over half of modern-day schizophrenia patients are vulnerable to frequent or "chronic" delusional activity after the acute phase. Schizophreniform patients and other types of psychotic disorders are vulnerable to posthospital delusional activity, but less frequently, less severely, and more episodically. Delusional activity is associated with work disability. Internal factors such as good premorbid developmental achievements and favorable prognostic factors are protective factors that reduce the probability of chronic multiyear, delusional activity in schizophrenia (P < .01).

The relationship between dysphoria and proneness to hallucination and delusions among young adults

Previous research suggests that measures of dysphoria relate to positive schizophrenic symptoms. These relationships have rarely been studied within the dimensionality of psychopathology framework. The present study examined the relationship between 3 distinct aspects of dysphoria (depression and state and trait anxiety) and delusion and hallucination proneness in a nonclinical sample of young adults. A total of 472 participants were assessed on measures of dysphoria and delusion and hallucination proneness. Correlation analyses revealed significant associations between both anxiety and depression and hallucination and delusion proneness, suggesting that the association between dysphoria and positive symptoms is also present at a nonclinical level. Partial correlations, and hierarchical regression models, suggest an independent contribution of depression, over anxiety, in influencing hallucination and delusional proneness. The results are discussed in the framework of the cognitive account of schizophrenia and the dimensional model of psychopathology.

Toward defining schizophrenia as a more useful clinical concept

Delineating schizophrenia remains elusive despite considerable interest and study for more than a century. During this time, a variety of terms and defining features have been ascribed to the construct. The predominant contemporary construct, for which substantial limitations persist, has changed little in the past 30 years. With the approaching arrival of the DSM-V, interest in the nosology of schizophrenia has rebounded. Recent publications have focused principally on the following: integrating dimensional approaches to diagnosis, subtypes of schizophrenia, endophenotypes, and identifying those at early risk as part of a staging process. Some have even suggested replacing the term. Although an etiopathic diagnosis remains out of reach, contemporary research is marching down several distinct paths toward defining schizophrenia as a construct of greater clinical utility.

Sense of coherence among delusional patients: prediction of remission and risk of relapse

Delusional diseases are characterized by a remitting/relapsing course, which, in current studies, is not contextualized with experience and well-being. This study applied the salutogenic model in order to predict the course of delusional disease, using the "sense of coherence" (SOC) concept, which reflects patients' experiences of their disorder. In a prospective study, 48 delusional schizophrenic inpatients were interviewed, using self-report scales for delusions, SOC, depression and expressed emotion (EE), at 3 time points over a 1-year period, with an additional 6-month follow-up based on treatment staff reports and medical files. Sense of coherence was found to be strongly correlated with delusional symptoms over the study period. Higher SOC scores at the "acute delusional state" predicted better prognosis with regard to delusions. However, SOC was found to be lower during remission, suggesting decreased well-being during remission. Sense of coherence was found to be a stronger predictor of 1-year prognosis for delusions when EE or depression were high at the acute state. A complex relationship was found between delusions, SOC, depression, and EE, suggesting possible use of the SOC scale as a prognostic tool. In addition, the results stress the necessity of an integrative biopsychosocial treatment approach, which would include interventions aimed at enhancing elements of SOC, particularly during periods of remission. To the best of our knowledge, this is the first longitudinal study of SOC in delusional patients moving through remissions and relapses.

Depression in schizophrenia: methodological artifact or distinct feature of the illness?

In schizophrenia, there is a conceptual overlap between depressive and negative symptoms. This study examined the dimensional structure of depressive symptoms and their overlap with negative symptoms in a large sample of older medicated schizophrenia outpatients. Self-reported depression was obtained with the Beck Depression Inventory-II (BDI-II). Three components from this scale (i.e., dysphoria, psychosomatic and regret domains) showed excellent factorability and good consistency. However, adequate construct validity and correlates with outcomes were found for the dysphoria and regret domains, but not for the total score or the psychosomatic domain. Thus, the evaluation of domains within the BDI-II provides a more pure and clinically-relevant assessment of depressed mood in schizophrenia than the use of this scale as a whole.

Gene expression profiling in Brodmann's area 46 from subjects with schizophrenia

OBJECTIVE

To identify altered gene expression in the dorsolateral prefrontal cortex obtained after death from subjects with schizophrenia.

METHOD

Restriction fragment differential display (RFDD) was used to measure levels of mRNA in Brodmann area (BA) 46 from schizophrenia and control subjects. Findings on specific mRNA identified with RFDD were further investigated using real-time polymerase chain reaction (real-time PCR), PCR and western blotting.

RESULTS

Levels of mRNA for 63 of approximately 12,500 genes differed in BA 46 in schizophrenia. Subsequent real-time PCR has shown that mRNA for muscleblind protein 1 (MBNL1) and protocadherin 17 (PCDH17) are increased in BA 46 from subjects with schizophrenia of short, but not long, duration. Altered levels of mRNA for neither gene were present in BA 9 from subjects with schizophrenia or in either cortical area from subjects with bipolar 1 disorder. By contrast, both RFDD and real-time PCR failed to show altered expression of the schizophrenia candidate gene disrupted in schizophrenia 1 (DISC1) BA46 from any diagnostic cohort.

CONCLUSION

The present study has identified genes that are differentially expressed in BA 46 in schizophrenia. Initial studies have shown that there is a need for a careful validation of genes shown to be affected in schizophrenia using high-throughput technologies. In addition the present study has shown that gene expression may vary considerably depending on the duration of schizophrenia. This raises the hypothesis that changing gene expression may be underlying the change in symptom profile that occurs with disease progression in some subjects with schizophrenia.

Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods

The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.

Dimensions and the psychosis phenotype

In this paper, we discuss the conceptual background for including a dimensional component to the DSM V diagnoses for psychoses. We review the evidence for a continuous distribution of psychosis like symptoms in the general population and summarise the research validating the clinical usefulness of psychopathological dimensions. We conclude that diagnostic models using both categorical and dimensional representations of psychosis have better predictive validity than either model independently. Dimensions do not appear to be diagnosis specific so a flexible scoring of dimensions across all psychotic and major affective disorders may be potentially more informative than a system where categorical diagnoses are kept artificially dimension-specific.

Distribution of symptom dimensions across Kraepelinian divisions

BACKGROUND

Dimensional structures are established for many psychiatric diagnoses, but dimensions have not been compared between diagnostic groups.

AIMS

To examine the structure of dimensions in psychosis, to analyse their correlations with disease characteristics and to assess the relative contribution of dimensions v. diagnosis in explaining these characteristics.

METHOD

Factor analysis of the OPCRIT items of 191 Maudsley Family Study patients with schizophrenia, mood disorders with psychosis, schizoaffective disorder, and other psychotic illnesses, followed by regression of disease characteristics from factor scores and diagnosis.

RESULTS

Five factors were identified (mania, reality distortion, depression, disorganisation, negative); all were more variable in schizophrenia than in affective psychosis. Mania was the best discriminator between schizophrenia and affective psychosis; the negative factor was strongly correlated with poor premorbid functioning, insidious onset and worse course. Dimensions explained more of the disease characteristics than did diagnosis, but the explanatory power of the latter was also high.

CONCLUSIONS

Kraepelinian diagnostic categories suffice for understanding illness characteristics, but the use of dimensions adds substantial information.

Suicidal behavior in schizophrenia

There is a high prevalence of suicidal behavior in individuals suffering from schizophrenia and recent investigations substantially elucidate this problem and provide useful insights about clinical risk factors, neurobiologic underpinnings and the impact of various treatments on reducing such behavior. The risk of suicide is greatest early in the course of schizophrenic illness but continues throughout life; risk factors for suicidal behavior include psychosis, depression and substance abuse. Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization and instilling hope are important elements in this treatment approach. The newer generation of atypical antipsychotics (particularly clozapine) and new psychologic approaches (particularly cognitive behavioral therapy) appear to be useful in reducing suicidality in schizophrenia. The significant advances in defining the neurobiologic basis of suicidality may enable the development of more effective treatments. The renewed emphasis on resilience and recovery as desired outcomes in schizophrenia and the accompanying sense of hope encourage optimism about effectively reducing suicidality in schizophrenia. Over the past 10 years, much has been learnt and hopefully this momentum will be translated into increasingly better outcomes.

Depressed mood and its functional correlates in institutionalized schizophrenia patients

OBJECTIVE

To determine the frequency of depressed mood in institutionalized schizophrenia patients and its association with illness-related and functional variables.

METHODS

Out of 657 institutionalized schizophrenia patients, patients with depressed mood were identified and compared to non-depressed patients, matching for potential confounders.

RESULTS

Forty-eight (7.3%) patients had moderate to severe depressed mood. They were younger, more educated and had fewer years since their first hospitalization than non-depressed patients. After matching for these variables, depressed patients showed more positive symptoms and exhibited better social and cognitive functioning. When controlling for negative symptoms, the differences in social and cognitive functioning between the depressed and non-depressed patients disappeared, and depressed patients showed more positive symptoms and more impaired impulse control.

CONCLUSIONS

Unlike the negative impact of depressed mood in other populations, this study shows that symptoms of depressed mood may identify a subgroup of institutionalized schizophrenia patients who show better functioning across a variety of indicators. Future studies should determine differential treatment responses and long-term outcomes of these patients.

The relationships between symptom dimensions and dysphoria in schizophrenia

Previous studies have suggested that qualitatively distinct aspects of dysphoria (anxiety and depression) are related to specific dimension of schizophrenia symptomatology. Most of these studies used simple dimensions and dysphoria models, although finer distinctions could help defining specific relationships. This study examined the relationships of distinctive aspects of depression and anxiety (both state and trait) with symptom dimensions. Forty patients with a DSM-IV diagnosis of schizophrenia were assessed for symptoms (SAPS-SANS), trait and state anxiety (STAI) and depression (CDS). Symptoms ratings were summarized as dimensional scores according to a two-, three- or five-dimensional models proposed in the literature. The correlation analysis replicates previous observations that distinct aspects of dysphoria are associated with specific dimensions of schizophrenia, with the exception of disorganization. Moreover, controlling for intercorrelated variables revealed that schizophrenia and dysphoric symptoms might act in combination and/or through indirect links to contribute to illness expression. Our data further suggested that these associations may be best understood in terms of interactions between various processing biases alluded in the most recent cognitive accounts of schizophrenia symptoms.

Change in the relationship between anhedonia and functional deficits over a 20-year period in individuals with schizophrenia

Although early theorists suggested that deficits in emotional experience be considered a hallmark characteristic of schizophrenia, there has been limited research, and inconsistent findings, on the relationship between anhedonia and functional capacity in individuals after the onset of schizophrenia. Stronger relationships have typically been reported for chronic samples in contrast to first episode samples, although it is not clear whether this is due to selection biases that influence recruitment in these different groups, or whether results reflect a change over the course of illness. The current longitudinal study examined the relationship between physical anhedonia and functional status in a sample of 61 individuals with schizophrenia at regular intervals over a 20-year period. Subjects were recruited into the study during an index hospitalization and completed assessments at 2-, 4.5-, 7.5-, 10-, 15-, and 20-year follow-ups. Analyses indicate that the relationship between anhedonia and impairments increases over time, although mean performance on these measures is stable across this same time period. These results suggest increasing convergence of impairments in emotional, adaptive, and cognitive capacities over time, with physical anhedonia associated with poorer outcome.

Negative symptoms of schizophrenia could explain discrepant data on the association between the 5-HT2A receptor gene and response to antipsychotics

Pharmacogenetic studies assessing the role of 5-HT(2A) receptor gene in antipsychotic efficacy yielded conflicting data. Phenotypical heterogeneity of schizophrenia might explain such discrepancies. For example, negative symptoms are known to reflect severity of illness and to restrain therapeutic response. On this basis, we re-assessed the possible influence of the -1438A/G polymorphism of the 5-HT(2A) receptor gene on the clinical efficacy of atypical antipsychotics with focus on several relevant dimensions. One hundred and sixteen French schizophrenic subjects treated for at least 1 month by atypical antipsychotics were screened for treatment response according to the May and Dencker scale. Gender, age at onset, duration and severity of illness, intensity of negative and positive symptoms at discharge were investigated. The intensity of negative symptoms at discharge was the only variable explaining May and Dencker score (p < 0.001), and was significantly associated with the AA genotype of the -1438A/G polymorphism of the 5-HT(2A) receptor gene (p = 0.03). However, the A allele was not independently associated with refractoriness to atypical antipsychotics. Accordingly, the score reached in the Scale for the Assessment of Negative Symptoms (SANS) appeared as a confounding factor between therapeutic response and the -1438A/G polymorphism of the 5-HT(2A) receptor gene, at least in our sample. This data indicate that negative symptoms are worth being systematically assessed in pharmacogenetic studies aimed at analysing candidate genes in schizophrenia.

Changes in the neuropsychological correlates of clinical dimensions between the acute and stable phase of schizophrenia

This study was designed to investigate whether the neuropsychological correlates of the symptom dimensions of schizophrenia vary with the clinical state in patients followed from the acute to stable the phase of the illness. Fifteen patients were assessed for symptoms (SAPS-SANS) and undergone a complete neuropsychological assessment at two sessions. The first session (S1) was carried out within six days after admission, i.e., acute phase and the second (S2) at least two month after hospitalization, i.e., stable phase. The data were analyzed using stepwise regression models in which neuropsychological scores were in entered to predict each dimensional score. This analysis was applied on the S1 and S2 data as well as on the S2-S1 difference to assess the neuropsychological predictors of clinical changes. Generally, the results replicate the previous associations between neuropsychological and dimensional measures found in stable patients. In addition, this study shows if each dimension appears to rely on a key structure, symptom variations seems to involve changes in the spread of the dysfunction and/or changes in the connectivity between the key and other regions. The results also suggest that functional changes related to some symptoms dimensions occur to compensate for the dysfunction associated with other symptoms.

Stability in schizophrenia symptoms over time: Findings from the Mount Sinai Pilgrim Psychiatric Center Longitudinal Study

This study examined the stability of symptoms of schizophrenia over time, focusing on the stability of symptom structure. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). The sample consisted of 215 chronic patients followed up for as long as 4 years. Exploratory factor analysis identified 6 factors. Several statistical techniques were used to examine the stability of these symptoms, including longitudinal confirmatory factor analysis. Low-to-moderate rank-order stability and high absolute stability of the factors were found, with the structure of the PANSS-assessed symptoms consistent over time. The results demonstrate that despite changes in the severity of symptoms in individual patients with schizophrenia, the factor structure and interrelatedness of symptoms have considerable stability over time.

Clinical profiles, scope and general findings of the Western Sydney First Episode Psychosis Project

OBJECTIVE

To examine the clinical profile, treatment and social functioning of a community-based sample of young people presenting with their first episode of psychosis.

METHODS

Over a 2-year period, young people with their first episode of psychosis referred to early intervention services in two area mental health services in western Sydney were assessed with a battery of clinical, neuropsychological, psychophysiological and neuroanatomical measures. This paper reports the clinical results of the baseline section of the study.

RESULTS

Of the 224 referrals to the project, 94 subjects meet inclusion criteria and agreed to take part. Subjects were divided into three diagnostic groups--'Schizophrenia', 'Mood Disorders' and 'Mixed Psychosis', the latter principally comprised of substance induced psychotic disorders. Subjects from the 'Schizophrenia' group differed significantly from the other two groups in that they had higher levels of negative symptoms and general psychopathology, and were less likely to be employed or engaged in study. They had poorer overall social functioning. Subjects with 'Mixed Psychosis' were similar to those from the 'Schizophrenia' group in that they were older and male, but they did not have the same burden of negative symptoms as the 'Schizophrenia' group. The 'Mood Disorders' group was younger, female and had overall a higher level of psychosocial functioning than the other two groups. Subjects from the 'Mood Disorders' group were more likely to be managed with mood stabilisers and multiple drug therapies. The use of atypical antipsychotic medication was almost universal.

CONCLUSIONS

Even shortly after the time of presentation to mental health services young people with a schizophrenia spectrum diagnosis have a heavier burden of symptoms and are significantly more impaired by them than young people with other psychotic illnesses. This and their symptom profile differentiated them from young people with other psychotic disorders.

The timing of negative symptom exacerbations in relationship to positive symptom exacerbations in the early course of schizophrenia

Although positive and negative symptoms appear to represent independent symptom dimensions of psychopathology when evaluated cross-sectionally among individuals with schizophrenia, it is not known if exacerbations of symptoms on these two dimensions are independent. This prospective longitudinal study examined the temporal relationship between the positive and negative symptom exacerbations among 48 recent-onset schizophrenia or schizoaffective patients who received symptom ratings every 2 weeks on the Brief Psychiatric Rating Scale. Patients were followed for a period of at least 1 year and a mean of 3 years. To examine the temporal relationship between positive and negative symptoms, six time periods were defined in relation to psychotic exacerbation or relapse (e.g., prodromal, concurrent, post-psychotic) and used to compare the timing of positive and negative symptom exacerbations. A substantial proportion of patients had exacerbations of positive symptoms (77%) and negative (42%) symptoms. Negative symptom exacerbations occurred simultaneously with positive symptom exacerbations to a significantly greater extent than expected by chance, and occurred less frequently than expected by chance during the time period most temporally removed from positive symptom exacerbations. Results suggest that the timing of some negative symptom exacerbations is linked to that of positive symptom exacerbations during the early course of schizophrenia.

Meta-analysis and the science of schizophrenia: variant evidence or evidence of variants?

Quantification (meta-analysis) of the neuroscience evidence on schizophrenia shows very modest average differences between patient and control distributions across a great variety of measures and literatures. The strongest findings involve cognitive and psychophysiological measures. Several possible explanations for this situation are reviewed including technical immaturity, methodological variability, dimensional and multiple illness models and the nature of cognitive measurement. An argument is developed that biological subtypes and endophenotypes within the broad diagnostic category of schizophrenia underpin the meta-analytic evidence. Considerations in the use of this evidence to identify illness variants are described and four candidate subtypes are proposed. Schizophrenia is a disease that will resist biological definition until its variants are isolated and extracted from the generic patient population.

The five symptom dimensions and depression in schizophrenia

The aim of this study was to investigate the relationship between the five-factor model of psychopathology and depression in schizophrenia. Symptoms were rated using the Positive and Negative Syndrome Scale (PANSS) and the Montgomery and Asberg Depression Rating Scale (MADRS) in 105 chronic patients with schizophrenia. Principal-component analysis (PCA) produced a five-factor solution for the PANSS (psychomotor poverty, disorganisation, reality distortion, excitement, and depression), and a two-factor solution for the MADRS (psychological and behavioural depression). The PANSS depression factor was highly associated with the MADRS psychological depression factor but not with MADRS behavioural depression. By contrast, the PANSS excitement factor showed a strong positive correlation with the behavioural depression factor but not with psychological depression. These MADRS factors were not associated significantly with the core PANSS factors, including psychomotor poverty. It is suggested that depression exists as an independent domain, differentiated from negative symptoms, in the structure of schizophrenia symptomatology.

Influence of depressive symptoms and premorbid adjustment on factor structure of phenomenology of schizophrenia: a study from India

This study investigated the nature of factor structure of schizophrenia syndromes using a sample of 151 patients with schizophrenia according to DSM-IV. The patients were assessed on the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), Hamilton Depression Rating Scale (HDRS) and the Phillips Rating Scale of Premorbid Adjustment in schizophrenia. Three factors-negative syndrome, reality-distortion syndrome and disorganized syndrome were extracted when only SAPS and SANS were analysed. Addition of the Phillips Rating Scale scores to SAPS and SANS ratings in the factorial equation led to splitting of the negative syndrome though reality-distortion and disorganized syndromes remained stable. Factor analysis of the HDRS scores with SAPS and SANS ratings resulted in the HDRS loading highly on reality-distortion syndrome and splitting of negative syndrome. Factor analysis of all the variables taken together resulted in delineation of four factors. The study suggests a link between depression and reality distortion. Apathy and anhedonia seem to be linked to premorbid adjustment.

Hierarchical and nonhierarchical approaches in psychiatric diagnosis: a case report of change in psychiatric symptoms and diagnosis over time

The article reports the case of a 39-year-old male who was diagnosed with and treated for bipolar disorder. Over the past 18 months, the patient has experienced new onset of auditory hallucinations and worsening of his psychotic symptoms. The treating psychiatrists changed the diagnosis from bipolar disorder to schizoaffective disorder. The authors discuss hierarchical and nonhierarchical approaches to psychiatric diagnosis in relation to this case report.

Depressive episodes in stable schizophrenia: critical evaluation of the DSM-IV and ICD-10 diagnostic criteria

Depressive episodes are a common and potentially severe occurrence in schizophrenia but are poorly recognised by psychiatrists. Coherent diagnostic criteria are necessary to improve diagnosis and treatment of these conditions. To evaluate the usefulness of the ICD-10 category of post-schizophrenic depression (PSD) and the DSM-IV category of postpsychotic depressive disorder of schizophrenia (PDDS), 80 clinically stable schizophrenic outpatients were evaluated with two independent measures of depression, a dimensional measure and a categorical measure. One rater applied the DSM-IV criteria for major depressive episodes (MDE), and the other applied the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Extrapyramidal Symptoms Rating Scale. Thirteen patients (16.3%) met criteria for MDE. All of them met the DSM-IV PDDS research criteria, but only two patients matched the ICD-10 PSD criteria, which require that the episode occurred in the 12 months after the last psychotic episode. There was no significant difference in the incidence of depressive episodes within 12 months after an acute psychotic episode and outside this time period. The data suggest that depressive episodes in schizophrenia are not restricted to the first year following the psychotic episode. Useful criteria for depressive episodes in schizophrenia should avoid a temporal relation with the psychotic episode.

Negative symptoms, anger, and social support: response of an inpatient sample to news coverage of the September 11 terrorist attacks

We examined the reactions of 17 male inpatients on a secure psychiatric unit to television news coverage of the September 11 attacks. All had psychotic diagnoses. We hypothesized that self-exposure and affective response to the news coverage and use of social support would be influenced by predominance of negative symptoms. Additionally, we examined for the emergence of common stress symptoms and exacerbations of psychosis. Results showed a dose-response relationship between amount of viewing and magnitude of response to the coverage. Anger was the emotion most clearly tied to coverage exposure and the other response variables. A wide range of stress symptoms was reported. Hypotheses concerning the influence of negative symptoms were partially supported. A significant minority of the patients disclosed exacerbation of psychotic symptoms in response to the attacks. Patients who reported a negative emotional reaction were more likely to talk to others about the attacks, but social contact did not predictably lead to affective relief.