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

Modelling the longitudinal dynamics of paranoia in psychosis: A temporal network analysis over 20 years

BACKGROUND

Paranoia is a key feature of psychosis that can be highly debilitating. Theories of paranoia mostly interface with short-scale or cross-sectional data models, leaving the longitudinal course of paranoia underspecified.

METHODS

We develop an empirical characterisation of two aspects of paranoia - persecutory and referential delusions - in individuals with psychosis over 20 years. We examine delusional dynamics by applying a Graphical Vector Autoregression Model to data collected from the Chicago Follow-up Study (n = 135 with a range of psychosis-spectrum diagnoses). We adjusted for age, sex, IQ, and antipsychotic use.

RESULTS

We found that referential and persecutory delusions are central themes, supported by other primary delusions, and are strongly autoregressive - the presence of referential and persecutory delusions is predictive of their future occurrence. In a second analysis we demonstrate that social factors influence the severity of referential, but not persecutory, delusions.

IMPLICATIONS

We suggest that persecutory delusions represent central, resistant states in the cognitive landscape, whereas referential beliefs are more flexible, offering an important window of opportunity for intervention. Our data models can be collated with prior biological, computational, and social work to contribute toward a more complete theory of paranoia and provide more time-dependent evidence for optimal treatment targets.

Neurocognitive function and delusion severity in schizophrenia spectrum disorders

The role of basic neurocognitive function in delusions is unclear despite the association to difficulties in reasoning and decision-making. We investigated 812 individuals with schizophrenia spectrum disorders (SSD) using a broad neuropsychological test battery encompassing motor and mental processing speed, working memory, learning and memory, and executive function. Premorbid and current intellectual function was assessed with NART and WASI. Delusion level and other clinical symptoms were measured with the PANSS and GAF. Hierarchical and k-means cluster analysis using standardized scores showed the presence of two separate clusters where the group with the higher delusion level (n = 291) was characterized by more severe neurocognitive deficits (>1.5 standard deviations below the healthy control mean), higher PANSS scores, lower GAF scores, and lower intelligence levels compared to the cluster with mild impairments (n = 521). We conclude that a higher delusion level is related to neurocognitive deficits across domains. Further, the validity of the two separate clusters was indicated by significant differences in clinical symptoms, everyday function, and intellectual ability. Compared to those with mild delusion levels, SSD patients with higher delusion levels seem particularly disadvantaged, with co-occurring general symptoms and lower daily function, underscoring the need for clinical and psychosocial support programs. A limitation of this study is the cross sectional design. Longitudinal studies are needed to determine the causal relationship between delusions and neurocognitive function.

Impact of Delusions and Hallucinations on Clinical Insight Dimensions in Schizophrenia Spectrum Disorders

INTRODUCTION

Insight in psychosis has been conceptualized as a continuous, dynamic, and multidimensional phenomenon. This study aims to determine the impact of delusions and hallucinations in different dimensions of clinical insight in schizophrenia spectrum disorders.

METHODS

Cross-sectional multicenter study including 516 patients (336 men) diagnosed with schizophrenia spectrum disorders. Based on dichotomized scores of Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations), patients were assigned to four groups according to current clear presence of delusions (scores 4 or above 4 in PANSS item P1) and/or hallucinations (scores 4 or above 4 in PANNS item P3). Insight was assessed using the three main dimensions of the Scale of Unawareness of Mental Disorder (SUMD).

RESULTS

Around 40% of patients showed unawareness of illness; 30% unawareness of the need for treatment; and 45% unawareness of the social consequences of the disorder. Patients with current clear presence of delusions had higher overall lack of awareness, regardless of current clear presence of hallucinations. Similarly, the clear presence of delusions showed a greater predictive value on insight than the presence of hallucinations, although the implication of both in the prediction was modest.

CONCLUSIONS

Our results confirm that lack of insight is highly prevalent in schizophrenia spectrum disorders, particularly when patients experience delusions. This study adds insight-related data to the growing symptom-based research, where specific types of psychotic experiences such as hallucinations and delusions could form different psychopathological patterns, linking the phenomenology of delusions to a lack of clinical insight.

'Are these my thoughts?': A 20-year prospective study of thought insertion, thought withdrawal, thought broadcasting, and their relationship to auditory verbal hallucinations

The co-occurrence of delusions and other symptoms at the onset of psychosis is a challenge for theories about the aetiology of psychosis. This paper explores the relatedness of delusions about the experience of thinking (thought insertion, thought withdrawal, and thought broadcasting) and auditory verbal hallucinations by describing their trajectories over a 20-year period in individuals diagnosed with schizophrenia, affective and other psychosis, and unipolar depression nonpsychosis. The sample consisted of 407 participants who were recruited at index hospitalization and evaluated over six follow-ups over 20 years. The symptom structure associated with thought insertion included auditory verbal hallucinations, somatic hallucinations, other hallucinations, delusions of thought-dissemination, delusions of control, delusion of self-depreciation, depersonalization and anxiety. The symptom constellation of thought withdrawal included somatic hallucinations, other hallucinations, delusions of thought dissemination, delusions of control, sexual delusions, depersonalization, negative symptoms, depression, and anxiety. The symptom constellation of thought broadcasting included auditory verbal hallucinations, somatic hallucinations, delusions of thought-dissemination, delusion of self-depreciation, fantastic delusions, sexual delusions, and depersonalization. Auditory verbal hallucinations and delusions of self-depreciation were significantly associated with both thought insertion and thought broadcasting. Thought insertion and thought withdrawal were significantly associated with other hallucinations, delusions of control, and anxiety; thought withdrawal and thought broadcasting were significantly related to sexual delusions. We hypothesize that specific symptom constellations over time might be explained as the product of pseudo-coherent realities created to give meaning to the experience of the world and the self of individuals in psychosis based on both prior top-down and ongoing bottom-up elements.

Characterization and prediction of individual functional outcome trajectories in schizophrenia spectrum disorders (PREDICTS study): Study protocol

Schizophrenia spectrum disorders (SSDs) are associated with significant functional impairments, disability, and low rates of personal recovery, along with tremendous economic costs linked primarily to lost productivity and premature mortality. Efforts to delineate the contributors to disability in SSDs have highlighted prominent roles for a diverse range of symptoms, physical health conditions, substance use disorders, neurobiological changes, and social factors. These findings have provided valuable advances in knowledge and helped define broad patterns of illness and outcomes across SSDs. Unsurprisingly, there have also been conflicting findings for many of these determinants that reflect the heterogeneous population of individuals with SSDs and the challenges of conceptualizing and treating SSDs as a unitary categorical construct. Presently it is not possible to identify the functional course on an individual level that would enable a personalized approach to treatment to alter the individual's functional trajectory and mitigate the ensuing disability they would otherwise experience. To address this ongoing challenge, this study aims to conduct a longitudinal multimodal investigation of a large cohort of individuals with SSDs in order to establish discrete trajectories of personal recovery, disability, and community functioning, as well as the antecedents and predictors of these trajectories. This investigation will also provide the foundation for the co-design and testing of personalized interventions that alter these functional trajectories and improve outcomes for people with SSDs.

Decreased insight, but not self-stigma or belief about medicine, is associated with greater severity of delusions in a sample of long-stay patients with schizophrenia: a cross-sectional study

BACKGROUND

There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia.

METHODS

A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used.

RESULTS

The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta = 0.004) was significantly associated with more delusions, whereas higher insight (Beta = - 0.89) was significantly associated with less delusions. No significant associations were found between insight, self-stigma and hallucinations.

CONCLUSION

Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.

The prognosis of schizophrenia: A systematic review and meta-analysis with meta-regression of 20-year follow-up studies

OBJECTIVE

The aim was to examine the general outcome of schizophrenia after 20 years or more.

METHODS

Using the PRISMA guidelines, we conducted a systematic review and meta-analysis with meta-regression on long-term follow-up studies of schizophrenia up until April 21, 2021. We included prospective studies with at least 20 years of follow-up on patients with a diagnosis of schizophrenia, and the studies had to include face-to-face clinical evaluation. We examined outcome in three nested groups: 'recovery', 'good or better' (including also 'recovery'), and 'moderate or better' (including also 'recovery' and 'good or better'). We used random-effects meta-analysis and meta-regression to examine mean estimates and possible moderators.

RESULTS

We identified 1089 records, which were screened by two independent researchers. 14 prospective studies (1991 patients) published between 1978 and 2020 were found eligible. The studies used a range of different scales and definitions for outcome, and some used the same definitions for different outcomes. To compare outcome across studies, we designed and applied a unified template for outcome definitions and cutoffs, based on earlier studies' recommendations. Our meta-analysis found that 24.2 % had 'recovered' (n = 246, CI: 20.3-28.0 %), 35.5 % had a 'good or better' outcome (n = 766, CI: 26.0-45.0%), and 59.7% had 'moderate or better' outcome (n = 1139, CI: 49.3-70.1 %).

CONCLUSIONS

The results contribute to debunk the myth that schizophrenia inevitably has a deteriorating course. Recovery is certainly possible. Schizophrenia remains, however, a severe and complex mental disorder, exhibiting a limited change in prognosis despite >100 years of research and efforts to improve treatment.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

'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.

Characteristics and stability of hallucinations and delusions in patients with borderline personality disorder

BACKGROUND

Psychotic features have been part of the description of the borderline personality disorder (BPD) ever since the concept "borderline" was introduced. However, there is still much to learn about the presence and characteristics of delusions and about the stability of both hallucinations and delusions in patients with BPD.

METHODS

A follow-up study was conducted in 326 BPD outpatients (median time between baseline and follow-up = 3.16 years). Data were collected via telephone (n = 267) and face-to-face interviews (n = 60) including the Comprehensive Assessment of Symptoms and History interview, Positive And Negative Syndrome Scale and the Psychotic Symptom Rating Scale.

RESULTS

The point prevalence of delusions was 26%, with a median strong delusion conviction. For the group as a whole, the presence and severity of both hallucinations and delusions was found to be stable at follow-up. Participants with persistent hallucinations experienced more comorbid psychiatric disorders, and they differed from those with intermittent or sporadic hallucinations with their hallucinations being characterized by a higher frequency, causing a higher intensity of distress and more disruption in daytime or social activities.

CONCLUSIONS

Delusions in patients with BPD occur frequently and cause distress. Contrary to tenacious beliefs, hallucinations and delusions in participants with BPD are often present in an intermittent or persistent pattern. Persistent hallucinations can be severe, causing disruption of life. Overall, we advise to refrain from terms such as "pseudo", or assume transience when encountering psychotic phenomena in patients with BPD, but rather to carefully assess these experiences and initiate a tailor-made treatment plan.

Mediating effect of empowerment on the relationship between global function and personal recovery among community-dwelling patients with schizophrenia: a cross-sectional study

BACKGROUND

Functional degradation among community-dwelling patients with schizophrenia can negatively influence their recovery. Given the importance of patient empowerment during recovery, this study examined the mediating effect of empowerment on the relationship between global function and personal recovery among community-dwelling patients with schizophrenia.

METHODS

This cross-sectional study recruited community-dwelling patients with schizophrenia from northern and central Taiwan. Questionnaires with verified reliability and validity were provided and collected on site by trained nurses. Global function, empowerment, and personal recovery were measured using the Global Assessment of Functioning (developed by the American Psychiatric Association), Empowerment Scale, and Questionnaire on the Process of Recovery, respectively. The causal steps approach proposed by Baron and Kenny and the Sobel test were utilized to verify the mediation effect. The causal steps approach tested the four following pathways (regression coefficients): global function on empowerment (Path a), global function and empowerment as predictors of personal recovery (Path b), global function on personal recovery (Path c), and global function and empowerment on personal recovery (Path c').

RESULTS

A total of 373 participants completed the survey. After controlling for factors associated with recovery, Paths a (β = .24, p < .001), b (β = .68, p < .001), and c (β = .19, p < .001) were found to be significant; however, Path c' was not significant (β = .03, p = .452). Empowerment was determined to exert "full mediation" over the effects of global function on personal recovery, and the Sobel test indicating significant mediation (Z = 3.61, p < .001).

CONCLUSIONS

Empowerment fully mediates the association between global function and personal recovery. This study suggested that offering empowerment-oriented care services may be more effective than global function improvement in recovery among these patients.

Impact of Negative Symptom Domains and Other Clinical Characteristics on Functional Outcomes in Patients with Schizophrenia

Negative symptoms of schizophrenia have generally been defined using five factors; however, few studies have examined the relationship between these five factors and functional outcomes. In addition, there is no definitive conclusion regarding the association between negative symptoms and various aspects of functional outcomes (daily living, social, and vocational). This study is aimed at examining the relationship between these five domains of negative symptoms and different functional outcomes. Patients diagnosed with chronic schizophrenia (n = 100) were selected for the evaluation. We used the Brief Negative Symptom Scale to assess negative symptoms, the Brief Psychiatric Rating Scale to assess positive symptoms, the Schizophrenia Cognition Rating Scale to assess cognition, and the Evaluative Beliefs Scale (negative self-assessment) to assess psychological factors. We analyzed their relative impact on Social Functioning Scale domains using hierarchical multiple regression analysis. Concerning the relationship between daily living and negative symptoms, cognitive function showed the highest association with residential outcomes, such as self-care and shopping, while avolition appeared to show an additional contribution; however, for recreational outcomes, avolition showed the main association, whereas cognitive function showed no additional contribution. For social outcomes, asociality and negative self-assessment showed the main associations, while vocational outcomes were determined by both cognitive function and multiple negative symptoms, such as avolition, anhedonia, asociality, and alogia. Since negative symptom domains appear to differentially impact each outcome, specifically daily living outcome, it is important to evaluate the residential outcomes and recreational outcomes separately. Overall, the present study points to the importance of formulating psychosocial treatment strategies specific for each type of preferred outcome in patients with schizophrenia.

Seventeen-year clinical outcome of schizophrenia in Bali

Objective

To examine the 17-year clinical outcome of schizophrenia and its predictors in Bali.

Methods

Subjects were 59 consecutively admitted first-episode schizophrenia patients. Their clinical outcome was evaluated by standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale (PANSS) scores and operational functional remission criteria at 17-year follow-up. The standardized mortality ratio (SMR) over 17 years was also calculated as another index of clinical outcome.

Results

Among these 59 patients, 43 (72.9%) could be followed-up, 15 (25.4%) had died, and one (1.7%) was alive but refused to participate in the study. Combined remission (i.e. symptomatic and functional remission) was achieved in 14 patients (23.7% of original sample). Duration of untreated psychosis (DUP) was a significant baseline predictor of combined remission. Mean age at death of deceased subjects was 35.7, and SMR was 4.85 (95% CI: 2.4–7.3), indicating that deaths were premature. Longer DUP was associated with excess mortality.

Conclusions

The long-term outcome of schizophrenia in Bali was heterogeneous, demonstrating that a quarter achieved combined remission, half were in nonremission, and a quarter had died at 17-year follow-up. DUP was a significant predictor both for combined remission and mortality.

Sustained antipsychotic effect of metacognitive training in psychosis: A randomized-controlled study

Persistent psychotic symptoms represent a major challenge for psychiatric care. Basic research has shown that psychotic symptoms are associated with cognitive biases. Metacognitive training (MCT) aims at helping patients to become aware of these biases and to improve problem-solving. Fifty-two participants fulfilling diagnostic criteria of schizophrenia or schizoaffective disorders and persistent delusions and stabilized antipsychotic medication were enrolled in this study. Following baseline assessment patients were randomized either to treatment as usual (TAU) conditions or TAU + MCT. The intervention consisted of eight weekly 1-hour sessions (maximum: 8 hours). Participants were assessed at 8 weeks and 6-months later by blind assessors. Participants were assessed with the Psychotic Symptoms Rating Scales (PSYRATS) and the positive subscale of the PANSS. Between-group differences in post- and pre-test values were significant at a medium effect size in favor of the MCT for the PSYRATS delusion scale and the positive scale of the PANSS both at post and follow-up. The results of this study indicate that MCT training has a surplus antipsychotic effect for patients suffering from schizophrenia-related disorders who demonstrate only a partial response to antipsychotic treatment and that the effect of the intervention persists for at least 6 months after the intervention.

Barriers to stopping neuroleptic (antipsychotic) treatment in people with schizophrenia, psychosis or bipolar disorder

Most guidelines recommend long-term, indefinite neuroleptic (or antipsychotic) treatment for people with schizophrenia, recurrent psychosis or bipolar disorder, on the basis that these medications reduce the chance of relapse. However, neuroleptics have significant adverse effects, including sexual dysfunction, emotional blunting, metabolic disturbance and brain shrinkage, and patients often request to stop them. Evidence for the benefits of long-term treatment is also not as robust as generally thought. Short-term randomised trials show higher rates of relapse among those whose neuroleptic treatment is discontinued compared with those on maintenance treatment, but they are confounded by adverse effects associated with the withdrawal of established medication. Some longer-term studies show possible advantages of medication reduction and discontinuation in terms of improved social functioning and recovery. Therefore, there is a good rationale for supporting patients who wish to stop their medication, especially given the patient choice agenda favoured by The National Institute for Clinical Excellence (NICE). The major barrier to stopping antipsychotics is an understandable fear of relapse among patients, their families and clinicians. Institutional structures also prioritise short-term stability over possible long-term improvements. The risk of relapse may be mitigated by more gradual reduction of medication, but further research is needed on this. Psychosocial support for patients during the process of reducing medication may also be useful, particularly to enhance coping skills. Guidelines to summarise evidence on ways to reduce medication would be useful. Many patients want to try and stop neuroleptic medication for good reasons, and psychiatrists can help to make this a realistic option by supporting people to do it as safely as possible, with the best chance of a positive outcome.

Social Status and Suicidal Activity Among Psychiatric Patients: Moderating Effects of Gender, Race and Psychiatric Diagnosis

The relationship between suicide and social class has proved to be complex. Durkheim predicted suicide rates would increase with social status, while others thought the opposite. Results have been mixed. In some studies, suicidality has increased with increasing social status, and in other studies, the two variables have had an inverse relationship. These studies have been primarily conducted on general non-psychiatric populations The present study, in contrast, examines this relationship on a 20-year prospective longitudinal sample of 400 psychiatric patients (differentiated by psychiatric diagnosis) after index hospitalization. Of these, 160 patients show some sign of suicide risk (87 cases of suicidal ideation, 41 of suicide attempts, and 32 suicide completions). A complicated pattern emerges across psychiatric diagnosis, gender, and race. The great majority of patients show no statistically significant relationship between social status and suicide risk. At the maximally different extremes, however, a dramatic difference does emerge. White women diagnosed with nonpsychotic depression show a positive relationship between social status and suicide risk (p < .01) while black men diagnosed with schizophrenia show a negative relationship between these 2 variables (p < .02). The relationship between social status and suicidality among psychiatric patients varies across race, gender, and psychiatric diagnosis. More research needs to be done on this complex and important topic, especially with regard to samples of psychiatric patients. The role of anomie should be studied.

Longitudinal analysis of statistical and clinically significant psychosocial change following mental health rehabilitation

Purpose: With appropriate mental health rehabilitation, schizophrenia is increasingly associated with reports of recovery and stability. However, there is little empirical evidence evaluating the efficacy of services delivering this care. This study evaluated the effectiveness of rehabilitation for improving psychosocial function in consumers with schizophrenia.Methods: An electronic database of standardized assessment instruments mandated and maintained by the health service was retrospectively reviewed to extract ratings of psychosocial function, daily living skills, and mood state from consecutive admissions to an inpatient rehabilitation service. Outcomes were compared at admission, discharge, and one-year follow-up to identify statistically significant change. Individual reliable and clinically significant change was also assessed by comparison with a normative group of clients functioning independently in the community.Results: From admission to discharge the rehabilitation group made statistically significant gains in psychosocial function and daily living skills. Improvements were reliable and clinically significant in one-quarter to one-third of individual consumers. Approximately half sustained their improvements at follow-up, although this represented only a small fraction of the overall cohort. Consumers not demonstrating gains exhibited psychometric floor effects at admission.Conclusions: Rehabilitation can produce statistically and clinically significant immediate improvement in psychosocial function for a sub-set of consumers with elevated scores at admission. The durability of any gains is less clear, and strategies promoting longer-term maintenance are encouraged. Furthermore, currently mandated outcome measures are confounded by issues of sensitivity and reporting compliance, and exploration of alternative instruments for assessing recovery is recommended.Implications for RehabilitationRoutinely collected standardized outcome measures can be used to investigate the effectiveness of mental health rehabilitationIn addition to statistical significance, the clinical significance of outcomes should be evaluated to identify change that is individually meaningfulCurrently mandated outcomes instruments do not adequately evaluate many individuals' recovery journeyMental health service evaluation and quality improvement processes would likely benefit from adoption of recovery-oriented measures.

Embracing Psychosis: A Cognitive Insight Intervention Improves Personal Narratives and Meaning-Making in Patients With Schizophrenia

Schizophrenia is a complex psychiatric disorder with unknown and presumably heterogeneous etiology. While the disorder can have various outcomes, research is predominantly "deficit-oriented" emphasizing the hardship that the disorder inflicts on sufferers as well as their families and society. Beyond symptom reduction, imparting patients with hope and meaning in life is increasingly considered an important treatment target, which may raise self-esteem, and reduce self-stigma and suicidal ideation. The present study compared a psychotherapeutic treatment aimed at improving cognitive insight, individualized metacognitive intervention (MCT+), with an active control in order to elucidate if personal meaning-making and hope can be improved in patients with psychosis across time. A total of 92 patients were randomized to either individualized metacognitive therapy (MCT+) or CogPack (neuropsychological training) and followed up for up to 6 months. The "Subjective Sense in Psychosis Questionnaire" (SUSE) was administered which covers different salutogenetic vs pathogenetic views of the disorder, valence of symptom experiences and the consequences of psychosis. Patients in the MCT+ group showed a significant positive shift in attitudes towards the consequences of their illness over time relative to patients in the active control condition. There was some evidence that MCT+ also enhanced meaning-making. The perceived negative consequences of psychosis were highly correlated with depression and low self-esteem, as well as suicidality. The study shows that a cognitive insight training can improve meaning-making in patients and help them come to terms with their diagnosis.

Stability and development of psychotic symptoms and the use of antipsychotic medication - long-term follow-up

BACKGROUND

Few studies have evaluated the development in the use of antipsychotic medication and psychotic symptoms in patients with first-episode psychosis on a long-term basis. Our objective was to investigate how psychotic symptoms and the use of antipsychotic medication changed over a 10-year period in a cohort of patients with first-episode psychosis.

METHOD

The study is a longitudinal prospective cohort study over 10 years with follow-ups at years 1, 2, 5 and 10. A total of 496 patients with first-episode psychosis were included in a multi-centre study initiated between 1998 and 2000 in Copenhagen and Aarhus, Denmark.

RESULTS

At all follow-ups, a large proportion (20-30%) of patients had remission of psychotic symptoms without use of antipsychotic medication at the time of the follow-up. Patients who were in this group at the 5-year follow-up had an 87% [95% confidence interval (CI) 77-96%] chance of being in the same group at the 10-year follow-up. This stability was also the case for patients who had psychotic symptoms and were treated with antipsychotic medication at year 5, where there was a 67% (95% CI 56-78%) probability of being in this group at the consecutive follow-up.

CONCLUSIONS

A large group of patients with psychotic illness were in remission without the use of antipsychotic medication, peaking at year 10. Overall there was a large degree of stability in disease courses over the 10-year period. These results suggest that the long-term outcome of psychotic illness is heterogeneous and further investigation on a more individualized approach to long-term treatment is needed.

Antipsychotic medication and remission of psychotic symptoms 10years after a first-episode psychosis

BACKGROUND

Several national guidelines recommend continuous use of antipsychotic medication after a psychotic episode in order to minimize the risk of relapse. However some studies have identified a subgroup of patients who obtain remission of psychotic symptoms while not being on antipsychotic medication for a period of time. This study investigated the long-term outcome and characteristics of patients in remission of psychotic symptoms with no use of antipsychotic medication at the 10-year follow-up.

METHODS

The study was a cohort study including 496 patients diagnosed with schizophrenia spectrum disorders (ICD 10: F20 and F22-29). Patients were included in the Danish OPUS Trial and followed up 10years after inclusion, where patient data was collected on socio-demographic factors, psychopathology, level of functioning and medication.

FINDINGS

61% of the patients from the original cohort attended the 10-year follow up and 30% of these had remission of psychotic symptoms at the time of the 10-year follow up with no current use of antipsychotic medication. This outcome was associated with female gender, high GAF-F score, participation in the labour market and absence of substance abuse.

CONCLUSION

Our results describe a subgroup of patients who obtained remission while not being on antipsychotic medication at the 10-year follow-up. The finding calls for further investigation on a more individualized approach to long-term treatment with antipsychotic medication.

Recovery assessment scale: Examining the factor structure of the German version (RAS-G) in people with schizophrenia spectrum disorders

BACKGROUND

The recovery framework has found its way into local and national mental health services and policies around the world, especially in English speaking countries. To promote this process, it is necessary to assess personal recovery validly and reliably. The Recovery Assessment Scale (RAS) is the most established measure in recovery research. The aim of the current study is to examine the factor structure of the German version of the RAS (RAS-G).

METHODS

One hundred and fifty-six German-speaking clients with schizophrenia or schizoaffective disorder from a community mental health service completed the RAS-G plus measures of recovery attitudes, self-stigma, psychotic symptoms, depression, and functioning. A confirmatory factor analysis of the original 24-item RAS version was conducted to examine its factor structure, followed by reliability and validity testing of the extracted factors.

RESULTS

The CFA yielded five factors capturing 14 items which showed a substantial overlap with the original subscales Personal Confidence and Hope, Goal and Success Orientation, Willingness to Ask for Help, Reliance on Others, and No Domination by Symptoms. The factors demonstrated mean to excellent reliability (0.59-0.89) and satisfactory criterial validity by positive correlations with measures of recovery attitudes and functioning, and negative correlations with measures of self-stigma, and psychotic and depressive symptoms.

CONCLUSIONS

The study results are discussed in the light of other studies examining the factor structure of the RAS. Overall, they support the use of the RAS-G as a means to promote recovery oriented services, policies, and research in German-speaking countries.

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.

The Twenty-Year Trajectory of Suicidal Activity Among Post-Hospital Psychiatric Men and Women with Mood Disorders and Schizophrenia

The Chicago Follow-up Study has followed the course of severe mental illness among psychiatric patients for more than 20 years after their index hospitalization. Among these patients are 97 schizophrenia patients, 45 patients with schizoaffective disorders, 102 patients with unipolar nonpsychotic depression, and 53 patients with a bipolar disorder. Maximum suicidal activity (suicidal ideation, suicidal attempts and suicide completions) generally declines over the 3 time periods (early, middle, and late follow-ups) following discharge from the acute psychiatric hospitalization for both males and females across diagnostic categories with two exceptions: female schizophrenia patients and female bipolar patients. A weighted mean suicidal activity score tended to decrease across follow-ups for male patients in the schizophrenia, schizoaffective, and depressive diagnostic groups with an uneven trend in this direction for the male bipolars. No such pattern emerges for our female patients except for female depressives. Males' suicidal activity seems more triggered by psychotic symptoms and potential chronic disability while females' suicidal activity seems more triggered by affective symptoms.

Neurophysiological differences between patients clinically at high risk for schizophrenia and neurotypical controls--first steps in development of a biomarker

BACKGROUND

Schizophrenia is a severe, disabling and prevalent mental disorder without cure and with a variable, incomplete pharmacotherapeutic response. Prior to onset in adolescence or young adulthood a prodromal period of abnormal symptoms lasting weeks to years has been identified and operationalized as clinically high risk (CHR) for schizophrenia. However, only a minority of subjects prospectively identified with CHR convert to schizophrenia, thereby limiting enthusiasm for early intervention(s). This study utilized objective resting electroencephalogram (EEG) quantification to determine whether CHR constitutes a cohesive entity and an evoked potential to assess CHR cortical auditory processing.

METHODS

This study constitutes an EEG-based quantitative neurophysiological comparison between two unmedicated subject groups: 35 neurotypical controls (CON) and 22 CHR patients. After artifact management, principal component analysis (PCA) identified EEG spectral and spectral coherence factors described by associated loading patterns. Discriminant function analysis (DFA) determined factors' discrimination success between subjects in the CON and CHR groups. Loading patterns on DFA-selected factors described CHR-specific spectral and coherence differences when compared to controls. The frequency modulated auditory evoked response (FMAER) explored functional CON-CHR differences within the superior temporal gyri.

RESULTS

Variable reduction by PCA identified 40 coherence-based factors explaining 77.8% of the total variance and 40 spectral factors explaining 95.9% of the variance. DFA demonstrated significant CON-CHR group difference (P <0.00001) and successful jackknifed subject classification (CON, 85.7%; CHR, 86.4% correct). The population distribution plotted along the canonical discriminant variable was clearly bimodal. Coherence factors delineated loading patterns of altered connectivity primarily involving the bilateral posterior temporal electrodes. However, FMAER analysis showed no CON-CHR group differences.

CONCLUSIONS

CHR subjects form a cohesive group, significantly separable from CON subjects by EEG-derived indices. Symptoms of CHR may relate to altered connectivity with the posterior temporal regions but not to primary auditory processing abnormalities within these regions.

[Deactualization and orthostrophy. Phenomenological psychopathology of receding delusions]

In this article we develop a phenomenological psychopathology of receding delusions in persons with a diagnosis of schizophrenia. Drawing on Klaus Conrad's (1905-1961) descriptions of beginning schizophrenia and an in-depth single case study, we develop descriptions of the process of receding delusions as opposed to ongoing delusions in the manner of a double-orientation to reality. We distinguish two stages in this process of social recovery and term these stages deactualization and orthostrophy. We argue that delusional convictions lose importance and persuasive power if they are no longer supported by corresponding value apprehensions or perceptions and perception-like experiences (i.e. hallucinations). Consequently, we propose that the process of receding delusions proceeds in layers comparable to a regression of the process of upcoming delusions. Lastly we discuss both stages of receding delusions (deactualization and orthostrophy) and ongoing delusions (double-orientation to reality) as possible continuous manners of social recovery concerning delusional psychosis (diagnosis of schizophrenia) and argue for specific interventions according to these different continuous manners.

Evaluation of a recovery-oriented care training program for mental healthcare professionals: effects on mental health consumer outcomes

OBJECTIVES

To examine the effects of a recovery-oriented care training program for mental healthcare professionals on mental health consumer outcomes.

METHODS

The Mental Health Recovery Measure (MHRM) and the Recovery-Promoting Relationship Scale (RPRS) were administered to a sample of 142 consumers with severe mental illness. A repeated measurement design with six measurement occasions was used.

ANALYSES

Separate analyses were performed for the MHRM and RPRS subscales. Data were analyzed by means of the software package AMOS for structural equation modeling. First, the means of the five scales were computed at each measurement occasion. Next, two series of regression analyses were conducted: the first series aimed to ascertain whether gender and age have a significant effect on the MHRM and RPRS scores, and the second series aimed to detect a systematic trend in the average scale response of the MHRM and RPRS.

RESULTS

Scores showed a significant change over time for the subscale 'Learning & new potentials' of the MHRM. Significant effects were also found for gender, with men scoring higher than women on the subscales 'Self-empowerment' and 'Learning & new potentials'. Age had no effect on the MHRM and RPRS. The scores on the RPRS showed no significant change over time.

CONCLUSIONS

One year after completion of the recovery-oriented training program for professionals, positive results were found for two subscales of the MHRM, that is, 'Self- empowerment' and 'Learning & new potentials'.

Coping with delusions in schizophrenia and affective disorder with psychotic symptoms: the relationship between coping strategies and dimensions of delusion

BACKGROUND

Self-generated coping strategies and the enhancement of coping strategies are effective in the treatment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhancement therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric approach, the relationship between coping and the dimensions of delusion were examined.

METHODS

Thirty schizophrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were interviewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analyses of variance were conducted to investigate differences between the groups, and Spearman's rank-based correlations were used to examine the correlations between coping factors and the dimensions of delusion.

RESULTS

Schizophrenia spectrum patients used more medical care and symptomatic coping, whereas patients with affective disorder engaged in more depressive coping. In the schizophrenia spectrum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the action-oriented dimension was related to coping factors.

CONCLUSION

Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies.

Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study

BACKGROUND

This research assesses whether multi-year treatment with antipsychotic medications reduces or eliminates psychosis in schizophrenia. It provides 20 years of longitudinal data on the frequency and severity of psychotic activity in samples of schizophrenia patients (SZ) treated versus those not treated with antipsychotic medications.

METHOD

A total of 139 early young schizophrenia and mood-disordered patients were assessed at index hospitalization and then reassessed six times over 20 years for psychosis and other major variables.

RESULTS

At each follow-up assessment over the 20 years, a surprisingly high percentage of SZ treated with antipsychotics longitudinally had psychotic activity. More than 70% of SZ continuously prescribed antipsychotics experienced psychotic activity at four or more of six follow-up assessments over 20 years. Longitudinally, SZ not prescribed antipsychotics showed significantly less psychotic activity than those prescribed antipsychotics (p < 0.05).

CONCLUSIONS

The 20-year data indicate that, longitudinally, after the first few years, antipsychotic medications do not eliminate or reduce the frequency of psychosis in schizophrenia, or reduce the severity of post-acute psychosis, although it is difficult to reach unambiguous conclusions about the efficacy of treatment in purely naturalistic or observational research. Longitudinally, on the basis of their psychotic activity and the disruption of functioning, the condition of the majority of SZ prescribed antipsychotics for multiple years would raise questions as to how many of them are truly in remission.

Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) "front-loading" research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

Beyond the usual suspects: positive attitudes towards positive symptoms is associated with medication noncompliance in psychosis

Antipsychotic medication represents the treatment of choice in psychosis according to clinical guidelines. Nevertheless, studies show that half to almost three-quarter of all patients discontinue medication with antipsychotics after some time, a fact which is traditionally ascribed to side-effects, mistrust against the clinician and poor illness insight. The present study investigated whether positive attitudes toward psychotic symptoms (ie, gain from illness) represent a further factor for medication noncompliance. An anonymous online survey was set up in order to prevent conservative response biases that likely emerge in a clinical setting. Following an iterative selection process, data from a total of 113 patients with a likely diagnosis of schizophrenia and a history of antipsychotic treatment were retained for the final analyses (80%). While side-effect profile and mistrust emerged as the most frequent reasons for drug discontinuation, 28% of the sample reported gain from illness (eg, missing voices, feeling of power) as a motive for noncompliance. At least every fourth patient reported the following reasons: stigma (31%), mistrust against the physician/therapist (31%), and rejection of medication in general (28%). Approximately every fifth patient had discontinued antipsychotic treatment because of forgetfulness. On average, patients provided 4 different explanations for noncompliance. Ambivalence toward symptoms and treatment should thoroughly be considered when planning treatment in psychosis. While antipsychotic medication represents the evidence-based cornerstone of the current treatment in schizophrenia, further research is needed on nonpharmacological interventions for noncompliant patients who are willing to undergo intervention but refuse pharmacotherapy.

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.

"Hearing voices" in schizophrenia: who's voices are they?

Paranoid schizophrenia is a subtype within the group of schizophrenia disorders. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), delusions and hallucinations are the first and second symptoms required for the diagnosis of schizophrenia. Empirical data and clinical observations allow us to present the hypothesis that paranoid schizophrenia can be divided into two subgroups: (1) Hallucinatory subgroup, patients with prominent hallucinations and delusions influenced by auditory hallucinations, (2) Delusional subgroup, patients with prominently impaired thought content, in which hallucinations are not significant clinical factors. Furthermore, we believe that auditory hallucinations are not disturbances of perception but rather of thought - or "pseudo-perceptions". According to our hypothesis there are epidemiological and clinical differences between the hallucinatory and delusional subgroups of patients diagnosed with schizophrenia, paranoid type. Patients in the Hallucinatory subgroup have more severe positive and negative symptoms and greater functional impairment than the patients in the Delusional subgroup. A patient deep in thought might not realize that he is thinking (malfunction of thought) but is rather "hearing voices" without external stimulus. Thus, hearing voices is not a disturbance of perception but rather of thought - or "pseudo-perception". The prognosis seems to be poorer for paranoid schizophrenia patients with prominent hallucinations, thus therapeutic rehabilitation programs for hallucinatory patients need to be developed accordingly. Further research is warranted to investigate additional aspects of these two groups.

Long-term healthcare costs and functional outcomes associated with lack of remission in schizophrenia: a post-hoc analysis of a prospective observational study

BACKGROUND

Little is known about the long-term outcomes for patients with schizophrenia who fail to achieve symptomatic remission. This post-hoc analysis of a 3-year study compared the costs of mental health services and functional outcomes between individuals with schizophrenia who met or did not meet cross-sectional symptom remission at study enrollment.

METHODS

This post-hoc analysis used data from a large, 3-year prospective, non-interventional observational study of individuals treated for schizophrenia in the United States conducted between July 1997 and September 2003. At study enrollment, individuals were classified as non-remitted or remitted using the Schizophrenia Working Group Definition of symptom remission (8 core symptoms rated as mild or less). Mental health service use was measured using medical records. Costs were based on the sites' medical information systems. Functional outcomes were measured with multiple patient-reported measures and the clinician-rated Quality of Life Scale (QLS). Symptoms were measured using the Positive and Negative Syndrome Scale (PANSS). Outcomes for non-remitted and remitted patients were compared over time using mixed effects models for repeated measures or generalized estimating equations after adjusting for multiple baseline characteristics.

RESULTS

At enrollment, most of the 2,284 study participants (76.1%) did not meet remission criteria. Non-remitted patients had significantly higher PANSS total scores at baseline, a lower likelihood of being Caucasian, a higher likelihood of hospitalization in the previous year, and a greater likelihood of a substance use diagnosis (all p < 0.05). Total mental health costs were significantly higher for non-remitted patients over the 3-year study (p = 0.008). Non-remitted patients were significantly more likely to be victims of crime, exhibit violent behavior, require emergency services, and lack paid employment during the 3-year study (all p < 0.05). Non-remitted patients also had significantly lower scores on the QLS, SF-12 Mental Component Summary Score, and Global Assessment of Functioning during the 3-year study.

CONCLUSIONS

In this post-hoc analysis of a 3-year prospective observational study, the failure to achieve symptomatic remission at enrollment was associated with higher subsequent healthcare costs and worse functional outcomes. Further examination of outcomes for schizophrenia patients who fail to achieve remission at initial assessment by their subsequent clinical status is warranted.

Are there gender-specific risk factors for suicidal activity among patients with schizophrenia and depression?

Are there gender-specific risk factors for suicidal activity among patients with schizophrenia and depression? A total of 74 schizophrenia patients (51 men, 23 women) and 77 unipolar nonpsychotic depressed patients (26 men, 51 women) from the Chicago Follow-up Study were studied prospectively at 2 years posthospitalization and again at 7.5 years. Poor early posthospital global functioning is significantly associated with later suicidal activity only for men in both our schizophrenia and depressive samples. Early display of psychotic symptoms is associated with later suicidal activity among male schizophrenia patients. Early cognitive impairment is not significantly associated with later suicidal activity for any of the four groups of patients. The study results must be seen as exploratory and will hopefully spur future research on this important topic.

Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study

BACKGROUND

The prevailing standard of care in the field involves background assumptions about the importance of prolonged use of antipsychotic medications for all schizophrenia (SZ) patients. However, do all SZ patients need antipsychotics indefinitely? Are there factors that help to identify which SZ patients can enter into prolonged periods of recovery without antipsychotics? This 20-year longitudinal research studied these issues.

METHOD

A total of 139 early young psychotic patients from the Chicago Follow-up Study, including 70 patients with SZ syndromes and 69 with mood disorders, were assessed, prospectively, at the acute phase and then followed up six times over the next 20 years. Patients were assessed with standardized instruments for major symptoms, psychosocial functioning, personality, attitudinal variables, neurocognition and treatment.

RESULTS

At each follow-up, 30-40% of SZ patients were no longer on antipsychotics. Starting at the 4.5-year follow-ups and continuing thereafter, SZ patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently.

CONCLUSIONS

The data indicate that not all SZ patients need treatment with antipsychotics continuously throughout their lives. SZ patients not on antipsychotics for prolonged periods are a self-selected group with better internal resources associated with greater resiliency. They have better prognostic factors, better pre-morbid developmental achievements, less vulnerability to anxiety, better neurocognitive skills, less vulnerability to psychosis and experience more periods of recovery.

Remission and recovery during the first outpatient year of the early course of schizophrenia

BACKGROUND

Although in the early course of schizophrenia relapse prevention is of paramount importance, there is an increasing emphasis on establishing and maintaining sustained periods of symptom remission. Recovery in the early course of illness is also possible, although the rates of recovery are lower than for symptom remission. Symptom remission and recovery rates vary considerably across recent-onset schizophrenia studies because of a lack of consistency in treatment interventions and in applying operational outcome criteria.

METHOD

Patients who were within two years of their first psychotic episode (N=77) that were treated with continuous antipsychotic medication in conjunction with psychosocial interventions (without targeted work rehabilitation) were assessed during the first outpatient year after hospital discharge. Published operational criteria were used to classify symptom remission and recovery.

RESULTS

The rate of full symptom remission maintained for 6 months was 36%, while the rate of recovery for 6 months was 10%. When the same criteria were applied for a continuous period of one year, 22% of patients were found to achieve symptom remission but only 1% of patients met recovery criteria. Using multivariate prediction, the WAIS Comprehension score was a significant predictor of 6 months of good functional outcome.

CONCLUSIONS

Although some schizophrenia patients can achieve both symptom remission and recovery in the early course of illness, the overall rate of symptom remission during the first post-hospitalization year is much higher than the rate of recovery. This suggests that interventions targeting work and social functioning are likely necessary to raise the chances of recovery. Cognitive factors can be predictive of good functional outcome even in the early course of schizophrenia.

Using computational patients to evaluate illness mechanisms in schizophrenia

BACKGROUND

Various malfunctions involving working memory, semantics, prediction error, and dopamine neuromodulation have been hypothesized to cause disorganized speech and delusions in schizophrenia. Computational models may provide insights into why some mechanisms are unlikely, suggest alternative mechanisms, and tie together explanations of seemingly disparate symptoms and experimental findings.

METHODS

Eight corresponding illness mechanisms were simulated in DISCERN, an artificial neural network model of narrative understanding and recall. For this study, DISCERN learned sets of autobiographical and impersonal crime stories with associated emotion coding. In addition, 20 healthy control subjects and 37 patients with schizophrenia or schizoaffective disorder matched for age, gender, and parental education were studied using a delayed story recall task. A goodness-of-fit analysis was performed to determine the mechanism best reproducing narrative breakdown profiles generated by healthy control subjects and patients with schizophrenia. Evidence of delusion-like narratives was sought in simulations best matching the narrative breakdown profile of patients.

RESULTS

All mechanisms were equivalent in matching the narrative breakdown profile of healthy control subjects. However, exaggerated prediction-error signaling during consolidation of episodic memories, termed hyperlearning, was statistically superior to other mechanisms in matching the narrative breakdown profile of patients. These simulations also systematically confused autobiographical agents with impersonal crime story agents to model fixed, self-referential delusions.

CONCLUSIONS

Findings suggest that exaggerated prediction-error signaling in schizophrenia intermingles and corrupts narrative memories when incorporated into long-term storage, thereby disrupting narrative language and producing fixed delusional narratives. If further validated by clinical studies, these computational patients could provide a platform for developing and testing novel treatments.

Revisiting the diagnosis of schizophrenia: where have we been and where are we going?

Appropriate and reliable classification of mental illness is crucial for advancing the field of psychiatry as agreement on diagnosis has broad implications for treatment of mental disorders and research into the etiopathophysiology of mental disorders. Since schizophrenia was first recognized by Kraepelin (as dementia praecox), there has been much discussion about what does and does not diagnostically constitute the disorder. The importance placed upon different symptoms and course types associated with schizophrenia has been as heterogeneous as the disorder itself. This article focuses upon the classification of schizophrenia over the last 100 years, the current diagnosis of schizophrenia, changes for schizophrenia planned in the upcoming DSM 5, future directions for improving the diagnosis of schizophrenia, and the implications of a new diagnostic paradigm for the illness.

Contrasting monosymptomatic patients with hallucinations and delusions in first-episode psychosis patients: a five-year longitudinal follow-up study

BACKGROUND

The main aim of this study was to identify subgroups of patients characterized by having hallucinations only or delusions only and to examine whether these groups differed with regard to demographic characteristics, clinical characteristics and outcome factors, including suicidality.

METHODS

Out of 301 consecutively admitted patients with first-episode psychosis, individuals with delusions only (D) and hallucinations only (H) were identified based on Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations) scores at baseline and through 4 follow-up interviews over 5 years. The subgroups were compared with regard to demographic data, premorbid functioning, duration of untreated psychosis, clinical variables, time to remission and suicidality.

RESULTS

Two groups of patients were identified; H (n = 16) and D (n = 106). 179 patients experienced both hallucinations and delusions (dual symptom group). The H group was significantly younger, had a longer duration of untreated psychosis, poorer premorbid function and better insight than the D group. Notably, the H group scored higher on measures of suicidality, and at 5 years follow-up a significantly higher proportion of patients was lost to suicide in this group. The dual symptom group was closer to the D group on significant parameters, including suicidality and suicide rate.

CONCLUSIONS

Patients with hallucinations only can be separated from patients with delusions only and the subgroups differ with regard to demographical data, clinical variables and notably with regard to suicidality. These findings suggest distinctions in the underlying biological and psychological processes involved in hallucinations and in delusions.

Are we using excessive neuroleptics? An argument for systematic neuroleptic dose reduction in stable patients with schizophrenia with specific reference to clozapine

Pharmacological intervention using antipsychotic agents is the cornerstone of treatment in schizophrenia. Polypharmacy and the use of higher doses is often practised in the hope of getting better symptom control in multi-episode, chronically unwell, people with schizophrenia. However, these regimes often pose unacceptable and at times dangerous risks. The current review examines the factors that influence dosing and argues that optimization is transient and needs ongoing consideration throughout the course of the illness. What is defined as 'the optimal dose' changes over the course of the illness and this should be reflected in treatment. The evidence presented in the current paper suggests that given the negative symptoms associated with neuroleptic medication, dosage should be discussed as part of the case review process and dosage should be systematically reduced as part of the standard treatment protocol. A case-study is presented of a patient who had her dosage of clozapine reduced and the subsequent health and lifestyle benefits from this reduction. We argue that the focus needs to be shifted away from the specific aim of treatment of psychotic symptoms to a more holistic view of treatment that incorporates function and psychosocial function as a measure of improvement.

Implausibility and Evidentiality in Schizophrenic Delusions: A Case of High Risk of Suicide

This article presents the case of a patient who, tormented by auditory hallucinations, made an almost fatal suicide attempt by shooting himself. He expressed the firm conviction that traumatic events in his life, including his suicide attempt, were going to occur again in the same form. The case was conceptualized in terms of phenomenological, psychodynamic, and linguistic concepts that informed his psychotherapeutic treatment. He was also treated with standard pharmacological intervention. This case uses previously neglected insights from linguistics to illustrate how implausibility of delusions can best be understood in terms of competing rules of evidentiality rather than abnormal reasoning and faulty interpretations of experience. The favorable outcome is explained by the replacement of delusional with nondelusional ways of making sense of the world, the decrease of hyperreflexivity, and the restoration of the patient’s sense of power over his life.

Schizophrenia Course, Long-Term Outcome, Recovery, and Prognosis

Our 26-year longitudinal study and other longitudinal studies confirm older views that outcome for schizophrenia, while showing some variation for different schizophrenia patients, is still significantly poorer than that for other psychiatric disorders, with the exception of the dementias. Our research leads us to propose that risk factors, either stress related or those related to vulnerability to psychosis, account for the episodic course of periods of recovery followed by periods of recurrence that is experienced by most schizophrenia patients. These risk factors interact with personality, temperament, and cognitive traits that, while not causing psychosis, influence its course. It is these interactions that account for the heterogeneous outcome trajectories of different subgroups of people with this condition. Our research and that of others has focused on the contributions of these risk factors, such as vulnerability to trait anxiety, poor developmental achievements before the illness, personality traits such as locus of control, cognitive styles, neurocognitive impairments, length of untreated psychosis, and several others. Despite the proven efficacy of antipsychotic medications over the short term, there is a subgroup of schizophrenia patients who, a few years after the acute phase, function adequately or experience periods of recovery for a number of years, without treatment.

Periods of recovery in deficit syndrome schizophrenia: a 20-year multi-follow-up longitudinal study

Periods of recovery were examined in patients with and without deficit syndrome schizophrenia. Fifty-six patients with schizophrenia were studied, 39 of whom were divided into deficit and nondeficit syndrome schizophrenia subtypes using a proxy method. We also studied 39 nonpsychotic depressive comparison patients. Patients were evaluated as part of the Chicago Follow-up Study, which prospectively examined patients at regular intervals over a 20-year period. Using standardized instruments, patients were evaluated for the deficit syndrome, global recovery, rehospitalization, social dysfunction, occupational disability, and symptom presentation. Recovery was examined at 6 time points measured at 2-, 4.5-, 7.5-, 10-, 15-, and 20-year postindex hospitalization. Cumulatively, over the 20-year period, 13% of patients classified as meeting criteria for the deficit syndrome showed 1 or more 1-year periods of global recovery, in comparison to 63% of nondeficit schizophrenia patients and 77% of depressed patient controls. Results indicate that the deficit syndrome represents a persistently impaired subsample of schizophrenia patients, with continuous social, occupational, and symptom impairment. In contrast, nondeficit syndrome schizophrenia patients showed at least some periods of remission or recovery, with the likelihood of these periods increasing as they became older. Findings provide further support for the validity of the deficit syndrome concept and suggest that deficit status is characterized by a more persistently impaired course of illness and particularly poor long-term prognosis.

Neurocognition in schizophrenia: a 20-year multi-follow-up of the course of processing speed and stored knowledge

Individuals with schizophrenia have relative deficits in cognition, although little is known regarding the course of such deficits across the life span and at various stages of the illness. Furthermore, the relationship between psychosis and cognition has not been adequately explored to this point. Prospective, longitudinal, multi-assessment studies of the same patients across time are rare in the field and provide a unique opportunity to examine long-term changes in cognition among individuals with schizophrenia. As part of The Chicago Follow-up Study, we prospectively assessed 244 psychiatric inpatients, including individuals with schizophrenia, other psychotic disorders, and nonpsychotic depression. Assessments were conducted 7 times (once at index hospitalization and then 6 times subsequently for the next 20 years) to provide longitudinal data about cognition and symptoms, with a focus on 2 aspects of cognition: processing speed and the ability to access general knowledge. The Digit Symbol-Coding and Information subtests from the Wechsler Adult Intelligence scale were used to measure the 2 cognitive domains at each assessment. At all 7 assessments, individuals with schizophrenia performed more poorly than the other diagnostic groups on the 2 cognitive measures. However, after the acute phase (index hospitalization), individuals with schizophrenia demonstrated significant improvements in cognition and did not show evidence of cognitive decline over the remaining 6 assessments spanning 20 years. Our data support the presence of relative cognitive impairment in schizophrenia, as well as a pattern of stability in some cognitive areas after the acute phase. In addition, we find evidence for an association between relative cognitive impairment and psychosis.