Schizophreniform disorder, delusional disorder and psychotic disorder not otherwise specified: clinical features, outcome and familial psychopathology

Schizophreniform Disorder Related Hospitalizations: A Clinical and Demographic Analysis of a National Hospitalization Database

INTRODUCTION

Schizophreniform disorder manifests itself with similar symptoms to schizophrenia, but it is distinguished from the latter by its shorter duration, varying between at least one and six months. This study aimed to describe and analyze schizophreniform disorder related hospitalizations in a national hospitalization database.

METHODS

We planned a descriptive retrospective study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese mainland public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of schizophreniform disorder were selected based on the International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) code of diagnosis 295.4x. Data regarding birth date, sex, residence address, diagnoses, length of stay, discharge status, and hospital charges were obtained. Comorbidities were analyzed using the Charlson Index Score. Independent Sample t tests were performed to assess differences in continuous variables with a normal distribution and Mann-Whitney-U tests when no normal distribution was registered.

RESULTS

In Portuguese mainland public hospitals, a total of 594 hospitalizations with a primary diagnosis of schizophreniform disorder occurred during the eight-year study period. Most, 72.1% (n = 428), were observed in male patients. The mean age at admission was 34.34 years in male patients and 40.19 years in female patients. The median length of stay was 17.00 days and in-hospital mortality was 0.5% (n = 3). Only 6.1% (n = 36) of the hospitalization episodes had one or more registered comorbidities. Forty-one readmissions were documented.

CONCLUSION

Hospitalizations with a primary diagnosis of schizophreniform disorder occur more frequently in young male patients. This is, to the best of our knowledge, the first nationwide study analyzing all hospitalizations due to this diagnosis in Portugal.

Mnemonic discrimination deficits in multidimensional schizotypy

Current developmental psychopathology models indicate that schizophrenia can be understood as the most extreme expression of a multidimensional continuum of symptoms and impairment referred to as schizotypy. In nondisordered adults, schizotypy predicts risk for developing schizophrenia-spectrum psychopathology. Schizophrenia is associated with disruptions in detecting subtle differences between objects, which is linked to hippocampal dysfunction. These disruptions have been shown in the Mnemonic Similarity Task (MST) when patients are less likely to reject lures that are similar but not identical to studied objects, and instead mistake them for studied items. This pattern of errors may be a behavioral manifestation of impaired pattern separation, a key episodic memory ability associated with hippocampal integrity and overreliance on pattern completion. We examined whether multidimensional schizotypy is associated with such deficits in nondisordered young adults. Participants (n = 230) were assessed for positive, negative, and disorganized schizotypy and completed the MST and a perceptual discrimination task. MST performance showed that a combination of elevated negative and disorganized schizotypy was associated with decreased rejections of similar lures because they were mistakenly identified as studied items. These deficits were not observed in traditional recognition measures within the same task, nor in perceptual discrimination, suggesting that mnemonic discrimination deficits assessed by MST were selective and did not reflect generalized deficits. These findings extend the results obtained in schizophrenia patients and support a multidimensional model of schizophrenia-spectrum psychopathology.

Comparison of clinical features and 1-year outcomes between patients with psychotic disorder not otherwise specified and those with schizophrenia

AIM

Research on psychotic disorder not otherwise specified (PNOS) that clearly mentions its subgroups is very rare. This study was conducted to identify the demographic and clinical features, cognitive function, and 1-year outcomes of patients with early stage PNOS compared with those with early stage schizophrenia (SZ).

METHODS

The study subjects were 54 and 321 patients with PNOS and SZ, respectively, who were registered at least more than 1 year ago. Due to drop out, only 37 and 210 patients with PNOS and SZ were evaluated at the 1-year follow-up. We compared clinical variables (duration of untreated psychosis, symptom severity, self-rating scales, and so on), cognitive function, and short-term outcomes (treatment response, remission, compliance, drop out, relapse) between the two groups.

RESULTS

The patients with PNOS were associated with higher diagnostic stability (53.7%) compared with those in previous studies. They had lower symptom severity, better treatment response at 2 months and higher remission rates at 12 months, but poorer compliance at 6 months compared with patients with SZ. Level of cognitive impairment in PNOS was intermediate between those of SZ patients and healthy controls.

CONCLUSIONS

These findings indicate that PNOS has unique clinical features, suggesting that it should be treated as a distinct clinical syndrome. At the same time, however, prevention of its possible progression to other psychotic disorders in some patients with PNOS is also important.

Altered functional connectivity in psychotic disorder not otherwise specified

BACKGROUND

Few studies have investigated functional connectivity (FC) in patients with psychotic disorder not otherwise specified (PNOS). We sought to identify distinct FC differentiating PNOS from schizophrenia (SZ).

METHODS

In total, 49 patients with PNOS, 42 with SZ, and 55 healthy controls (HC) matched for age, sex, and education underwent functional magnetic resonance imaging (fMRI) brain scans and clinical evaluation. Using six functional networks consisting of 40 regions of interest (ROIs), we conducted ROI to ROI and intra- and inter-network FC analyses using resting-state fMRI (rs-fMRI) data. Correlations of altered FC with symptomatology were explored.

RESULTS

We found common brain connectomics in PNOS and SZ including thalamo-cortical (especially superior temporal gyrus) hyperconnectivity, thalamo-cerebellar hypoconnectivity, and reduced within-thalamic connectivity compared to HC. Additionally, features differentiating the two patient groups included hyperconnectivity between the thalamic subregion and anterior cingulate cortex in PNOS compared to SZ and hyperconnectivity of the thalamic subregions with the posterior cingulate cortex and precentral gyrus in SZ compared to PNOS.

CONCLUSIONS

These findings suggest that PNOS and SZ exhibit both common and differentiating changes in neuronal connectivity. Furthermore, they may support the hypothesis that PNOS should be treated as a separate clinical syndrome with distinct neural connectomics.

Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders

Background: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. Aims: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. Methods: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. Results: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. Conclusions: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.

Psychometric instruments for the assessment of depressive symptoms in patients with delusional disorder: A systematic review

Patients with delusional disorder (DD) are at an increased risk for the development of depressive symptoms. We aimed to examine the literature dealing with assessment tools to assess depressive symptoms in DD. A systematic review was performed by searching PubMed, Scopus and clinicaltrials.gov databases from inception until June 2021 (PRISMA guidelines). From 1863 initial retrieved records, 11 studies were included (N = 715 DD patients). Depressive comorbidity ranged from 20.9% to 53.5%. Seven studies used semistructured/structured interviews: OPCRIT 4.0 (n = 1), Manual for Assessment and Documentation of Psychopathology in Psychiatry (AMDP System) (n = 2), the MINI interview (n = 1), DSM-IV (n = 1), ICD-10 (n = 1); and the Diagnostic Interview Schedule (DIS-R) (n = 1). Seven studies used at least one observer-rated scale: Positive and Negative Syndrome Scale (PANSS)-depressive component (n = 2), Hamilton Rating Scale for Depression (HRSD, n = 3), Montgomery-Asberg Depression Rating Scale (MADRS, n = 1), Clinical Global Impression Scale (CGI, n = 1) and the Bipolar Affective Disorder Dimension Scale (BADDS, n = 1). Assessment scales administered in depressive disorders and schizophrenia are applied to DD. This is the first systematic review exploring the use of assessment tools for depressive symptoms in DD. The use of the MADRS to assess depressive symptoms can be recommended in combination with other clinical scales, for instance, the CGI.

A descriptive case-register study of delusional disorder

Objective

A few empirically based studies' data on delusional disorder (DD) exist. We aim to describe sociodemographic and clinical correlates of DD and to identify clinical profiles associated to DD and its subtypes.

Methods

This is a case-register study based on all those subjects attending community mental health services within a geographically well-defined area. Four hundred and sixty-seven patients had been diagnosed as DD cases at psychiatric services serving a catchment area of some 607,494 inhabitants living in South Barcelona (Spain) during a three-year period (2001–2003). A thorough systematic review of computerised medical records was used to establish DSM-IV diagnosis, rendering a valid sample of 370 patients who fulfilled DSM-IV criteria for DD. Independent variables gathered include sociodemographic data, family and personal psychiatric history, and comorbid diagnoses on all DSM-IV axes (including GAF). We used descriptive and univariate statistical methods to explore sample frequencies and correlates across DD types.

Results

The mean age of the patients was 55 years and the sample had a mean GAF score of 51 suggesting a poor functionality; 56.5% of the patients were female. The most frequent DD types were persecutory (48%), jealous (11%), mixed (11%) and somatic (5%), whilst 23% qualified for the NOS type. Most frequent symptoms identified were self-reference (40%), irritability (30%), depressive mood (20%) and aggressiveness (15%). Hallucinations were present in 16% of the patients (6% tactile; 4% olfactory). Nearly 9% had a family history of schizophrenia (higher among those with the jealous subtype) and 42% had a comorbid axis II diagnosis (mostly paranoid personality disorder). Depression was significantly more frequent among the persecutory and jealous types. Finally, global functioning was significantly better among jealous and mixed types and worse amongst erotomanic and grandiose cases (p = 0.008).

Conclusions

In the absence of other similar empirical data, this modest study provides unique empirical evidence of some clinical and risk correlates of DD and its subtypes.

Symptom Profiles in Psychotic Disorder Not Otherwise Specified

Introduction: Approximately 10% of patients with psychotic disorders receive the diagnosis "Psychotic disorder not otherwise specified" (PNOS). However, there is a lack of knowledge about the clinical presentations captured by this diagnosis in the mental health services. Therefore, we examined the symptom profiles of participants with PNOS compared to participants with bipolar disorder (BD) and schizophrenia spectrum disorder (SZ) diagnoses. Methods: We here included 1,221 participants from the Thematically Organized Psychosis-study at Oslo University Hospital; 792 with SZ, 283 with BD, and 146 with PNOS, assessed with SCID-I for DSM-IV. The participants with PNOS were categorized into subgroups based on SCID information. The GAF, PANSS, Alcohol Use Disorders Identification Test (AUDIT), and Drug Use Disorders Identification Test (DUDIT) were used to assess function, clinical symptoms, and substance use. Results: In the PNOS group, 44% did not meet the criteria for any specific psychotic disorder, 35.5% had contradictory information making a specific diagnosis difficult, and 20.5% had inadequate information to make a specific diagnosis. The most frequent reason for a PNOS diagnosis was difficulty ruling out a substance-induced psychotic disorder (n = 41, 28%). Participants with PNOS were younger and more often first-episode than participants with BD and SZ. They were intermediate between BD and SZ for GAF scores (BD>PNOS>SZ) and PANSS scores (BD<PNOS<SZ) and more often scored above the clinical cut-off for substance misuse as measured by the AUDIT (BD = PNOS<SZ), DUDIT (BD = SZ<PNOS) and for the combination of both these measures. Conclusions: A PNOS diagnosis is more common in first-episode than in multi-episode patients. The diagnosis captures a heterogeneous group of psychotic syndromes, with a severity of symptoms and functional loss that is intermediate between BD and SZ.

Use of schizophrenia and bipolar disorder polygenic risk scores to identify psychotic disorders

BACKGROUND

There is increasing evidence for shared genetic susceptibility between schizophrenia and bipolar disorder. Although genetic variants only convey subtle increases in risk individually, their combination into a polygenic risk score constitutes a strong disease predictor.AimsTo investigate whether schizophrenia and bipolar disorder polygenic risk scores can distinguish people with broadly defined psychosis and their unaffected relatives from controls.

METHOD

Using the latest Psychiatric Genomics Consortium data, we calculated schizophrenia and bipolar disorder polygenic risk scores for 1168 people with psychosis, 552 unaffected relatives and 1472 controls.

RESULTS

Patients with broadly defined psychosis had dramatic increases in schizophrenia and bipolar polygenic risk scores, as did their relatives, albeit to a lesser degree. However, the accuracy of predictive models was modest.

CONCLUSIONS

Although polygenic risk scores are not ready for clinical use, it is hoped that as they are refined they could help towards risk reduction advice and early interventions for psychosis.Declaration of interestR.M.M. has received honoraria for lectures from Janssen, Lundbeck, Lilly, Otsuka and Sunovian.

Clinical Correlates of Suicide in Suicidal Patients with Schizophrenia Spectrum Disorders and Affective Disorders

BACKGROUND

The most common psychiatric illnesses in the background of suicide are schizophrenia spectrum disorders (SSD) and affective disorders (AD). While depression and hopelessness are important factors for suicide in psychiatric patients, the role of psychotic symptoms is unclear. We examine the comparative differences in the clinical correlates of suicide in SSD and AD patients with suicidal risk.

MATERIALS AND METHODS

One hundred and twenty suicidal psychiatric patients (aged between 17-60 years) were evaluated for depression severity, hopelessness, past attempts, and reasons for wanting to commit suicide at the emergency psychiatry centre. Of these 29% had SSD, 65% AD, and 6% other disorders.

RESULTS

Lifetime history of suicide attempts and suicide attempts in previous month were higher in SSD patients. Mean Beck Depression scores, Hopelessness, and Suicide Intention scores were significantly lower in patients with SSD as compared to AD (P ≤ 0.05). More than 60% patients with SSD attributed psychotic symptoms as a reason for wanting to commit suicide, while more than 50% patients with AD attributed it to family and personal stressors (P ≤ 0.001).

CONCLUSIONS

Factors associated with suicidal ideations were significantly different between SSD and AD patients. Hence, suicide prevention strategies should be based on the specific risk factors for each group, SSD and AD.

VRK2 gene expression in schizophrenia, bipolar disorder and healthy controls

BACKGROUND

Common variants in the Vaccinia-related kinase 2 (VRK2) gene have been associated with schizophrenia, but the relevance of its encoded protein VRK2 in the disorder remains unclear.

AIMS

To identify potential differences in VRK2 gene expression levels between schizophrenia, bipolar disorder, psychosis not otherwise specified (PNOS) and healthy controls.

METHOD

VRK2 mRNA level was measured in whole blood in 652 individuals (schizophrenia, n = 201; bipolar disorder, n = 167; PNOS, n = 61; healthy controls, n = 223), and compared across diagnostic categories and subcategories. Additionally, we analysed for association between 1566 VRK2 single nucleotide polymorphisms and mRNA levels.

RESULTS

We found lower VRK2 mRNA levels in schizophrenia compared with healthy controls (P<10(-12)), bipolar disorder (P<10(-12)) and PNOS (P = 0.0011), and lower levels in PNOS than in healthy controls (P = 0.0042) and bipolar disorder (P = 0.00026). Expression quantitative trait loci in close proximity to the transcription start site of the short isoforms of the VRK2 gene were identified.

CONCLUSIONS

Altered VRK2 gene expression seems specific for schizophrenia and PNOS, which is in accordance with findings from genome-wide association studies. These results suggest that reduced VRK2 mRNA levels are involved in the underlying mechanisms in schizophrenia spectrum disorders.

Access and latency to first antipsychotic treatment in Italian patients with schizophrenia and other schizophrenic spectrum disorders across different epochs

BACKGROUND

The duration of untreated illness (DUI) is a measure to express the latency to first psychopharmacological treatment: it differs among psychiatric disorders, being influenced by several illness-intrinsic and environmental factors. The present study aimed to assess differences in DUI and related variables in patients with schizophrenia (SKZ) versus other schizophrenic spectrum disorders (SSDs) across different epochs.

METHODS

101 SKZ or SSD patients were assessed with respect to DUI and related variables through clinical interview and questionnaire.

RESULTS

Patients with SKZ showed earlier ages of onset, first diagnosis and first antipsychotic treatment compared with patients with other SSDs (F = 11.02, p < 0.001; F = 12.68, p < 0.001; F = 13.74, p < 0.001, respectively) who showed an earlier access to benzodiazepines than SKZ patients (F = 6.547; p < 0.05). Dividing the total sample by the epoch of onset (before 1978; between 1978-2000; after 2000) showed a significantly later age of onset in patients with onset within the two most recent epochs (F = 7.46; p < 0.001) and a reduced DUI across epochs (from 144 to 41 to 20 months, on average; F = 11.78, p < 0.001).

CONCLUSION

Schizophrenic patients showed earlier onset and longer DUI compared with patients with other SSDs. Data on the total sample showed a later age of onset and a reduced DUI across epochs.

Outcome of Youth with Early-Phase Schizophrenia-Spectrum Disorders and Psychosis Not Otherwise Specified Treated with Second-Generation Antipsychotics: 12 Week Results from a Prospective, Naturalistic Cohort Study

OBJECTIVES

The purpose of this study was to assess differences in the outcomes of youth with schizophrenia-spectrum disorders (SCZ-S) and psychotic disorder not otherwise specified (PsyNOS) during early antipsychotic treatment.

METHODS

The study was a prospective, naturalistic, inception cohort study of youth ≤19 years old with SCZ-S (schizophrenia, schizoaffective disorder, schizophreniform disorder) or PsyNOS (PsyNOS, brief psychotic disorder) and ≤24 months of lifetime antipsychotic treatment receiving clinician's choice antipsychotic treatment. Baseline demographic, illness and treatment variables, and effectiveness outcomes were compared at 12 weeks last-observation-carried-forward across SCZ-S and PsyNOS patients, adjusting for significantly different baseline variables.

RESULTS

Altogether, 130 youth with SCZ-S (n=42) or PsyNOS (n=88), mostly antipsychotic naïve (76.9%), were prescribed risperidone (47.7%), olanzapine (19.2%), aripiprazole (14.6%), quetiapine (11.5%), or ziprasidone (6.9%). Compared with those with PsyNOS, SCZ-S youth were older (16.4±2.1 vs. 14.8±3.2, p=0.0040), and less likely to be Caucasian (19.1% vs. 42.5%, p=0.009). At baseline, SCZ-S patients had significantly higher Clinical Global Impressions-Severity (CGI-S) scores (6.0±0.9 vs. 5.5±0.8, p=0.0018) and lower Children's Global Assessment Scale (CGAS) scores (29.6±9.2 vs. 36.1±8.9, p=0.0002) and were more likely to be in the severely ill CGAS group (i.e., CGAS≤40). SCZ-S and PsyNOS patients did not differ regarding all-cause discontinuation (40.5 vs. 40.3%. p=0.49), discontinuation because of adverse effects (12.2% vs. 12.4%, p=0.97), or nonadherence (29.3% vs. 30.9%, p=0.88), but somewhat more SCZ-S patients discontinued treatment for inefficacy (19.5% vs. 7.4%, p=0.063). CGI-S and CGAS scores improved significantly in both diagnostic groups (p=0.0001, each). Adjusting for baseline differences, PsyNOS patients experienced significantly better CGI-I improvement (CGI-I) scores (p=0.012) and more frequently reached higher categorical CGAS group status (p=0.021) than SCZ-S patients.

CONCLUSIONS

Both youth with SCZ-S and those with PsyNOS experienced significant improvements with clinician's choice antipsychotic treatment. However, treatment discontinuation was common within 12 weeks, with greater inefficacy-related discontinuation in the SCZ-S group, whereas CGI-I and CGAS score-based improvements were greater in the PsyNOS group.

Polygenic risk score and the psychosis continuum model

OBJECTIVE

Schizophrenia (SZ) and bipolar disorder (BD) are heritable, polygenic disorders with shared clinical characteristics and genetic risk indicating a psychosis continuum. This is the first study using polygenic risk score (PGRS) to investigate the localization of diagnostic subcategories along the entire psychosis spectrum.

METHOD

Based on results from the Psychiatric Genomics Consortium (PGC), we assigned a SZ and BD PGRS to each individual in our independent sample [N=570 BD spectrum cases, 452 SZ spectrum cases and 415 healthy controls (CTR)]. Potential differences in mean SZ and BD PGRS across diagnostic spectrums and subcategories were explored.

RESULTS

SZ and BD PGRSs were significantly associated with both SZ and BD spectrums compared with CTR. For the subcategories, SZ PGRS was significantly associated with SZ, schizoaffective disorder, psychosis not otherwise specified, and BD1, while BD PGRS was significantly associated with BD1 and BD2. There were no significant differences between any of the diagnostic spectrums or subgroups for neither the SZ nor BD PGRS. Lifetime psychosis was significantly associated with SZ PGRS but not with BD PGRS.

CONCLUSION

These findings further support the psychosis continuum model and provide molecular polygenetic validation of the localization of diagnostic subcategories within this continuum.

Empirical redefinition of delusional disorder and its phenomenology: the DELIREMP study

AIMS

Since Kraepelin, the controversy has persisted surrounding the nature of delusional disorder (DD) as a separate nosological entity or its clinical subtypes. Nevertheless, there has been no systematic study of its psychopathological structure based on patient interviews. Our goal was to empirically explore syndromic subentities in DD.

METHODS

A cross-sectional study was conducted in 86 outpatients with DSM-IV-confirmed DD using SCID-I. Psychopathological factors were identified by factor analysis of PANSS scores. The association between these factors and clinical variables (as per standardized instruments) was analyzed using uni- and multivariate techniques.

RESULTS

PANSS symptoms were consistent with four factors (Paranoid, Cognitive, Schizoid, and Affective dimensions), accounting for 59.4% of the total variance. The Paranoid Dimension was associated with premorbid paranoid personality disorder, more adverse childhood experiences, chronic course, legal problems, worse global functioning, and poorer treatment adherence and response. The Cognitive Dimension was associated with poorer cognitive functioning, premorbid substance abuse, comorbid somatic diseases, mainly non-prominent visual hallucinations, fewer comorbid depressive disorders, and poorer global functioning. The Schizoid Dimension was associated with being single, a family history of schizophrenia, premorbid personality disorders (largely schizoid and schizotypal), non-prominent auditory hallucinations, and dysthymia. Finally, the Affective Dimension was associated with a family history of depression, premorbid obsessive personality, somatic delusions, absence of reference delusions, tactile and olfactory hallucinations, depressive and anxiety disorders, risk of suicide, and higher perceived stress.

CONCLUSION

The identification and clinical validation of four separate psychopathological dimensions in DD provide evidence toward a more accurate conceptualization of DD and its types.

[Validity of nonaffective functional psychosis of the DSM IV in a Congolese population. A transversal clinical trial]

BACKGROUND

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) distinguishes schizophrenia, schizophreniform disorder and brief psychotic disorder only according to the duration of the illness. Thus, the validity of these nosological concepts sounds uncertain.

AIM

The aim of this study was to evaluate the validity of the DSM IV concepts schizophrenia, schizophreniform disorder and brief psychotic disorder.

POPULATION AND METHODS

Seventy schizophrenics, 68 patients with brief psychotic disorder and 50 with schizophreniform disorder, all Congolese people, selected from the 'Telema' Mental Health Centre and the 'Neuropsychopathological centre of the University of Kinshasa, from 5(th) August 2003 to 14(th) March 2005 were compared with respect to the following clinical parameters: family schizophrenia and brief psychoses history, precipitating psychosocial factors, mode of onset of the disease, clinical syndromes linked to psychoses and general functioning. Statistical analyses included analysis of variances 'one way' (Anova), post hoc Tukey's test, discriminant analysis, and analysis of covariances.

RESULTS

Brief psychotic disorder differed from schizophrenia and schizophreniform Disorder in respect with positive syndrome (F=8.76, df=2; 179, p=0.0002), cognitive syndrome (F=3.79, df=2; 179, P=0.024), syndrome of excitement (F=3.23, df=2; 179, P=0.042), general functioning (F=13.73, df=2; 179, P<0.0001), family history of schizophrenia (χ(2)=8.65; P=0.013), precipitating psychosocial factors (χ(2)=19.82; P<0.0001), and mode of onset of the disease (χ(2)=91.3; P<0.0001). Schizophreniform disorder differered from schizophrenia only by a more frequent acute onset and a better general functioning. Two nosological realities were thus distinguishable: brief psychotic disorder and schizophrenia-schizophreniform disorder complex. Surprisingly, negative syndrome could not distinguish brief psychotic disorder from schizophrenia and schizophreniform (F=2.80, df=2; 179, P=0.063). Data of the discriminant analysis based on scores on general functioning, positive, negative, depressive, cognitive and excitement syndromes was conclusive (F=6.41, df=2; 185, P<0.0001) and allowed correct classification rates of 75% for brief psychotic disorder, 48% for schizophreniform disorder, 54% for schizophrenia. Schizophreniform disorder was thus the less distinguishable group; this is in the line with longitudinal studies, which demonstrated the lowest diagnostic stability of this affection, compared with the two other diseases. Total error rate was 41%.

CONCLUSIONS

Brief psychotic disorder could constitute a distinct affection from schizophrenia and schizophreniform disorder, whereas schizophreniform disorder and schizophrenia could be the same affection; the first being an acute and "good functioning" form of the second. However, these viewpoints need to be confirmed by data on long-term course. The data of this study validate ultimately a binary model of the major nonaffective functional psychoses, like that of the tenth edition of the International classification of mental and behavioural disorders (ICD-10).

Predictors of remission, schizophrenia, and bipolar disorder in adolescents with brief psychotic disorder or psychotic disorder not otherwise specified considered at very high risk for schizophrenia

OBJECTIVE

The aim of this study was to examine predictors of diagnostic and symptomatic outcome in adolescents with either psychotic disorder not otherwise specified (PsyNOS) or brief psychotic disorder (BrPsy) followed in a schizophrenia prodromal program.

METHODS

As part of a naturalistic study of adolescents considered at clinical high risk for schizophrenia, 26 youths (mean age, 15.9 +/- 2.6 years, 65.4% male) with psychosis not fulfilling criteria for schizophrenia/schizoaffective disorder and diagnosed with PsyNOS or BrPsy were evaluated for predictors of diagnostic and symptomatic outcome after at least 6 (mean, 22.8 +/- 19.4) months follow up.

RESULTS

Progression to schizophrenia, schizoaffective disorder, or psychotic bipolar disorder (n = 10, 38.5%) was predicted by fulfilling criteria for schizotypal personality disorder at baseline (p = 0.046). Development of schizophrenia/schizoaffective disorder (n = 7, 27.0%) was associated with worse executive functioning (p = 0.029) and absence of anxiety disorders (p = 0.027). Conversely, progression to bipolar disorder (n = 4, 15.4%), with (n = 3, 11.5%) or without (n = 1, 3.8%) psychosis, was associated with the presence of anxiety disorders (p = 0.014). Remission of all psychotic as well as attenuated positive or negative symptoms (n = 5, 19.4%) was predicted by Hispanic ethnicity (p = 0.0047), an initial diagnosis of BrPsy (p = 0.014), longer duration of antidepressant treatment (p = 0.035), and better attention at baseline (p = 0.042).

CONCLUSIONS

Results from this preliminary study suggest that patients with PsyNOS, BrPsy, or schizotypal personality disorder features in adolescence should be followed as separate risk groups in prodromal studies of schizophrenia and bipolar disorder. Executive function deficits and absence of anxiety disorders may be risk markers for schizophrenia, while presence of anxiety disorders may be linked to bipolar disorder risk. After achieving full remission, patients with sudden onset of psychosis and brief episodes could once be given the option of careful, supervised treatment discontinuation. The potential salutary effect of antidepressants during the psychotic prodrome and presence of characteristics differentiating patients at risk for schizophrenia or bipolar disorder should be investigated further.

Delusional disorder: Study from North India

The aim of the present study was to study sociodemographic profile, clinical parameters including comorbidity, usefulness of antipsychotics especially atypicals, family history, and follow-up rates for delusional disorder. The records of all subjects who were seen in the Department of Psychiatry during a period of 10 years (i.e. 1994-2003) were reviewed. Eighty-eight subjects fulfilling the inclusion criteria were enrolled. The sample consisted predominantly of female subjects (55.7%), most of the total subjects were married and had favorable social functioning. The most common delusion was persecutory (54.5%), followed by delusion of reference (46.6%). The majority of the subjects had a comorbid psychiatric disorder. Education was negatively correlated with age at onset and positively correlated with the number of delusions. Age at onset was negatively correlated with total number of delusions. The sociodemographic profile of delusional disorder is consistent across various cultures, has high comorbidity and, when treated appropriately, responds to various antipsychotic agents.

Status of first-episode psychosis patients presenting for routine care in a defined catchment area

OBJECTIVE

To examine the clinical and behavioural status of all first-episode psychosis (FEP) patients admitted to hospital within a defined catchment area.

METHOD

We used a structured format to review clinical records of all first admissions to hospitals from a catchment area (population 390 000) with diagnosis of a first episode of nonaffective psychosis over a 3-year period.

RESULTS

Patients were somewhat older than usually reported for FEP (mean age 31.3 years). They were mostly male (63.7%), single (80.8%), unemployed (87.4%), with a primary diagnosis of schizophrenia spectrum psychoses (85%), and had spent a mean of 31 days in an open inpatient unit and 2.93 days in an intensive care psychiatric unit during their first admission. Most (60.3%) were admitted involuntarily; 34.2% had a history of legal involvement; 18.8% had attempted suicide prior to admission; 31.5% had demonstrated violence toward people, property, or animals; 14.4% had suffered injuries; and 15.9% had shown aggressive behaviour during the hospital admission.

CONCLUSIONS

These results identify some of the potential needs of FEP patients, toward whom early intervention services should be directed.

Genetics and delusional disorder

This article gives an overview of genetic research approaches and their application to delusional disorder. Most studies have been based on small samples and have had other methodological limitations, so it is not clear whether there is a genetic contribution to the aetiology of delusional disorder. It is unlikely that delusional disorder is strongly related genetically to affective disorder or schizophrenia, but more subtle relationships cannot be ruled out. The rarity of multiply affected families prohibits linkage studies and, to date, molecular genetic investigations have been mainly limited to small association studies of dopamine receptor polymorphisms. A range of considerably larger, epidemiologically rigorous studies is required, but the uncommonness and other features of the disorder put strong limitations on the prospects for ascertaining adequate samples.

Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome

OBJECTIVE

The aim of this study was to examine the characteristics and outcome of adolescents with psychotic disorder not otherwise specified (PsyNOS) and brief psychotic disorder (BrPsy), two neglected subsyndromal diagnostic entities.

METHODS

As part of an ongoing, naturalistic study investigating adolescents considered to be prodromal for schizophrenia, 29 youngsters (mean age, 16.2 +/- 2.7 years) with PsyNOS or BrPsy were identified as theoretically at highest risk for schizophrenia and followed for over 6 (mean, 22.8 +/- 19.4) months.

RESULTS

Contrary to our expectations, only 7 of the 26 individuals (27.0%) with follow-up data developed schizophrenia or schizoaffective disorder, and only 2 subjects (7.7%) retained their diagnosis of BrPsy/PsyNOS. The most frequent other diagnoses at follow-up were mood disorders (34.6%), personality disorders (11.5%), and obsessive-compulsive disorder (7.7%). Regarding severity of outcome, 38.5% of the patients progressed to a syndromal psychotic disorder, 23.1% continued to have attenuated positive symptoms, and 38.4% improved to having attenuated negative symptoms only, or no positive or negative symptoms. BrPsy was associated with lower maximum levels of negative symptoms (p = 0.02) and higher likelihood of symptom remission (p = 0.02).

CONCLUSIONS

This study indicates that psychotic symptoms not fulfilling criteria for schizophrenia or a psychotic mood disorder are unreliable predictors of a syndromal psychotic disorder outcome at 2 years. Long-term studies of PsyNOS and BrPsy are needed to clarify where these disorders fall in the developmental course of schizophrenia.

Symptom and demographic profiles in first-episode schizophrenia

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

Outcome of schizophreniform disorder

The aim of this review is to find data about the outcome of schizophreniform disorder. As different definitions of schizophreniform disorder were found in the literature, it was not surprising that data on its outcome, and on the relationship of schizophreniform disorder to schizophrenia and to mood disorders (as this relationship is linked to outcome), were often different and opposite. Its classic description of an acute onset psychotic episode with mood instability and a relatively brief duration should be the focus of future studies. Current studies, apart from a small number, lump together different (and probably distinct) subtypes of schizophreniform disorder (one with good prognostic features, and one without good prognostic features, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Studies of mixed samples led to different results, probably depending on the relative prevalence of one subtype over the other one. The few studies on schizophreniform disorder with good prognostic features found more often an episodic, recurrent course, and a family history of mood disorders. These features link this schizophreniform disorder subtype more to mood disorders than to schizophrenia. If confirmed by future studies, these preliminary findings can have very important treatment implications, given the very different treatment strategies in mood disorders compared with schizophrenia.

Distinguishing between first-admission schizophreniform disorder and schizophrenia

BACKGROUND

The validity of schizophreniform disorder remains controversial. Past research suggests that cases of schizophreniform disorder may be: (1). atypical cases of affective disorders, (2). cases of schizophrenia in early course, or (3). a heterogeneous group of disorders including a subgroup with benign course and outcome which maintains this diagnosis in the long term.

METHOD

We tested the validity of the schizophreniform disorder diagnosis by comparing the socio-demographic and baseline clinical characteristics, 24-month course and outcome, and 6- and 24-month research diagnoses of 34 cases initially diagnosed with schizophreniform disorder, and 128 cases with schizophrenia, drawn from a cohort of 628 first-admission patients in the Suffolk County Mental Health Project.

RESULTS

Compared to patients with schizophrenia, those with schizophreniform disorder were more likely to remit fully by 6 months and retain this status by 24 months. Only about half of the patients with schizophreniform disorder were re-diagnosed with schizophrenia or schizoaffective disorder at 24-month follow-up, 13% were re-diagnosed with affective disorders and 19% retained the diagnosis of schizophreniform disorder. In contrast, 92% of cases with a baseline diagnosis of schizophrenia retained this diagnosis at 24-month follow-up. The findings were similar in comparisons with schizophrenia patients having onset of symptoms within 6 months of hospitalization.

CONCLUSIONS

Schizophreniform disorder is a heterogeneous category, which includes a small group with benign psychotic disorders who maintain this diagnosis over at least 24 months. Better delineation of this subgroup has important treatment implications.

Boundaries of schizophrenia

The frontiers of schizophrenia are being increasingly challenged from several directions. In addition to ongoing debate as to divisions between schizophrenia and disorders of the schizophrenic spectrum, including schizotypal personality disorder and schizophreniform disorder, it has been suggested that obsessive-compulsive disorder might overlap phenomenologically with schizophrenia. There has been a long debate around the relationship of schizophrenia to affective disorders, particularly bipolar and schizoaffective disorder. The evidence suggests that although schizotypal personality and schizophreniform disorders are not homogeneous syndromes, they are related to or represent milder forms of schizophrenia. Obsessive-compulsive disorder seems to involve pathology in many of the same regions as observed in some patients with schizophrenia, which may account for the significant incidence of obsessive-compulsive symptoms in a subset of patients with schizophrenia. Despite similarities between schizophrenia and bipolar disorder, significant differences extend across suggested causes, phenomenology, and pathophysiology. These findings support the current conceptualization that the two disorders represent distinct disorders, probably with heterogeneous causes, rather than the ends of a spectrum of symptoms comprising a single syndrome. Schizoaffective disorder likely is made up of patients from the schizophrenic and bipolar cluster of illnesses. The long-standing debate as to the boundaries of schizophrenia is ultimately must await the eventual further elaboration of the underlying causes of schizophrenia and other psychotic disorders.

Classification of nonschizophrenic psychotic disorders: a historical perspective

The existence of a group of psychoses that are symptomatologically and prognostically different from schizophrenia and affective psychotic disorders is supported by clinical and epidemiologic evidence. Although such "atypical" psychoses account for up to 10% of all psychotic disorders, their aetiology, pathophysiology, and neuropathology remain insufficiently understood. Moreover, they have been described by different schools of psychiatry a variety of ways, including non-process schizophrenia, schizophreniform psychosis, reactive (or psychogenic) psychosis, bouffées délirantes, and cycloid psychoses, but the extent to which these diagnostic categories overlap or differ has not been systematically explored. Neither Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), nor International Classification of Disease, Tenth Revision (ICD-10), provides adequate diagnostic criteria and classificatory categories for this group of disorders. Special attention to the refinement of the diagnosis and classification of the acute and transient psychotic disorders in future versions of the two classifications will be warranted.

A.E. Bennett Research Award. Prenatal rubella, premorbid abnormalities, and adult schizophrenia

BACKGROUND

Premorbid neurocognitive, neuromotor, and behavioral function tends to be disturbed in schizophrenia. We previously demonstrated that a birth cohort clinically and serologically documented with prenatal rubella evidenced a marked increase in risk of nonaffective psychosis. In our study, we examined whether rubella-exposed subjects destined to develop schizophrenia and other schizophrenia spectrum disorders (SSD), compared with exposed control subjects, had greater impairment in several premorbid functions.

METHODS

Subjects were interviewed using a direct, comprehensive research assessment and diagnosed by consensus. We compared the degree of IQ decline, as well as premorbid neuromotor and behavioral dysfunction, between rubella-exposed subjects who developed schizophrenia spectrum psychosis (SSP) and exposed control subjects from the cohort. We also compared the gestational timing of rubella infection between the cases and control subjects.

RESULTS

This rubella-exposed birth cohort evidenced a markedly increased risk of SSD (20.4% or 11/53). Rubella-exposed SSP cases, compared with rubella-exposed control subjects, demonstrated a decline in IQ from childhood to adolescence, and increased premorbid neuromotor and behavioral abnormalities. Moreover, it appears that early gestational rubella exposure may represent a period of increased vulnerability for SSD.

CONCLUSIONS

These findings link a known prenatal exposure, a deviant neurodevelopmental trajectory in childhood and adolescence, and SSP in adulthood within the same individuals.

Neuropsychological deficits in pediatric patients with childhood-onset schizophrenia and psychotic disorder not otherwise specified

OBJECTIVE

Children with transient psychotic symptoms and serious emotional disturbances who do not meet current criteria for schizophrenia or other presently recognized diagnostic categories commonly present diagnostic and treatment problems. Clarifying the connections between children with narrowly defined schizophrenia and children with a more broadly defined phenotype (i.e., Psychotic Disorder Not Otherwise Specified, PD-NOS) has implications for understanding the pathophysiology of schizophrenia. In this study, the neuropsychological test performance of a subgroup of children with atypical psychosis was compared with that of patients with childhood-onset schizophrenia (COS).

METHOD

Cognitive function was assessed with neuropsychological test battery regimens in 51 neuroleptic-nonresponsive patients within the first 270 at NIMH testing (24 PD-NOS, 27 COS) were included in this analysis. Seventeen (39%) of 44 COS subjects were unavailable for this study as their IQ tested <70. The PD-NOS patients were younger than the COS patients at the time of testing (12.0+/-2.8 vs 14.4+/-1.8years, respectively, p<0.004). The test levels of these groups were compared with each other.

RESULTS

The neuropsychological test results for the PD-NOS and COS patients were 1-2standard deviations below normative data across a broad array of cognitive functions. There were no overall differences in the test levels for the six summary scales (F=2.82, df=1, 36, p=0.10) or in the profile shape (F=1.70, df=5, 180, p=0.14) between the PD-NOS and COS groups. For the COS patients, there was a significant difference between their mean full-scale WISC IQ (84.7+/-16.2) and their average standard scores for both the spelling (97.7+/-16.1, n=23, t=4.0, p=0.001) and reading decoding subtests (97.7+/-13.7, n=23, t=3.7, p=0.001) of the Kaufman Test of Educational Achievement.

CONCLUSIONS

Treatment-refractory PD-NOS and COS patients share a similar pattern of generalized cognitive deficits, including deficits in attention, learning and abstraction which are commonly observed in adult patients with schizophrenia. These data support a hypothesis that at least some of the PD-NOS cases belong within the schizophrenic spectrum, which is of importance for future genetic studies planned for this cohort.

Monozygotic twins, folie à deux and heritability: a case report and critical review

A case report of shared delusional disorder, with a primary diagnosis of delusional disorder, is described in identical twins of proven zygosity. A review of literature shows that the primary diagnosis in identical twin pairs, suffering from folie à deux, is delusional disorder. This is in contrast to the reported excess of schizophrenia, as a primary diagnosis, in non-twin cases of folie à deux. Moreover, schizophrenia is poorly related to delusional disorders on the basis of demographic and familial studies. In the light of this paradox, nosological status of this disorder and the sociogenic and genetic factors are critically discussed.

DSM-III-R schizophreniform disorder with good prognostic features: a six-year follow-up

OBJECTIVE

To determine the outcome of DSM-III-R schizophreniform disorder with good prognostic features.

METHOD

A 6-year follow-up of 20 cases was conducted with structured interviews (comprehensive assessment of symptoms and history) and assessments of functioning scales (global assessment of functioning, Strauss-Carpenter Scale).

RESULTS

Thirty-five percent of the cases had major affective disorders, 35% had schizophreniform episodes and major affective disorders, 5% had schizophreniform episodes only, 10% developed schizophrenia, and 15% had no disorders.

CONCLUSION

The findings suggest an association between schizophreniform disorder with good prognostic features and affective illness.

Delusional disorder and eye tracking dysfunction: preliminary evidence of biological and clinical heterogeneity

This study used eye tracking movement tests to examine the relationships between frontal field functions and clinical features. Smooth pursuit and voluntary saccadic eye movements were recorded and analyzed in 34 delusional disorder (DD) patients and in 40 normal subjects. The DD group differed significantly from the group of normal subjects in some eye tracking performances. As reported in our previous study (Gambini et al., 1993), DD patients showed abnormalities of voluntary saccadic eye movements. In this study, we also found abnormal smooth pursuit eye movements, indicating a cerebral dysfunction similar to those detected in schizophrenic patients. Moreover, normal smooth pursuit eye movement performance in DD patients was related to remitted depressive mood and probably to benefit from antipsychotic medications, thus supporting the idea of the biological and clinical heterogeneity of DD.