[Early stages of schizophrenia, challenges and prospects]

Despite a relatively extensive treatment armamentarium, the evolution of schizophrenic patients overall remains unfavourable. Early treatment is essential and influences the prognosis. Facilitating access to care through the creation of specialised assessment centres to complement the current system of care is one of the possible avenues for improvement.

Family expressed emotion prior to onset of psychosis

This study compared components of expressed emotion (EE; rejection, warmth, protectiveness, and fusion) across three samples: two in which the subjects had an established schizophrenic or mood disorder, and a third in which the subjects were at high risk for an initial psychosis.

METHODS

Family members rated themselves on the Social Adjustment Scale-III and, in the prodromal sample, estimated the duration of the prodrome.

RESULTS

Scores were all but identical in the two established-disorder samples but were markedly higher than scores in the prodromal sample on all four factors. In mothers, warmth (decreasing), rejection, protectiveness, and fusion (increasing) were significantly correlated with duration of prodrome, whereas for fathers, warmth and protectiveness were similarly correlated.

CONCLUSION

These data suggest that expressed emotion is largely reactive to deterioration manifested by the young person developing a psychotic disorder, rather than a trait of family members.

Schizotypal dimensions: continuity between schizophrenia and bipolar disorders

BACKGROUND

Family studies have suggested that schizophrenia and bipolar disorders share some susceptibility factors. Schizotypal personality disorder (SPD) may be an intermediate phenotype common both to schizophrenia and bipolar disorders. We explored the familiality of schizotypal dimensions by comparing the magnitude of schizotypal dimensions between schizophrenic and bipolar relatives. We also looked for intra-familial resemblance for these dimensions, and for an increased familial risk of schizophrenia and/or bipolar disorders associated with a particular schizotypal dimension.

METHODS

We used the Schizotypal Personality Questionnaire (SPQ) to study the three schizotypal dimensions (disorganization, negative and positive) in a sample of unaffected first-degree relatives of schizophrenic (N=85), psychotic bipolar (N=63) and bipolar (N=32) probands. Differences between groups were tested using a two-tailed t-test or ANOVA for continuous variables and a chi-squared test for discrete variables. We used the intraclass correlation method to study the intra-familial correlation. Linear mixed models were used to measure the familial risk.

RESULTS

The disorganization dimension appears to be common to relatives of both schizophrenia and psychotic bipolar disorders, but not in the relatives of non-psychotic bipolar probands. This dimension also increases the familial risk of these two disorders. The negative dimension shows intra-familial resemblance (R=0.29), we failed to observe the expected familiality for the disorganized dimension.

CONCLUSIONS

The shared nature of the disorganization dimension shown by a similar familial risk for schizophrenia and psychotic bipolar disorders suggests that same genetic background may underlie psychotic disorders. Although, negative dimension is familial, it is not associated for an increased familial risk for both disorders.

Anomalous subjective experience among first-admitted schizophrenia spectrum patients: empirical investigation

Our research group has for several years conducted philosophically informed, phenomenological-empirical studies of morbid alterations of conscious experience (subjectivity) in schizophrenia (Sz) and its spectrum of disorders. Some of these experiential alterations constitute, in our view, the vulnerability markers to Sz--indicators that are intrinsic to this disorder and which were historically considered as constituting the phenotypic anchor of the very concept and the diagnostic validity of Sz spectrum disorders. In a more pragmatic clinical context, these indicators, considered here as symptoms, may be potentially effective for early differential diagnosis. In this study, 151 consecutive first-admitted patients (with bipolar, melancholic and organic patients excluded) diagnosed according to the ICD-10, were evaluated on a number of expressive and experiential psychopathological dimensions, with special emphasis on the experiences of perplexity, disorders of self-awareness, perceptual disorders and anomalous bodily experiences. The a priori scales derived from the item pool of a slightly modified OPCRIT and BSABS were used for analyses. Sz and schizotypal disorder scored equally on the subjective dimensions, suggesting a basic phenomenological affinity of these disorders. In contrast, anomalies of subjective experience were clearly more pronounced among the patients within, as compared to those outside the Sz spectrum.

[Psychotic disorders and drug abuse in adolescents]

OBJECTIVES

The relation between substance abuse and symptoms of psychosis as well as related disorders was evaluated among patients at the Hospital for Child and Adolescent Psychiatry and Psychotherapy of the University of Marburg.

METHODS

Using a child and adolescent version of the IRAOS (Instrument of the Retrospective Assessment of the Onset of Schizophrenia, Häfner et al., 1990), all patients with a co-morbid substance abuse were assessed. Patients with a drug-induced psychosis (n = 8) were compared to psychotic patients with co-morbid substance abuse and to patients with other psychiatric disorders and substance abuse (n = 30).

RESULTS

These three groups could be significantly distinguished on the basis of pre-morbid symptoms and pre-morbid functioning.

CONCLUSIONS

The IRAOS shows some evidence that psychotic patients with co-morbid substance abuse can be distinguished from patients with a drug-induced psychosis according to the course of the initial psychopathology and pre-morbid functioning.

Prodromes of first-episode psychosis: how can we challenge nonspecificity?

Prevention of functional psychosis is a major concern of modern psychiatry. The aim is to avoid biological and psychosocial deterioration at the earliest possible stage of the illness. The term "prodrome" has become crucial for identification of the very early stage. Recent years have yielded intensive research effort in defining prodromal signs and symptoms; however, the conclusion of most researchers is that they are nonspecific. We present the descriptive and phenomenological findings of the prodrome concept. Although prodromes are nonspecific, their discrepancy with persisting social impairment over time is a frequently encountered and highly alarming feature in young at-risk individuals. The inclusion of phenomenological findings may suggest the presence of psychosis-like inner experiences already as early as the prodromal phase, and thus bears in itself the question of the starting point for psychopharmacological and psychosocial treatment. Finally, a decision pathway for clinicians is proposed in their difficult task of identifying young individuals at risk.

Vocational interests and career indecision among psychosis-prone college students

This study investigated the relationship between scores on scales that purport to measure psychosis-proneness and scores on vocational interests, identity, and differentiation scales in a sample of 233 college students who completed the Perceptual Aberration and Magical Ideation scales, the Strong Campbell Interest Inventory, and the Career Decision Scale. The present findings are consistent with prior work indicating a sex-related association of scores on measures of psychosis-proneness and vocational interests. A positive correlation between scores on vocational indecision and measures of psychosis-proneness was also found, suggesting that both men and women who score high on psychosis-proneness find it difficult to formulate long-term career goals. Finally, there was no significant correlation between scores on measures of psychosis-proneness and Holland's Vocational Differentiation Index. Present results are discussed in light of previously reported sex differences among psychosis-prone adults and diagnosed schizophrenics. The implications of the findings for vocational counselors are also addressed.

Recognition of warning signs: a consideration for cost-effective treatment of severe mental illness

Warning signs of decompensation, also known as prodromal symptoms, and problems related to poor recognition of warning signs were examined in a sample of 370 adult outpatients with severe mental illness. Clinicians' ratings, client interviews, and eight months of client service records revealed that poor recognition of warning signs was a prevalent problem in this population and was related to poorer treatment outcomes and greater use of the most expensive types of services. Poor recognition was more likely to improve when it was specifically treated than when not treated. Improvement in recognition was related to better outcomes and lower costs. Results suggest the need for patients' recognition of warning signs to receive standardized assessment, treatment, and monitoring.

Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study

The present prospective follow-up study of 163 schizophrenic patients admitted to hospital for the first time examined the relationship between premorbid adjustment and different measures of the 3-year course and outcome. The same instruments had been used in all phases of the study. The Premorbid Adjustment Scale was used to assess premorbid social functioning. Outcome measures were positive symptoms, negative symptoms, social disability and number of rehospitalizations. The results of the multiple regression analyses showed that premorbid adjustment was the strongest overall predictor of outcome. Premorbid adjustment was significantly associated with negative symptoms and social disability over the 3-year course of illness. In a further step, we examined the relationship between good, moderate and poor premorbid adjustment and the course of positive symptoms, negative symptoms and social disability within the first 3 years after index admission. The most important finding was that premorbid functioning showed a stronger correlation with the course of negative symptoms and social disability than with the course of positive symptoms. Poor premorbid social functioning implies a poor social course of the illness. Female subjects showed better premorbid functioning than male subjects. Good premorbid adjustment was strongly associated with an acute onset of the illness, and poor premorbid adjustment with an insidious onset.

Prodromal symptoms of relapse in schizophrenia: a review

It is often stated that there are identifiable prodromal symptoms of psychosis in patients suffering from schizophrenia. In this article, we review the evidence for the existence of such prodromal symptoms. Computerized and direct searches of the psychiatric literature were conducted to identify relevant reports. The methods and findings of the studies were then examined for their relevance to several issues concerning prodromal symptoms. We found that very few studies have directly assessed the relationship between putative prodromal symptoms and the exacerbation of psychosis. The research that has been reported suggests that prodromal symptoms have only modest power as predictors of relapse. It appears that while some individual schizophrenia patients may show reasonably consistent patterns of prodromal symptoms, such symptoms are probably of limited general value in predicting psychosis. Two particular issues that warrant further investigation are individual differences in patterns of prodromal symptoms and the extent to which such symptoms actually precede changes in level of psychosis.

Buspirone use in an adolescent with social phobia and mixed personality disorder (cluster A type)

The use of buspirone for the treatment of social phobia has been reported in some adult patients; however, to the authors' knowledge, there are no reports of its use in adolescents with this disorder. Use of buspirone in children and adolescents with anxiety disorders is reviewed. An unusual case study is presented of a 16-year-old male patient with social phobia and a mixed personality disorder predominantly with schizotypal features, who responded well to an open trial of buspirone for anxiety and "soft" psychotic symptoms.

[Detection of early warning signs in schizophrenic patients. Possible applications in prevention of recurrence]

In the treatment of schizophrenia, two new strategies have been developed with the aim of adequate relapse prevention accompanied by lowest possible risk of side-effects. One strategy is to have the patient continue to take medication at a highly reduced dosage (10-20% of the standard dose). The other is to gradually stop neuroleptic medication after remission and to reinstitute medication only in the case of prodromal symptoms (termed targeted or intermittent treatment). According to Herz and Melville [13] many schizophrenic patients show signs of relapse well before recurrence of overt psychotic features. Monitoring to detect prodromal symptoms is especially important in targeted treatment because, otherwise, neuroleptic medication often cannot be initiated in time. In the present study of 51 schizophrenic patients we were able to replicate the results of Herz & Melville in the German-speaking countries. Prior to acute exacerbation of psychosis, most patients experience alterations of feelings and behaviour. These alterations may also be recognized by family members. Such early warning signs of relapse mainly consist of non-specific, non-psychotic symptoms: tenseness and nervousness, eating less, trouble concentrating and sleeping, depressive mood and seeing friends less. Furthermore, the regular monitoring and use of early warning signs specific to each patient in the aftercare of schizophrenic patients seems to be practicable, especially in psychoeducative family therapy.

The shared image guiding the treatment process. A precondition for integration of the treatment of schizophrenia

The aim of the study reported here was to develop psychotherapeutic in-patient treatment for acute schizophrenia, following the principles of a need-adapted approach. To improve the integration of experiences which hospital staff have with acutely psychotic patients and their families, systematic supervision sessions were organised. In these sessions, it was possible to achieve shared psychological images through while the whole staff could integrate patients' behaviour and symptoms, both symbolic and non-symbolic. Such an image was called 'the shared image guiding the treatment process' (SIGTP). The process of achieving the SIGTP was interpreted through Peircean semiotics, especially the concepts of indexical, iconic, and symbolical signs. An SIGTP was considered to have been achieved in the early phase of the supervision process in 32 of the 54 cases. For the patients, SIGTP and the need-adaptation connected with it meant achieving a more realistic and more functional ordering of their experiences.

Early intervention in schizophrenia

The management of schizophrenia may be characterised by two paradigms. The first approaches the schizophrenias as episodic relapsing disorders, where treatment is provided through both acute (crisis) care and to achieve prophylaxis. The second paradigm, sometimes arising from a failure of the first, is of "rehabilitation", involving amelioration of disabilities, occasionally within a framework of relative asylum. We would propose a third paradigm of "early intervention", involving a combination of medical and psychosocial interventions targeted at young, vulnerable people with the aim of preventing or limiting likely social, psychological and mental deterioration. Vigorous intervention early in the course of illness, early recognition and treatment of relapse and the promotion of psychological adjustment to psychotic illness are proposed as key elements of this third paradigm.

IRAOS: an instrument for the assessment of onset and early course of schizophrenia

Since Kraepelin's first description of dementia praecox in 1889 many data and theories have been published on the onset and course of schizophrenia. Until now studies on these topics had to rely on first admission data and on the subsequent course of the disease. However, first hospitalisation is preceded by a wide variety of patterns and duration of the early course. Items taken from the pre-admission phase of the disease are often incorrectly used as premorbid characteristics, understandably preceding the subsequent course and outcome of schizophrenia with high predictive power. In relation to our interest to study the beginning of schizophrenia, systematically, paying special attention to the age and gender distribution of true onset and the symptomatology and pattern of the early and later course, we developed an 'Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)'. It allows an objective, reliable, and valid assessment of the symptoms, psychological impairments, demographic and social characteristics as well as the referring points in time of the early course of psychosis. The instrument is administered as a semi-structured interview with both the patient and a key informant. The obtained information is extended by a systematic examination of the clinician's case notes. Some results derived from an ongoing study on age and gender differences in onset and patterns of early course are added to demonstrate the use of the instrument.

The use of a correctional setting for follow-up care of psychiatrically disturbed adolescents

The authors studied the first 88 adolescents boys who were placed on the secure unit of a correctional school during an 18-month period and found that 52 (59.1%) of the boys had previously received psychiatric residential treatment or psychiatric hospitalization. The authors hypothesize that many of these boys may have been transferred from a psychiatric setting to a correctional facility during adolescence when long-standing aberrant behaviors became more threatening to staff. At present the number of psychiatric hospital beds is decreasing and the criteria for hospitalization of children are becoming more stringent. The data indicate that correctional facilities are now expected to function as psychiatric treatment centers for disturbed adolescents no longer welcome in therapeutic settings.

Postural and reflex integration in schizophrenic patients

The relationship among primitive postural reflexes, postural and bilateral integration, and premorbid adjustment were examined in 29 subjects who were divided into 3 groups: normal, chronic process nonparanoid schizophrenic, and chronic paranoid schizophrenic. Significant differences were found between the normal and szhizophrenic groups on the tonic labyrinthine reflex and on five of the six measures of postural and bilateral integration. No significant differences were found between the two schizophrenic groups on any of the test variables. There were significant positive correlations between the tonic labyrinthine reflex, postural and bilateral integration, and premorbid status in the subjects studied.

Long-term prognosis and followup in schizophrenia

The long-term course or natural history of schizophrenia is correlated with differing diagnostic criteria and commonly agreed upon prognostic variables. A review of 38 long-term followup studies of hospitalized schizophrenics reveals that unspecified or Kraepelinian-type schizophrenia has a much worse prognosis than atypical schizophrenia, schizoaffective psychosis, reactive psychosis, or other good premorbid types. Diagnoses based on longitudinal as well as cross-reactional data are more predictive of outcome than cross-sectionally based diagnoses. Drug and psychosocial treatment results must be evaluated in terms of prognostic variables, many of which are incorporated in some currently employed diagnostic criteria. There is no firm evidence that maintenance medication is indicated in some good prognosis patients. The paucity of long-range followups, the inadequacies of outcome assessments, and diagnostic disagreements limit our understanding of the effects of drug treatment, a treatment which is not without dangerous neurological side effects in many patients.