Pre-onset sub-threshold psychotic symptoms and cortical organization in the first episode of psychosis

Individuals with sub-threshold psychotic symptoms (STPS) are considered at clinical high risk for psychosis (CHR). Imaging studies comparing CHR and patients shortly after a first episode of psychosis (FEP) support progressive cortical thinning by illness stage. However, at least 30% of FEP patients deny pre-onset STPS, suggesting no history of CHR. This calls into question the generalizability of previous imaging findings. To better understand the physiology of early psychosis symptomology, we investigated the relationship between pre-onset STPS and cortical thickness (CT) among FEP patients, examining regional CT and structural covariance (SC). Patients (N = 93) were recruited from PEPP-Montreal, a FEP clinic at the Douglas Mental Health University Institute. The Circumstances of Onset and Relapse Schedule was administered to retrospectively identify patients who recalled at least one of nine expert-selected STPS prior to their FEP (STPS+, N = 67) and to identify those who did not (STPS-, N = 26). Age and sex-matched healthy controls (HC) were recruited (N = 84) for comparison. Participants were scanned between one and three times over the course of two years. CT values of 320 scans (143 HC, 123 STPS+, 54 STPS-) that passed quality control were extracted for group analysis. Linear mixed effects models accounting for effects of age, sex, education, and mean thickness were applied for vertex-wise, group comparisons of cortical thickness and SC. Multiple comparison corrections were applied with Random Field Theory (p-cluster = 0.001). Compared to controls, only STPS- patients exhibited significantly reduced CT in a cluster of the right ventral lateral prefrontal cortex. The vertex with the highest t-statistic within this cluster was employed as a seed in the subsequent SC analysis. After RFT-correction, STPS+ patients exhibited significantly stronger SC between the seed and right pars orbitalis compared to STPS- patients, and HC exhibited significantly stronger SC between the seed and right middle temporal gyrus compared to STPS- patients. Our results revealed patterns of SC that differentiated patient subgroups and patterns of cortical thinning unique to STPS- patients. Our study demonstrates that the early course of sub-threshold psychotic symptoms holds significance in predicting patterns of CT during FEP.

Interplay of hippocampal volume and hypothalamus-pituitary-adrenal axis function as markers of stress vulnerability in men at ultra-high risk for psychosis

BACKGROUND

Altered hypothalamus-pituitary-adrenal (HPA) axis function and reduced hippocampal volume (HV) are established correlates of stress vulnerability. We have previously shown an attenuated cortisol awakening response (CAR) and associations with HV specifically in male first-episode psychosis patients. Findings in individuals at ultra-high risk (UHR) for psychosis regarding these neurobiological markers are inconsistent, and assessment of their interplay, accounting for sex differences, could explain incongruent results.

METHOD

Study participants were 42 antipsychotic-naive UHR subjects (24 men) and 46 healthy community controls (23 men). Saliva samples for the assessment of CAR were collected at 0, 30 and 60 min after awakening. HV was determined from high-resolution structural magnetic resonance imaging scans using a semi-automatic segmentation protocol.

RESULTS

Cortisol measures and HV were not significantly different between UHR subjects and controls in total, but repeated-measures multivariate regression analyses revealed reduced cortisol levels 60 min after awakening and smaller left HV in male UHR individuals. In UHR participants only, smaller left and right HV was significantly correlated with a smaller total CAR (ρ = 0.42, p = 0.036 and ρ = 0.44, p = 0.029, respectively), corresponding to 18% and 19% of shared variance (medium effect size).

CONCLUSIONS

Our findings suggest that HV reduction in individuals at UHR for psychosis is specific to men and linked to reduced post-awakening cortisol concentrations. Abnormalities in the neuroendocrine circuitry modulating stress vulnerability specifically in male UHR subjects might explain increased psychosis risk and disadvantageous illness outcomes in men compared to women.

The pathways to mental health care of first-episode psychosis patients: a systematic review

BACKGROUND

Although there is agreement on the association between delay in treatment of psychosis and outcome, less is known regarding the pathways to care of patients suffering from a first psychotic episode. Pathways are complex, involve a diverse range of contacts, and are likely to influence delay in treatment. We conducted a systematic review on the nature and determinants of the pathway to care of patients experiencing a first psychotic episode.MethodWe searched four databases (Medline, HealthStar, EMBASE, PsycINFO) to identify articles published between 1985 and 2009. We manually searched reference lists and relevant journals and used forward citation searching to identify additional articles. Studies were included if they used an observational design to assess the pathways to care of patients with first-episode psychosis (FEP).

RESULTS

Included studies (n=30) explored the first contact in the pathway and/or the referral source that led to treatment. In 13 of 21 studies, the first contact for the largest proportion of patients was a physician. However, in nine of 22 studies, the referral source for the greatest proportion of patients was emergency services. We did not find consistent results across the studies that explored the sex, socio-economic, and/or ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay.

CONCLUSIONS

Additional research is needed to understand the help-seeking behavior of patients experiencing a first-episode of psychosis, service response to such contacts, and the determinants of the pathways to mental health care, to inform the provision of mental health services.

Signs and symptoms in the pre-psychotic phase: description and implications for diagnostic trajectories

BACKGROUND

Few studies have examined the underlying factor structure of signs and symptoms occurring before the first psychotic episode. Our objective was to determine whether factors derived from early signs and symptoms are differentially associated with non-affective versus affective psychosis.

METHOD

A principal components factor analysis was performed on early signs and symptoms reported by 128 individuals with first-episode psychosis. Factor scores were examined for their associations with duration of untreated illness, drug abuse prior to onset of psychosis, and diagnosis (schizophrenia versus affective psychosis).

RESULTS

Of the 27 early signs and symptoms reported by patients, depression and anxiety were the most frequent. Five factors were identified based on these early signs and symptoms: depression, disorganization/mania, positive symptoms, negative symptoms and social withdrawal. Longer duration of untreated illness was associated with higher levels of depression and social withdrawal. Individuals with a history of drug abuse prior to the onset of psychosis scored higher on pre-psychotic depression and negative symptoms. The two mood-related factors, depression and disorganization/mania, distinguished the eventual first-episode diagnosis of affective psychosis from schizophrenia. Individuals with affective psychosis were also more likely to have a 'mood-related' sign and symptom as their first psychiatric change than individuals later diagnosed with schizophrenia.

CONCLUSIONS

Factors derived from early signs and symptoms reported by a full diagnostic spectrum sample of psychosis can have implications for future diagnostic trajectories. The findings are a step forward in the process of understanding and characterizing clinically important phenomena to be observed prior to the onset of psychosis.

Premorbid adjustment in first episode schizophrenia and schizoaffective disorders: a comparison of social and academic domains

OBJECTIVE

Recent evidence suggests that premorbid adjustment in schizophrenia and related disorders can be separated into social and academic domains. In this paper, we examine the correlates of and prognostic significance of social and academic premorbid adjustment in a sample of 113 patients.

METHOD

Premorbid adjustment, symptoms and cognitive functioning were assessed at presentation for treatment and symptoms were re-assessed after a year of treatment.

RESULTS

Females and those with a diagnosis of schizoaffective disorder were found to have better premorbid adjustment in the academic domain, but not in the social domain. Neurocognitive functioning was more consistently related to academic than social adjustment. Better social and academic premorbid adjustment was correlated with lower negative symptoms after 1 year of treatment, but neither was a significant predictor of positive symptoms.

CONCLUSION

Social and academic premorbid adjustments show different relations to gender, specific diagnosis and neurocognitive functioning in schizophrenia and related disorders.

Understanding delay in treatment for first-episode psychosis

BACKGROUND

A lengthy delay often occurs between the onset of symptoms of psychotic disorders and initiation of adequate treatment. In this paper we examine the extent to which this represents a delay in individuals contacting health professionals or a delay in receiving treatment once such contact is made.

METHOD

Pathways to care were examined in 110 patients of the Prevention and Early Intervention Program for Psychosis in London, Canada. Data were collected using structured interviews with patients, family members, consultation with clinicians and review of case records.

RESULTS

Family physicians and hospital emergency rooms were prominent components of pathways to care. Both delay to contact with a helping professional and delay from such contact to initiation of adequate treatment appear to be about equally important for the sample as a whole, but some individuals appear to be at risk for particularly lengthy delay in the second component. Individuals with younger age of onset, or who had initial contact with professional helpers before the onset of psychosis and were being seen on an ongoing basis at the time of onset of psychosis, had longer delays from first service contact after onset to initiation of adequate treatment. The greater delay to treatment for those being seen at the onset of psychosis does not appear to reflect differences in age, gender, symptoms, drug use or willingness to take medication.

CONCLUSIONS

Interventions to reduce treatment delay should increase the public's awareness of the symptoms of psychotic illness and the need to seek treatment, but of equal importance is the education of service providers to recognize such illness and the potential benefits of earlier intervention.

Determinants of quality of life in first-episode psychosis

OBJECTIVE

To assess patient and/or illness characteristics associated with aspects of quality of life (QOL) in first-episode psychosis (FEP).

METHOD

Patient characteristics, symptom ratings and Wisconsin QOL scale (client version) were assessed. Data were analysed with correlation coefficients and a hierarchical regression analysis.

RESULTS

Patients presented with varying levels of QOL on different domains. The level of 'general satisfaction' was related to age of onset and social premorbid adjustment; 'weighted index of QOL' to social premorbid adjustment and inversely to educational premorbid adjustment; 'social relations' inversely to duration of untreated psychosis (DUP), length of prodrome and negative symptoms; 'psychological well-being' inversely to depression and educational premorbid adjustment; 'activities of daily living' to social premorbid adjustment and inversely to negative symptoms; and 'outlook on symptoms' to level of depression.

CONCLUSION

Domains of self-rated QOL in FEP patients are differentially associated with malleable and non-malleable aspects of patient and illness characteristics.

Symptoms, cognition, treatment adherence and functional outcome in first-episode psychosis

BACKGROUND

The differential strength of correlation between symptoms, cognition and other patient characteristics with community functioning in first-episode psychosis has not been fully investigated.

METHOD

In a sample of 66 first-episode psychosis patients demographic variables, ratings of pre-morbid adjustment, positive and negative symptoms, duration of untreated psychosis (DUP) and assessment of cognitive functions at baseline, and symptoms, cognitive functions and adherence to medication 1 year, were correlated with scores on social relations and activities of daily living (ADL) (outcome) at 1 year. Hierarchical regression analysis was used to confirm the independent contribution of baseline and concurrent variables to functional outcome at 1 year.

RESULTS

Scores on functioning related to social relations and ADL were both significantly correlated with pre-morbid adjustment, all dimensions of residual positive and negative symptoms and adherence to medication at 1 year. Scores on social relations were also modestly correlated with DUP and several cognitive measures at baseline and 1 year (verbal IQ, attention, visual memory, word fluency and working memory). Hierarchical regression confirmed independent contribution of pre-morbid adjustment, total residual symptoms and adherence to medication at 1 year for both dimensions of outcome, and psychomotor poverty and working memory for social relations.

CONCLUSIONS

In addition to pre-morbid adjustment potentially malleable variables such as level of residual (but not acute) symptoms, adherence to medication and cognitive deficits are likely to influence outcome on aspects of community functioning in individuals treated for first episode of psychosis.

Cognitive functioning in stabilized first-episode psychosis patients

This paper describes the cognitive functioning of a community cohort of individuals presenting with a first episode of a schizophrenia spectrum psychosis. Data were obtained for 107 patients (mean age 25 years) following stabilization of acute psychotic symptoms, mostly with the use of novel antipsychotics, on measures of intellectual, memory, attentional and executive functioning using a standardized battery of cognitive measures, including WAIS III and WMS III. While patients generally performed in the average range across the majority of measures, deficits (Z-scores >1.0 S.D.) were observed on measures of speed of information processing (PASAT, WAIS III) and executive functions (Stroop Test and Trails B), with the greatest deficits observed on tests of processing speed (PASAT). Discrepancy scores between the NART and the WAIS suggest subtle but statistically significant declines in full scale and performance IQ following onset of psychosis. Differences in cognitive functioning between diagnostic groups were not supported. Comparison of the highest and lowest functioning patients with respect to the cognitive measures also did not support any demographic or clinical differences between these two subgroups. Our results suggest a relatively benign cognitive profile in first-episode schizophrenia spectrum psychosis, regardless of diagnosis, when most potential incidence cases in the community are included. The most severe deficits reported were on measures of speeded information processing, and level of performance did not distinguish between patients demographically or clinically.

Duration of untreated psychosis and cognitive functioning in first-episode patients

BACKGROUND

The "toxicity" model of duration of untreated psychosis (DUP) suggests that longer DUP will be associated with poorer performance on cognitive tests in first-episode patients.

AIMS

To test this hypothesis on a sample of 113 patients in a community-based early intervention programme for psychosis.

METHOD

Information was collected concerning a number of possible predictors of cognitive functioning including DUP. These were examined for their relation to performance on an extensive battery of cognitive tests administered shortly after the patients' admission to the programme.

RESULTS

Although several variables such as gender, premorbid adjustment, education and handedness predicted cognitive functioning, no relation was found between DUP and performance on any component of the test battery.

CONCLUSIONS

Findings do not provide support for a toxic effect of DUP on cognitive functioning. Other mechanisms through which DUP might affect outcome such as psychological engulfment, social support and adherence to medication are discussed.

Impact of phase-specific treatment of first episode of psychosis on Wisconsin Quality of Life Index (client version)

OBJECTIVE

The objective of this study was to assess the impact of a phase-specific community-focused treatment program on different dimensions of self-reported quality of life in a representative sample of first episode psychosis patients.

METHOD

Data were collected on patients presenting with a first episode of psychosis on the Wisconsin Quality of Life Index (client version), positive and negative symptoms, and demographic and clinical variables at baseline following clinical stabilization and at 1 year.

RESULTS

Complete data on a representative sample of 41 patients showed a significant improvement in most dimensions of the WQOL at 1 year; these changes were generally independent of changes in symptoms and there were no significant differences in the magnitude of improvement in QOL between those with DUP < or >6 months.

CONCLUSION

Patients with a first episode of predominantly schizophrenia spectrum psychosis show a highly significant improvement in subjectively assessed quality of life following a year of phase-specific comprehensive treatment.

Duration of untreated psychosis: a critical examination of the concept and its importance

BACKGROUND

The concept of duration of untreated psychosis (DUP) has recently attracted much interest because of its possible relationship to treatment outcome and implications for preventive efforts with reference to psychotic disorders, especially schizophrenia. In this paper we review critically the literature concerning the concept and its importance.

METHODS

Articles concerned with measuring DUP and those that have been suggested to provide indirect or direct evidence of the effect of DUP on treatment outcome are reviewed.

RESULTS

Evidence thus far suggests that DUP may be related to ease of reducing psychotic symptoms once treatment begins for first episode patients, but there is no evidence of a relationship to likelihood of relapse. There has been little investigation of the relationship of DUP to other long-term outcomes such as negative symptoms and cognitive functioning neither have the possible confounds of DUP been widely investigated or controlled.

CONCLUSIONS

It is important that there should be more thorough investigations of DUP, its correlates, and the extent to which it does mediate any advantages of earlier intervention.

Family history of schizophrenia and the relationship of stress to symptoms: preliminary findings

OBJECTIVE

It has been hypothesized that patients with a diagnosis of schizophrenia who have a positive family history for schizophrenia will show greater reactivity of their symptoms to increasing levels of stress or negative affect than will patients without such a family history. In the past this hypothesis has only been tested through manipulations of negative affect in laboratory settings. In this paper we test this hypothesis using longitudinal clinical data.

METHOD

Data were derived from an earlier longitudinal study using monthly assessments of daily stressors (Hassles Scale) and symptom measures (the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms). We compared longitudinal stress to symptom relations in 12 patients with schizophrenia for whom a positive family history of schizophrenia could be identified with 12 matched schizophrenic patients without any known family history of psychiatric illness.

RESULTS

There was evidence that patients with a family history of schizophrenia demonstrated a stronger relation between stress and total score on the Scale for the Assessment of Positive Symptoms. This difference appears to have primarily reflected a greater reactivity to stress of reality distortion symptoms in the positive family history group. The two groups did not differ in apparent reactivity to stress of the disorganization and psychomotor poverty dimensions of symptomatology.

CONCLUSIONS

The results of this study provide support from a naturalistic, longitudinal clinical study for the hypothesis that reactivity to stress of some symptoms of schizophrenia may vary as a function of family history of the disorder.

A comparison of long-term outcome in first-episode schizophrenia following treatment with risperidone or a typical antipsychotic

BACKGROUND

Most reports assessing the efficacy and tolerability of risperidone have involved patients previously treated with typical antipsychotics. Such patients are more likely to have a greater resistance or intolerance to treatment, thus restricting our interpretation of the impact a new treatment might have on the course of schizophrenia and possibly biasing the results. The present study examines the relative effectiveness of risperidone and typical antipsychotics in patients being treated for their first episode of schizophrenia.

METHOD

From a cohort of 126 patients, 2 groups of 19 first-episode DSM-III-R/DSM-IV schizophrenia patients matched for age, gender, length of illness, and length of treatment and treated with either a typical antipsychotic or risperidone for a minimum of 1 year were compared on a number of outcome dimensions during their course of treatment and at follow-up. Treatment allocation was not random, and patients were judged to be compliant with medication. Patients treated with typical antipsychotics were followed up for a statistically nonsignificantly longer time (mean = 2.7 vs. 1.9 years).

RESULTS

Six patients (31.6%) from the typical antipsychotic group were admitted to the hospital within the first year following the index admission compared with 1 patient (5.3%) in the risperidone group (admitted at month 14). Patients in the risperidone group showed a statistically significantly lower length of first hospitalization (p < .01), utilization of inpatient beds during the course of treatment (p < .001), and use of anticholinergic medication (p < .05). There were no statistically significant differences in symptom levels, either during the course of treatment or at follow-up; in the use of antidepressant, antianxiety, or mood-stabilizing drugs; or in changes in living circumstances or employment.

CONCLUSION

These findings confirm at least equal long-term efficacy of typical antipsychotics and risperidone, but a possible advantage for risperidone in decreased service utilization and decreased use of anticholinergic drugs.

Does sex influence the relation between symptoms and neurocognitive functions in schizophrenia?

OBJECTIVE

A secondary analysis of our data to investigate if sex influences the specificity of the relationship between each of the 3 clinical syndromes (i.e., reality distortion, disorganization and psychomotor poverty) in schizophrenia and the neurocognitive functions that are thought to represent regional brain functions.

PATIENTS AND DESIGN

Fifty-seven male and 30 female patients with a DSM-III-R diagnosis of schizophrenia were rated on the Scale for Assessment of Negative Symptoms and the Scale for Assessment of Positive Symptoms to derive scores for psychomotor poverty, disorganization, and reality distortion syndromes. All subjects completed a battery of neuropsychological tests purported to assess functioning of left temporal, right temporal, left basal frontal, right basal frontal, and dorsolateral prefrontal cortex.

RESULTS

Correlation coefficients between syndrome scores and neuropsychological measures showed only word fluency (left frontal functioning) to have a statistically significant association with psychomotor poverty in women (p < 0.01). This relation was specific to psychomotor poverty syndrome. No relations between neurocognitive measures and symptoms were seen in men.

CONCLUSIONS

The lack of specific relations between symptom dimensions in schizophrenia may be influenced by the fact that the neuronal circuitry associated with particular symptom dimensions may differ in men and women.

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale

OBJECTIVE

Reports suggesting that quality of life in schizophrenia is more highly related to negative rather than positive symptoms are largely based on use of the Quality of Life Scale which was devised to assess deficit symptoms and does not include an assessment of subjective general wellbeing. In the current paper we examined symptoms, level of community functioning as well as living circumstances as correlates of Quality of Life Scale scores and scores on the General Well-Being Scale.

METHOD

One hundred and twenty-eight patients completed the General Well-Being Scale and were rated on the Quality of Life Scale as well as scales assessing positive and negative symptoms.

RESULTS

While negative symptoms, level of functioning and positive symptoms all were related to the scores on the Quality of Life Scale, General Well-Being Scale scores were primarily related to positive symptoms, particularly reality distortion.

CONCLUSION

The results highlight the importance of recognizing the complex nature of the concept of quality of life. They demonstrate that varying indices of quality of life are likely to have different predictors.

Predictors of service use and social conditions in patients with psychotic disorders

OBJECTIVE

To determine independent predictors of outcome on 3 separate dimensions--namely, relapse and service use, employment, and living conditions--in patients with psychotic disorders.

METHOD

One hundred and thirty-four patients, most with a diagnosis of schizophrenia or schizoaffective disorder (94%), were treated and followed up in a comprehensive treatment program with inpatient and community treatment components. Complete data on several predictor and outcome variables were available on 93 patients. Relationships between predictor variables and each dimension of outcome were analyzed using Spearman correlation and multiple regression analysis.

RESULTS

Results showed that the use of inpatient resources (days in hospital) during the follow-up period was predicted by days in hospital prior to entry into the program, as was employment status. Although substance abuse was related to employment status, it did not have any predictive value. Better living conditions were predicted by being female and having a later age of onset.

CONCLUSIONS

Use of inpatient resources and social dimensions of outcome in schizophrenia may be predicted by different patient- or illness-related variables. These relationships are likely to be modified by the nature and content of treatment received.

Exploring the longitudinal course of psychotic illness: a case-study approach

OBJECTIVE

Thirty-three patients with a diagnosis of a psychotic disorder (schizophrenia, bipolar disorder, atypical psychosis) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) were studied to qualitatively assess the longitudinal course of the disorder using a case-study approach.

METHODS

Weekly fluctuations in patient symptomatology and overall social and personal functioning using the Global Assessment Scale were assessed following index hospitalization. Patients were followed for 1 year.

RESULTS

The emergent courses showed no relationship to diagnosis but followed 3 general trends: 1) positive incline; 2) fluctuating; and 3) stable. Individual representations of each course were examined closely, and biological and psychosocial factors associated with each were evaluated.

CONCLUSIONS

The results supported the longitudinal patterns and individual interactions of Strauss's Interactive Developmental Model. The clinical course of psychotic disorders may be represented by 3 patterns. Key factors in the interaction between patient and environment that generate important changes in the evolution of each illness were illustrated.

A short echo proton magnetic resonance spectroscopy study of the left mesial-temporal lobe in first-onset schizophrenic patients

BACKGROUND

Past 1H magnetic resonance spectroscopy (MRS) studies of the temporal lobe in schizophrenic patients have shown decreased levels of N-acetylaspartate (NAA) suggesting reduced neuronal density in this region. However, the measured volumes have been large and included contributions from mostly white matter.

METHODS

Short echo 1H MRS was used to measure levels of NAA and other metabolites (i.e., glutamate and glutamine) from a 6 cm3 volume in the left mesial-temporal lobe of 11 first-episode schizophrenic patients and 11 healthy control subjects of comparable age, gender, handedness, education, and parental education levels. Spectra were quantified without operator interaction using automated software developed in our laboratory. Metabolite levels were normalized to the internal water concentration of each volume studied. Images were also obtained to determine temporal lobe gray and white matter volumes.

RESULTS

No significant differences were found between levels of NAA or other metabolites, or gray and white matter volumes, in first-episode schizophrenic patients and comparison subjects.

CONCLUSIONS

Since the volume studied was small compared to previous studies and contained mostly gray matter, this result suggests consequential NAA decreases may be restricted to regions of white matter.

Schizoaffective disorder in a fragile-X carrier

OBJECTIVE

Here we report the case of a schizoaffective psychosis in a female carrier of fragile-X (CGG sequence > 200).

CLINICAL PICTURE

The patient presented with symptoms of psychosis (hallucinations, delusions and disorganised thinking) and mania, preceded by decline in intellectual and social functioning.

TREATMENT AND OUTCOME

Initial treatment with antipsychotic drugs alone or in combination with sodium valproate was only partially effective, but the addition of lithium resulted in a complete remission.

CONCLUSIONS

One year later the patient presented predominantly with deficit symptoms and profound deficits in memory and executive functions. It is likely that the intellectual deterioration around the time of puberty associated with fragile-X increased her vulnerability to a schizoaffective disorder and eventually to poor functioning.

Switching from therapy with typical antipsychotic agents to risperidone: long-term impact on patient outcome

This paper reports the results of a retrospective, open-label study in 31 schizophrenic patients who had been switched from therapy with a typical antipsychotic agent to risperidone, a novel antipsychotic agent, in the course of their treatment in an outpatient/community program. The study was based on both a review of all 31 patients' charts and a structured interview of 26 of the patients. The change to risperidone had been made because of lack of efficacy or intolerance to typical antipsychotic agents after a mean of 3.5 years of therapy. Patients had been maintained on risperidone for a mean of 1.7 years at the time of the review. The impact of switching to risperidone was assessed by comparing clinical variables for the patients with their own historic control data. The current levels of symptoms, side effects, and social functioning were also assessed by means of the Interview for Retrospective Assessment of Onset of Schizophrenia and rating scales. Seventy-one percent and 81% of the patients exhibited a positive response, as measured by a 30% reduction in psychotic and disorganization syndromes, respectively. After the switch, significant declines were noted in service utilization; the level of psychotic, disorganization, and negative symptom dimensions; and the use of anticholinergic drugs (P < 0.01 for all). Assessments conducted at the time of the review revealed a low level of psychotic (mean, 3.5) and disorganization (mean, 3.0) symptoms, a moderate level of negative symptoms (mean, 19.5), and a low level of extrapyramidal symptoms (total mean parkinsonism score, 6.0). No significant changes were seen in the level of employment or in living conditions. Results of this study suggest that a switch to risperidone therapy because of the inefficacy of typical antipsychotic agents or patients' inability to tolerate them may lead to sustained and significant improvement in a substantial proportion of patients with schizophrenia.

Symptoms and cognition as predictors of community functioning: a prospective analysis

OBJECTIVE

It has been suggested that level of cognitive functioning as assessed by formal neurocognitive tests may be as important as, or even more important than, symptoms in predicting level of community functioning for patients with schizophrenia. The results of past prospective studies, when carefully examined, do not consistently support this hypothesis. In the current study, the authors used symptom and neurocognitive data to predict subsequent level of functioning in the community.

METHOD

Neurocognitive and symptom data collected as part of an earlier study were used to predict the community functioning of 50 patients with a diagnosis of schizophrenia. Using the Life Skills Profile, staff of a community mental health program assessed community functioning while blind to the earlier symptom ratings and neurocognitive performance.

RESULTS

Symptoms were more predictive of community functioning than were neurocognitive measures. Disorganization symptoms were generally more predictive of community functioning than was either psychomotor poverty or reality distortion.

CONCLUSIONS

The results of this study and of previous longitudinal studies suggest the importance of using symptom levels after optimal treatment, rather than symptoms during acute episodes, as predictors of community functioning. They also indicate the need to evaluate the effects of treatment on disorganization as a separable dimension of symptoms.

The treatment of negative symptoms: a clinical and methodological study

The primary objective of this study was to evaluate the efficacy, safety and tolerability of remoxipride (controlled release) versus haloperidol in patients with negative symptoms. The study comprised a multicentre, randomised, double-blind, parallel-group clinical trial. Two hundred and five patients were randomised to either remoxipride or haloperidol. Patients eligible for this study were aged 18-65 years, met the DSM-III-R diagnosis for chronic schizophrenia and the Positive and Negative Symptoms Scale (PANSS) criteria for predominant negative symptoms. There was a statistically significant reduction in the PANSS scores of at least 20% from baseline to last rating for 39 remoxipride (49.4%) and 45 haloperidol (47.6%) treated patients. There were no statistical differences found between the two treatment groups with respect to improvement of negative symptoms and adverse events. The PANSS data suggest that both remoxipride and haloperidol improve the cluster of negative symptoms concerned with social functioning. In addition, the design of the study provides a methodology that is appropriate to the study of primary negative symptoms in schizophrenia.

Computed tomographic findings in schizophrenia: relation with symptom dimensions and sex differences

OBJECTIVE

Loss of grey matter, a consistent finding in schizophrenia, is likely to be influenced by symptom heterogeneity and sex. This study was conducted to determine the extent and region of brain atrophy in schizophrenia and its relation to symptom syndromes and to patient sex.

DESIGN

Prospective study of consecutive patients.

SETTING

Psychiatric department of a general teaching hospital.

PATIENTS

Sixty-one consecutive patients (37 men and 24 women) admitted to hospital for acute exacerbation of schizophrenia, as diagnosed according to the DSM third edition, revised.

INTERVENTIONS

Computed tomographic examination of the head.

OUTCOME MEASURES

Diffuse atrophy and atrophy in the frontal and temporal regions and the sylvian fissure were rated using the CT Rating Scale for Schizophrenia. Ratings were contrasted between male and female subjects; relations between atrophy ratings and 3 symptom dimensions of schizophrenia were examined for male and female subjects separately.

RESULTS

Widening of the sylvian fissure was positively related to psychomotor poverty (r = 0.32, p < 0.01). There was a significantly stronger relation between diffuse atrophy and reality distortion in female than in male subjects. There was no sex difference in the atrophy rating in all regions of the brain, and this lack of sex difference was not related to age of onset, length of illness or age at the time of the CT scan.

CONCLUSION

The morphological changes in the brain on CT are no greater in men than in women with schizophrenia. Different mechanisms may be involved in producing reality distortion symptoms in men and women.

Aspects of dysphoria and symptoms of schizophrenia

BACKGROUND

In the past it has been postulated that dysphoric emotions may be related to positive and/or negative symptoms in schizophrenia. The results of several recent studies have suggested that composite dysphoria indices are more strongly related to positive than negative symptoms. In the current study we use part correlation techniques to examine the possible unique contributions of two aspects of dysphoria--depression and anxiety--to three syndromes of symptoms (reality distortion, disorganization and psychomotor poverty) within schizophrenia.

METHODS

Data were obtained from 60 patients with a DSM-III-R diagnosis of schizophrenia. Symptoms of schizophrenia were assessed using the SAPS and SANS and dysphoria was assessed using both self-report (BDI and BAI) and observer ratings (HRSD and HARS). Assessment of schizophrenia symptoms and ratings of depression and anxiety were completed by different observers. In addition, drug induced extrapyramidal side effects were rated.

RESULTS

Part correlations showed that unique aspects of anxiety (particularly physiological arousal) were correlated with reality distortion while unique aspects of depression (including psychomotor slowing and loss of social interest) were related to psychomotor poverty. At least part of the latter relationship may be due to extrapyramidal side effects of neuroleptic medication.

CONCLUSIONS

Although there is considerable overlap between anxiety and depression, it appears that the unique arousing or activating aspects of anxiety are related to the experience of reality distortion symptoms in schizophrenia and the unique slowing and withdrawal aspects of depression are particularly related to psychomotor poverty. Possible reasons for these relationships are discussed.

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome

OBJECTIVES

To provide an overview of a comprehensive and integrated case-management program that incorporates principles of assertive community treatment and combines effective medical and psychosocial interventions and to present the results of a process and outcome evaluation of the program, with particular emphasis on its impact on service utilization and consumer satisfaction.

METHOD

Data on demographic, clinical, and several outcome measures were collected on all patients who received care in the program for a minimum of 6 months. For process evaluation we assessed the extent to which the program adhered to its goals and satisfied the patients, their families, and community-service agencies. Outcome-evaluation data on the number and length of hospital admissions were compared for each subject with individual historical data for a period equal to the time spent in the program. In addition, relapses of psychotic symptoms that did not result in hospital admissions were calculated for each patient while in the program.

RESULTS

Demographic, clinical, and treatment characteristics of clients show that the program has succeeded in maintaining its focus on providing services to relatively chronically ill patients with psychotic disorders over a mean period of 3 years. The process-evaluation data indicated a high level of satisfaction by patients, families, and other service agencies with the services received. Information on outcome variable showed that the program achieved significantly lower rates of hospital admissions and relapse of psychosis than expected. There was a highly significant reduction achieved in the utilization of inpatient hospital resources for patients receiving care in the program. Most of the inpatient service utilization was attributed to patients either who were resistant to treatment with antipsychotic agents or who refused to accept or comply with medication.

CONCLUSIONS

It is possible to provide effective continuity of care from inpatient treatment to community adjustment for most individuals with psychotic disorders across the spectrum by blending hospital and community resources within an integrated case-management model of care.

Relationship between neurological 'soft signs' and syndromes of schizophrenia

Past research on the importance of 'soft' neurological signs in schizophrenia has often not examined the relationship between specific groups of neurological signs and different dimensions of schizophrenia psychopathology. Gender differences in the reported relationships have never been explored. In this paper we describe a study of 100 DSM-III-R (65 male and 35 female) schizophrenic patients who were rated for neurological 'soft signs' with the Neurological Evaluation Scale (NES) (1), and for schizophrenic symptomatology with the Scale for Assessment of Negative Symptoms (SANS) and the Scale for Assessment of Positive Symptoms (SAPS). Following a factor analysis of NES items, differential relationships were examined between the five derived NES factors and three well-established dimensions of schizophrenic symptomatology, namely psychomotor poverty, disorganization and reality distortion. Our results failed to show any relationship between NES dimensions and either the reality distortion or disorganization dimensions. There was a modest but differentially significant relationship between psychomotor poverty and an extrapyramidal factor on the NES. This relationship was shown only by male subjects, and was influenced by duration of illness but not by age or neuroleptic medication. On the other hand, female subjects showed a significant relationship between psychomotor poverty and an NES factor reflecting attention and initiative, and between reality distortion and coordination/sequencing of motor activity. These relationships in female subjects were, relative to relationships for male subjects, more independent of the effect of medication and duration of illness.

EEG coherence and syndromes in schizophrenia

BACKGROUND

Frith et al (1995) and others have hypothesised that disruptions in the connection between left frontal and temporal areas of the brain are a central deficit in schizophrenia. In this paper we examine whether such connectivity as assessed by EEG coherence is related to level of symptoms in patients with schizophrenia.

METHOD

For 73 patients with schizophrenia, assessment of the EEG coherence between frontal and temporal regions were carried out under conditions of activation by a mathematical task, and between frontal and occipital regions when performing a visuo-spatial task. We then examined the relationship between these coherence measures and the reality distortion, disorganisation and psychomotor poverty dimensions of symptomatology.

RESULTS

Only left frontal-temporal connectivity was found to have a significant negative relationship to symptomatology. This relationship was, however, specific to reality distortion rather than to symptoms of disorganisation or psychomotor poverty, and may be more characteristic of males than females.

CONCLUSIONS

Disruption of frontal-temporal connectivity appears to have a specific relationship to reality distortion symptoms in schizophrenia.

Neuropsychological correlates of syndromes in schizophrenia

BACKGROUND

On the basis of Liddle's three-syndrome model of schizophrenia, it was predicted that: (1) symptoms of psychomotor poverty would be particularly correlated with impaired performance on neuropsychological tests likely to reflect functioning of the dorsolateral prefrontal cortex; (2) disorganisation would be particularly correlated with impaired performance on tests sensitive to medio-basal prefrontal functioning; and (3) reality distortion would be particularly correlated with measures sensitive to temporal lobe functioning.

METHOD

The above hypotheses were tested on 87 subjects with a confirmed diagnosis of schizophrenia. Patients' symptoms were scored for each of the three syndromes. Patients completed six neuropsychological tests designed to measure impairment in specific areas of the brain.

RESULTS

There was no support for the first two hypotheses. There was, however, evidence of a specific relationship between reality distortion and neuropsychological performance usually considered to be related to left temporal lobe functioning.

CONCLUSIONS

Although not directly supporting the first two hypotheses; the results are, in general, consistent with there being different cortical-subcortical circuits associated with each of psychomotor poverty and disorganisation. Temporal lobe functioning appears to have particular significance for the reality distortion syndrome.

Relationship of obsessive-compulsive symptomatology to anxiety, depression and schizotypy in a clinical population

The relationship of obsessive-compulsive symptomatology to anxiety disorders, mood disorders and schizophrenia continues to be controversial. In a sample of 117 psychiatric out-patients, we examined the relationship of obsessive-compulsive symptomatology to indices of anxiety, depression and schizotypy. The relationship between obsessive-compulsive symptomatology and schizotypy was found to be significantly higher than that between obsessive-compulsive symptoms and either anxiety or depression. These findings are consistent with recent studies suggesting that there are similar cognitive deficits associated with obsessive-compulsive symptoms and schizotypy and that obsessive-compulsive disorders may be more closely aligned to the schizophrenic constellation of disorders than to anxiety disorders.

A study of the interrelationship between and comparative interrater reliability of the SAPS, SANS and PANSS

We assessed the comparative interrater reliability of the SANS/SAPS and PANSS as measures of symptomatology in schizophrenia and also examined the interrelationship between scores on these instruments. Two experienced raters used these Scales to assess positive and negative symptoms in a group of 85 patients with a DSM III-R diagnosis of schizophrenia. Ratings were based on structured clinical interviews, review of case notes and consultation with staff familiar with the patients. Comparable levels of interrater reliability were found for each system of measuring symptomatology, but levels of interrater reliability were on the whole lower than have been reported in the past. There were high correlations between overall indices of positive and negative symptomatology derived from the two measurement systems.

Negative symptoms and affective disturbance in schizophrenia and related disorders

OBJECTIVE

To review the data and discuss clinical recommendations for treating negative symptoms of schizophrenia. Negative symptoms (e.g., poverty of thought, affective blunting) have been regarded as part of schizophrenia since Kraepelin's early descriptions, although they remain a subject of controversy. For example, it is unclear if negative symptoms are distinct from other psychiatric symptoms such as depression, or are in actuality depression within schizophrenia. Recent evidence suggests that negative symptoms are independent of depression.

METHOD

Factor analytic studies have suggested that a negative factor (loss of affect, volition, poverty of thinking) may be distinguished from other components and is separable from a depression factor. Experimental use of vignettes have also been useful in the assessment of negative symptoms. A second controversial area is whether or not the presence or absence of affect is the fundamental issue separating schizophrenia from other psychoses.

RESULTS

A continuum of psychosis has been hypothesized, with unipolar psychotic depression at one pole and schizophrenia with defect state at the other. Within this proposed continuum, negative symptoms are associated only with schizophrenia without affect and with defect state schizophrenia. As such, variation in affect could be a primary determinant of the type of psychosis.

CONCLUSION

It appears that negative symptoms are a distinct aspect of schizophrenia and may aid in our understanding of psychotic disorders.

Relationship between movement planning and psychopathology profiles in schizophrenia

BACKGROUND

There has been evidence that psychopathology in schizophrenia consists of three separable syndromes: reality distortion, disorganisation, and psychomotor poverty. The objective of this study was to explore the relationship between planning and execution of movement and each of the syndromes in schizophrenia.

METHOD

Twenty-one right handed DSM-III-R schizophrenic patients performed a total of 80 trials of a motor movement task, varying distance of movement x size of the target x hand. Times taken to plan the movement (RT) and to carry it out (MT) were examined for their relationship with contemporaneous as well as lifetime profiles of the three syndromes in schizophrenia.

RESULTS

Significant correlations are reported between RT and current as well as lifetime measures of disorganisation syndrome. Somewhat weaker correlations are reported between RT and psychomotor poverty, but only for the right-handed tasks. Partial correlations suggest that the influence of neuroleptic medication explains all but one of the correlations between psychomotor poverty and RT, but does not account for the relationship between disorganisation and RT. No other relationship emerged between any of the movement and symptom measures.

CONCLUSIONS

These findings indicate that dysfunction in movement planning is related primarily to concurrent disorganisation, as well as to the prominence of disorganisation over the patient's history.

Understanding symptoms of schizophrenia

In examining the heterogeneity of symptomatology in schizophrenia, several theoretical models have been advanced. These models are useful in understanding the psychopathology of the disease, as well as possibly guiding treatment and determining prognosis. This paper discusses the two-syndrome and three-syndrome models for the primary symptoms of schizophrenia and their relationship to other symptoms often encountered. In addition, their significance and relevance for treatment are explored.

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.

The relationship between types of anxiety and depression

There has been considerable debate about the relationship between anxiety and depression. Most of the research in this area has examined relationships between composite indices of each construct. It has been suggested, however, that social anxiety may be more highly related to depression than are other forms of anxiety. We report the results of a study of the differential relationship of anxiety related to three sources (social evaluation, physical danger, and unfamiliar situations) to both self-report and clinician-rated levels of depression in a sample of 117 psychiatric outpatients. The results indicate that anxiety concerning social evaluation and unfamiliar situations was more highly related to depression than anxiety about physical danger.

A prospective study of daily stressors and symptomatology in schizophrenic patients

There has been very little research on the ability of a measure of daily stressors such as the Hassles Scale to predict symptomatology in schizophrenia. We examined this issue in a group of 55 outpatients with a DSM-III-R diagnosis of schizophrenia. The patients were assessed on a monthly basis for a minimum of 12 months. The Hassles Scale was used to assess daily stressors and the indices of symptomatology included the Scale for the Assessment of Positive Symptoms, the Scale for the Assessment of Negative Symptoms, the Beck Depression Inventory, the Self-Evaluation Questionnaire, and the General Health Questionnaire. Longitudinal data on the relationship between Hassles score and symptomatology were analyzed for each patient. Statistically significant correlations of symptoms with stressors for the previous month were found in a greater number of patients than would be expected by chance. There was some reduction in the number of significant correlations when the possible role of prior symptomatology was statistically controlled for.

Prodromal symptoms in schizophrenia

This paper describes a prospective study of the relationship between non-psychotic prodromal symptoms and psychotic symptoms in 55 schizophrenic (DSM-III-R) out-patients. Once a month, a number of non-psychotic symptoms generally regarded as prodromal symptoms in schizophrenia were assessed, as well as psychotic symptoms, with standardised self-administered instruments and rating scales for a minimum of 12 months (range 12-29). The data were analysed for each patient using a longitudinal correlational design with a 1-month lag between the prodromal and psychotic symptoms over the total period. Results showed that in less than one-fifth of subjects did any of the prodromal symptoms, individually or in combination, show a significantly positive correlation with the subsequent level of psychotic symptoms. Such relationships were significant in an even smaller proportion of subjects when the confounding effect of concurrent psychotic symptoms on prodromal symptoms was partialled out. High levels of prodromal symptoms appeared to have adequate specificity but low sensitivity in their power to predict high levels of subsequent psychotic symptoms. There were no differences in age, gender, medication levels, and the number of previous admissions between the subjects who did or did not show a relationship between putative prodromal symptoms and psychotic symptoms.

Correlations over time between dysphoric mood and symptomatology in schizophrenia

Monthly assessments of depression, anxiety, and positive and negative symptoms of schizophrenia were performed on 52 schizophrenic patients over periods ranging from 12 to 29 months. Data were analyzed to assess the extent to which symptoms of dysphoria (anxiety and depression) were more strongly related to negative or positive symptoms of schizophrenia. Consistent with past research using comparisons across subjects, the current longitudinal data show that there is a more consistent relationship between dysphoria and positive rather than negative symptoms.

Stability of positive and negative symptoms in schizophrenia

Fifty-nine DSM-III-R schizophrenic outpatients were assessed for positive and negative symptoms using Andreasen's Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). Reevaluation of these patients 12 months later revealed a moderate degree of stability for both SAPS and SANS total scores and most of their subscales. Only the subscale scores for apathy and bizarre behaviour failed to show a significant correlation in stability in 12 months. The results are discussed in the context of the reported literature.

Three syndrome concept of schizophrenia. A factor analytic study

One hundred and fifty-five DSM-IIIR schizophrenic patients were assessed for positive and negative symptoms using Andreasen's Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). Interrelationships of individual positive and negative symptoms were examined using a factor analysis. Results of the factor analysis are consistent with Liddle's proposition that there are three syndromes underlying symptomatology in schizophrenia: disorganization; psychomotor poverty and reality distortion.

Stressful life events and schizophrenia. I: A review of the research

Empirical research concerning the relationship between life event stressors and schizophrenia is critically reviewed. In accordance with the view that patients suffering from schizophrenia are vulnerable to stress, there is evidence of a relationship between stressors and variation in severity of symptoms over time. There is less indication that schizophrenic patients have had higher levels of stressors than the general population or than patients suffering from other psychiatric disorders. These findings are consistent with vulnerability-stress models of the development of schizophrenia.

Stressful life events and schizophrenia. II: Conceptual and methodological issues

Research on the relationship between stress and schizophrenia is fraught with conceptual and methodological problems. These problems include issues related to the nature and measurement of stress, the likelihood of reciprocal influences between stress and symptoms, and the adequate assessment of symptoms. Several recommendations are made regarding future research in this area. These include using multiple and broadly based measures of different types of stressors and symptoms, greater use of truly prospective research designs, and the evaluation of the effects of interventions specifically designed to reduce stress in patients who suffer from schizophrenia.

Dysphoric mood and symptomatology in schizophrenia

The relationships between depression, anxiety and positive and negative symptoms of schizophrenia were examined in a study of 95 schizophrenic patients who were receiving out-patient care. Various measures of depression and anxiety showed a pattern of interrelationships which suggested that they were measuring a general state of dysphoria rather than separate dimensions of anxiety and depression. Dysphoria was found to be more reliably related to level of positive symptomatology than to negative symptoms.

Subjective stress in schizophrenic patients

The relationship of major life events and daily stressors to subjective stress was investigated in outpatients suffering from schizophrenia. Daily stressors or hassles were found to be more predictive of subjective stress than were major life events. These findings were not influenced by whether a cross sectional or prospective analysis was used. The implications for future research on stress and schizophrenia are discussed.

Validation of the five minute speech sample in measuring expressed emotion

The relationship of the Five Minute Speech Sample (FMSS) to the Camberwell Family Interview and its coding system were evaluated. The Camberwell Family Interview and the FMSS were administered to twenty-three relatives of patients diagnosed with schizophrenia. Overall, the results supported the utility of the FMSS and its coding system as a brief screening device for measuring expressed emotion.