Negative and positive dimensions of schizotypal personality disorder

The positive (perceptual-cognitive) and negative (social-interpersonal) dimensions of schizotypal personality traits were examined in biological relatives of individuals with Axis I disorder. The subjects were young adult offspring from three contrasting parental groups, including schizophrenic disorder, affective disorder, and normal controls. Cognitive correlates, including digit span (presumed to assess working memory) and P3 amplitudes, were also examined. Preliminary results showed that positive and negative dimensions were distinguished by different prevalence patterns in the offspring subjects, and by a different pattern of correlations with cognitive measures. Negative dimensions were more frequent in offspring from the schizophrenic parental group than in the offspring from affective disorder and normal control parental groups. Digits forward and backward, and P3 amplitude decrements, characterized a subset of offspring with negative features from the schizophrenic parental group. Positive dimensions did not differ between the psychiatric parental groups, and did not covary with digit span or P3 amplitude assessments. These results support the view that positive and negative dimensions may reflect separable pathophysiologic processes.

Major depressive disorder in the 6 months after miscarriage

OBJECTIVE

To test a priori hypotheses that miscarrying women are at increased risk for a first or recurrent episode of major depressive disorder in the 6 months following loss and that this increased risk is greater for childless women, women with prior reproductive loss, and women aged 35 years or older; and to evaluate whether risk varies by time of gestation or by attitude toward the pregnancy.

DESIGN

Cohort study.

SETTING

The miscarriage cohort consisted of women attending a medical center for a spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230).

PARTICIPANTS

Miscarriage was defined as the involuntary termination of a nonviable intrauterine pregnancy before 28 completed weeks of gestation. Half of all participants were between 25 and 34 years of age; 40% were white and 35% Hispanic; 55% had more than a high school education. Participants constituted 60% of miscarrying women and 72% of community women who completed the first phase of this cohort study.

MAIN OUTCOME MEASURE

Major depressive disorder was measured using the Diagnostic Interview Schedule.

RESULTS

Risk for an episode of major depressive disorder among miscarrying women in the 6 months following loss was compared with the 6-month risk among community women who had not been pregnant in the preceding year. Among miscarrying women, 10.9% experienced an episode of major depressive disorder, compared with 4.3% of community women. The overall relative risk (RR) for an episode of major depressive disorder for miscarrying women was 2.5 (95% confidence interval [CI], 1.2-5.1) and was substantially higher for childless women (RR, 5.0; 95% CI, 1.7-14.4) than for women with children (RR, 1.3; 95% CI, 0.5-3.5) (P<.06). Among miscarrying women, 72% of cases of major depressive disorder began within the first month after loss; only 20% of community cases started during the comparable period. Among miscarrying women with a history of major depressive disorder, 54% experienced a recurrence. However, RR did not vary significantly by history of prior reproductive loss or by maternal age, nor did risk vary by time of gestation or attitude toward the pregnancy.

CONCLUSIONS

Physicians should monitor miscarrying women in the first weeks after reproductive loss, particularly women who are childless or who have a history of major depressive disorder. Where appropriate, supportive counseling or psychopharmacologic treatment should be considered.

Childhood antecedents of adolescent personality disorders

OBJECTIVE

The purpose of this study was to investigate the childhood antecedents of personality disorders that are diagnosed in adolescence.

METHOD

A randomly selected community sample of 641 youths was assessed initially in childhood and followed longitudinally over 10 years. Childhood behavior ratings were based on maternal report; diagnoses of adolescent personality disorders were based on data obtained from both maternal and youth informants. Four composite measures of childhood behavior problems were used: conduct problems, depressive symptoms, anxiety/fear, and immaturity. Adolescent personality disorders were considered present only if the disorders persisted over a 2-year period. For all analyses, personality disorders were grouped into the three clusters (A, B, and C) of DSM-III-R.

RESULTS

Logistic regression analyses indicated that all four of the putative childhood antecedents were associated with greater odds of an adolescent personality disorder 10 years later. Childhood conduct problems remained an independent predictor of personality disorders in all three clusters, even when other childhood problems were included in the same regression model. Additionally, depressive symptoms emerged as an independent predictor of cluster A personality disorders in boys, while immaturity was an independent predictor of cluster B personality disorders in girls. No moderating effects of age at time of childhood assessment were found.

CONCLUSIONS

These results support the view that personality disorders can be traced to childhood emotional and behavioral disturbances and suggest that these problems have both general and specific relationships to adolescent personality functioning.

Special report: DSM-IV: overview and examination of major changes

The American Psychiatric Association published the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) in May 1994. Referred to by some in the popular media as the mental health profession's diagnostic bible, the decisions reflected in this fourth edition are likely to shape diagnostic practice and education and may impact on treatment approaches as well. This article describes the goals and process involved in preparing this document, examines the major changes from DSM-III-R to DSM-IV and comments on the relevance of DSM-IV to psychiatric/mental health nursing.

Determinants of depressive symptoms in the early weeks after miscarriage

OBJECTIVES

We tested whether and under what conditions miscarriage increases depressive symptoms in the early weeks following loss.

METHODS

We interviewed 232 women within 4 weeks of miscarriage and 283 pregnant women and 318 community women who had not recently been pregnant. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

Among women who had miscarried, the proportion who were highly symptomatic on the CES-D was 3.4 times that of pregnant women and 4.3 times that of community women. Among childless women, the proportion of women who had miscarried who were highly symptomatic was 5.7 times that of pregnant women and 11.0 times that of community women. Women who had miscarried were equally depressed regardless of length of gestation; among pregnant women, depressive symptoms declined with length of gestation. Among women who had miscarried, symptom levels did not vary with attitude toward the pregnancy; among pregnant women, depressive symptoms were elevated in those with unwanted pregnancies. Prior reproductive loss and advanced maternal age (35+ years) were not associated with symptom levels in any cohort.

CONCLUSIONS

Depressive symptoms are markedly increased in the early weeks following miscarriage. This effect is substantially modified by number of living children, length of gestation at loss, and attitude toward pregnancy.

Depressive symptoms in women in the six months after miscarriage

This study, the first systematic investigation of the psychiatric impact of miscarriage, tests whether miscarriage markedly increases depressive symptoms in the 6 months after loss. We interviewed 382 miscarrying women entering the study at 2 weeks, 6 weeks, or 6 months after loss and, for comparison, 283 pregnant women and 318 community women not recently pregnant. Among women interviewed 2 weeks after miscarriage the proportion highly symptomatic on the Center for Epidemiologic Studies-Depression scale was 3.4 times that of pregnant women (95% confidence limits 2.0 and 5.0) and 4.3 times that of community women (95% confidence limits 3.0 and 5.8). Among women first interviewed 6 weeks and 6 months after miscarriage the proportion highly symptomatic was three times that of the community women. Women reinterviewed at 6 weeks and 6 months did not have elevated symptom levels, a result attributed to the unintended therapeutic and test effects of study interviews. Interviews were fully structured, readily administered by telephone by nonmedical personnel. The possibility that such interviews afford miscarrying women substantial psychologic benefits merits future investigation.

Obsessive compulsive disorder, depression, and fluoxetine

BACKGROUND

Fluoxetine, a selective serotonin reuptake blocker, is an antidepressant medication that has also been shown in open clinical trials and one controlled trial to be effective in the treatment of obsessive compulsive disorder (OCD). OCD is often complicated by depression, and depressive symptoms may interfere with response to both pharmacologic and behavioral treatments.

METHOD

We describe pilot data from 10 outpatients who met DSM-III-R criteria for OCD in whom the possibility of a depressive reaction or lack of antidepressant response occurred during an open trial of fluoxetine.

RESULTS

Rapid increase in fluoxetine dose to high doses was associated with depressive symptoms in 6 patients. In 8 patients, improvement in depression was associated with addition of a tricyclic antidepressant to fluoxetine treatment. In 5 patients, both OCD and depressive symptoms improved when the patient was switched to the partially selective serotonin reuptake blocker clomipramine.

CONCLUSION

This paper serves to alert clinicians to the possibility of a depressive reaction, or lack of antidepressant response, to fluoxetine in OCD patients. This possibility can only be resolved scientifically by adequately controlled experimental trials. If depression occurs, combined fluoxetine and tricyclic treatment, or a switch to a partially selective serotonin reuptake inhibitor, may be helpful. Special considerations and side effects of combined fluoxetine-tricyclic treatment are described.

Therapists' recognition of psychopathology: a model for quality review of psychotherapy

In this study 32 randomly selected psychiatric emergency room patients, who were in concurrent psychotherapy, completed the SCL-90 and a clinically oriented questionnaire. Their therapists independently rated the patients' degree of psychopathology on the nine SCL-90 symptom scales. Therapists were highly efficient in recognizing depression (94% of the cases) and anxiety (89%) but not psychotic (35%) and obsessive-complusive (16%) pathology. Variables significantly associated with the therapists' nonrecognition of psychopathology were the diagnosis of borderline, the patient's expression of inadequacy in comparison to the therapist, the patient's fear of offending the therapist, and the patient wanting but not receiving empathy from the therapist. The authors discuss the implications of these findings for peer review and further research.

Appearance of new symptoms in hospitalized patients: an instance of institutional iatrogenesis?

Data from the admission and termination forms of 100 consecutively discharged psychiatric inpatients were analyzed to determine the changes that occurred in the symptom profile of each patient during hospitalization. In general, patients entered the hospitalization. In general, patients entered the hospital with severe, chronic symptoms some of which were relieved and some of which remained unchanged. A number of symptoms, however, were reported present on the termination forms that had not been noted at admission. The results of this study offer evidence that a possible effect of the therapeutic process is the occasional appearance of new symptoms in some patients.