Anhedonia in adolescents at transdiagnostic familial risk for severe mental illness: Clustering by symptoms and mechanisms of association with behavior

BACKGROUND

Anhedonia is a transdiagnostic symptom of severe mental illness (SMI) and emerges during adolescence. Possible subphenotypes and neural mechanisms of anhedonia in adolescents at risk for SMI are understudied.

METHODS

Adolescents at familial risk for SMI (N = 81) completed anhedonia (e.g., consummatory, anticipatory, social), demographic, and clinical measures and one year prior, a subsample (N = 46) completed fMRI scanning during a monetary reward task. Profiles were identified using k-means clustering of anhedonia type and differences in demographics, suicidal ideation, impulsivity, and emotional processes were examined. Moderation analyses were conducted to investigate whether levels of brain activation of reward regions moderated the relationships between anhedonia type and behaviors.

RESULTS

Two-clusters emerged: a high anhedonia profile (high-anhedonia), characterized by high levels of all types of anhedonia, (N = 32) and a low anhedonia profile (low-anhedonia), characterized by low levels of anhedonia types (N = 49). Adolescents in the high-anhedonia profile reported more suicidal ideation and negative affect, and less positive affect and desire for emotional closeness than low-anhedonia profile. Furthermore, more suicidal ideation, less positive affect, and less desire for emotional closeness differentiated the familial high-risk, high-anhedonia profile adolescents from the familial high-risk, low-anhedonia profile adolescents. Across anhedonia profiles, moderation analyses revealed that adolescents with high dmPFC neural activation in response to reward had positive relationships between social, anticipatory, and consummatory anhedonia and suicidal ideation.

LIMITATIONS

Small subsample with fMRI data.

CONCLUSION

Profiles of anhedonia emerge transdiagnostically and vary on clinical features. Anhedonia severity and activation in frontostriatal reward areas have value for clinically important outcomes such as suicidal ideation.

Optimizing Scripted Dialogues for an e-Health Intervention for Suicidal Veterans with Major Depression

Suicide is a health concern among Veterans with depression. We had previously reported on scripted dialogues adapted for an e-health system that engages at-risk veterans with schizophrenia. Here we report a further adaptation of the dialogues for Veterans with depression. Usability was assessed with nine outpatients with a history of major depression and suicidality. We noted that participants preferred greater specificity in the wording of questions. Topics that elicited an emotional response dealt with questions on suicide, social isolation and family relationships. Based on feedback, dialogues were revised for patients with depression. We also compared responses between those with depression and those with schizophrenia who were previously tested. The two groups shared similar themes. Also, individuals with a history of major depression had less trouble with vocabulary comprehension but were less willing to answer more questions daily.

Using problem solving therapy to treat veterans with subsyndromal depression: a pilot study

OBJECTIVE

We conducted a pilot study comparing problem solving therapy for primary care (PST-PC) to a dietary education control condition in middle-aged and older veterans with symptoms of emotional distress and subsyndromal depression.

METHODS

This was a two-site study at the VA Pittsburgh Healthcare System and Philadelphia VA Medical Center. Participants included veterans >50 years of age referred from primary care clinics who were eligible if they obtained a pre-screen score >11 on the Centers for Epidemiologic Studies Depression (CES-D) scale. Exclusions were a DSM-IV Major Depressive Episode within the past year, active substance abuse/dependence within 1 month, current antidepressant therapy, and a Mini mental status exam score <24. Participants were randomized to receive one of two interventions--either PST-PC or an attention control condition consisting of dietary education (DIET)--each consisting of six to eight sessions within a 4-month period.

RESULTS

Of 45 individuals randomized, 23 (11 PST-PC and 12 DIET) completed treatment. Using regression models in completers that examined outcomes at end of treatment while controlling for baseline scores, there were significant differences between treatment groups in SF-36 mental health component scores but not in depressive symptoms (as assessed with either the 17-item Hamilton Rating Scale for Depression or the Beck Depression Inventory), social problem solving skills, or physical health status (SF-36 physical health component score).

CONCLUSIONS

These pilot study findings suggest that a six-to-eight session version of PST-PC may lead to improvements in mental health functioning in primary care veterans with subsyndromal depressive symptoms.

Development of a recovery manual for suicidal patients with schizophrenia: consumer feedback

A recovery-oriented manual was developed for patients with schizophrenia and suicidality. It included psychoeducational information, vignettes, "workbook" sections and was reviewed by experts in suicidology, recovery, patient education, manual development and psychosocial interventions. The revised version was tested in 22 consumers with schizophrenia and a history of suicidality. Consumer-based focus groups yielded five key themes which were used to further refine the manual. A satisfaction survey indicated that 85% stated the manual was 'somewhat easy', 'easy' or 'very easy to read.' All stated it was 'very useful', 'useful' or 'somewhat useful. Thus, the manual appears to be acceptable and useful.

Dysregulation of neurosteroids in obsessive compulsive disorder

Alterations in hormone concentrations, including adrenocorticotropin, corticotropin releasing hormone, and cortisol have been reported in patients with obsessive compulsive disorder (OCD). Dehydroepiandrosterone (DHEA) and its sulfated metabolite, DHEA-S, have not been assessed in patients with OCD. We report 24-h serum DHEA, DHEA-S, and cortisol concentrations in a young man with OCD and 15 healthy young men. Circadian patterns of DHEA and cortisol were markedly different in the subject with OCD than in the control subjects. DHEA and DHEA-S concentrations were substantially higher in the OCD subject than in the control subjects. In contrast, cortisol concentrations were similar in the OCD subject and the control subjects. Future clinical studies are needed to evaluate the significance of DHEA and DHEA-S in OCD.

A Clinical Trial to Test the Feasibility of a Telehealth Psychoeducational Intervention for Persons With Schizophrenia and Their Families: Intervention and 3-Month Findings

OBJECTIVE

To evaluate the feasibility of a telehealth psychoeducation intervention for persons with schizophrenia and their family members.

STUDY DESIGN

Randomized controlled trial.

PARTICIPANTS

30 persons with schizophrenia and 21 family members or other informal support persons.

INTERVENTIONS

Web-based psychoeducation program that provided online group therapy and education.

MAIN OUTCOME MEASURES

Measures for persons with schizophrenia included perceived stress and perceived social support; for family members, they included disease-related distress and perceived social support.

RESULTS

At 3 months, participants with schizophrenia in the intervention group reported lower perceived stress (p = .04) and showed a trend for a higher perceived level of social support (p = .06).

CONCLUSIONS

The findings demonstrate the feasibility and impact of providing telehealth-based psychosocial treatments, including online therapy groups, to persons with schizophrenia and their families.

Interpersonal control and expressed emotion in families of persons with schizophrenia: change over time

This study examined communication patterns in 62 families of persons with schizophrenia, comparing families with relatives who were low expressed emotion (EE) at the beginning and end of a 2-year study, those who were high EE at the beginning and end, and those whose EE status changed. Interaction was coded with the Relational Control Coding System and analyzed as a Markov process. Dialogues in the stable low-EE and stable high-EE families were rather similar initially, and both groups showed increasing flexibility at year 1. However, at year 2, low-EE dyads showed increasingly complex structure and flexibility in control, but high-EE dyads showed simpler structure and rigidly controlling patterns. When EE status changed, so did the structure of the dialogues and the patterning of control. Although earlier research found more "tightly joined" systems in families of high-EE relatives, it may be that over time, these family members distance from each other and so are less connected. It is also possible that relatives who remain high EE despite intervention are a subset of high-EE relatives who need more support or different therapeutic approaches to maintain change.

The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression

OBJECTIVE

This study investigated whether a higher frequency of reported childhood trauma would be found in depressed adults with higher levels of trait impulsivity, aggression, and suicidal behavior.

METHOD

In 136 depressed adult inpatients, the authors assessed trait impulsivity, aggression history, and number of lifetime suicide attempts as well as the medical lethality and the intent to die associated with the most lethal attempt. These variables were then compared between those with and those without a reported history of childhood physical or sexual abuse.

RESULTS

Subjects who reported an abuse history were more likely to have made a suicide attempt and had significantly higher impulsivity and aggression scores than those who did not report an abuse history. Impulsivity and aggression scores were significantly higher in subjects with a history of at least one suicide attempt. A logistic regression analysis revealed that abuse history remained significantly associated with suicide attempt status after adjustment for impulsivity, aggression history, and presence of borderline personality disorder. Among those who attempted suicide, there were no significant differences in severity of suicidal behavior between those with and without a childhood history of abuse.

CONCLUSIONS

Abuse in childhood may constitute an environmental risk factor for the development of trait impulsivity and aggression as well as suicide attempts in depressed adults. Alternatively, impulsivity and aggression may be inherited traits underlying both childhood abuse and suicidal behavior in adulthood disorders. Additional research is needed to estimate the relative contributions of heredity and environmental experience to the development of impulsivity, aggression, and suicidal behavior.

Delusions and suicidality

OBJECTIVE

Delusions have been considered a risk factor for suicidal behavior. To determine whether specific delusion types are related to suicidal behaviors, the authors compared the clinical characteristics of patients with mood disorders and schizophrenia who did and did not have a history of suicide attempts.

METHOD

After admission for inpatient or outpatient psychiatric treatment, 429 patients (ages 14-72 years; 47.1% male; and 73.0% Caucasian) were assessed with a structured clinical interview that generated axis I and II diagnoses. In addition, their psychiatric symptoms, history of suicide attempts, and overall functioning were rated.

RESULTS

Data for three diagnostic subgroups (223 patients with major depression, 150 with schizophrenia, and 56 with bipolar disorder) were analyzed separately. Multivariate analyses did not find evidence of a relationship between delusions and history of suicidal ideation or suicide attempts in any of the diagnostic groups.

CONCLUSIONS

This study did not find evidence that the presence of delusions distinguished persons with or without a history of suicide attempt.

Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder

This study investigated the impact of recent life events and social adjustment on suicide attempter status in 34 patients with major depression, 24 patients with borderline personality disorder, and 22 patients with co-morbid major depression and borderline personality disorder. Suicide attempters reported more recent life events and scored lower on a measure of social adjustment in their families and overall social adjustment, compared with non-attempters. Borderline disordered and borderline or depressed patients were more likely to have attempted suicide than patients with major depression only. Recent life events did not predict attempter status. Lower social adjustment in the immediate family and lower overall social adjustment were predictive of suicide attempter classification, regardless of diagnosis. Borderline disordered patients low on overall social adjustment were over 16 times more likely to have attempted suicide than patients diagnosed with major depression only. Recent life events may elevate suicide risk in groups already at high risk for suicide completion, whereas high levels of social adjustment may be protective against stress-related suicidal behavior.

Effects of behavioural family management on family communication and patient outcomes in schizophrenia

BACKGROUND

Family interventions for schizophrenia have proved to be highly effective in preventing relapse, but it is not clear how they work or how they should be structured.

AIMS

To examine the effects of a behavioural family intervention and a family support programme on communication, problem solving and outcome in order to determine the impact of structured communication training.

METHOD

Patients and family members participating in the Treatment Strategies in Schizophrenia study were videotaped engaging in 10-minute problem-solving conversations at baseline and after the conclusion of the family intervention. Tapes were subsequently evaluated for changes in communication patterns.

RESULTS

The intensive behavioural intervention did not produce differential improvement in communication, and change in communication was unrelated to patient outcomes.

CONCLUSIONS

The data suggest that intensive behavioural family interventions may not be cost efficient, and that change in family communication patterns may only be important for a subset of families.

Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters

OBJECTIVE

Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors.

METHODS

Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n = 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time.

RESULTS

Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity.

LIMITATIONS

The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied.

CONCLUSIONS

Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts.

Protective factors against suicidal acts in major depression: reasons for living

OBJECTIVE

Over 30,000 people a year commit suicide in the United States. Prior attempted suicide and hopelessness are the most powerful clinical predictors of future completed suicide. The authors hypothesized that "reasons for living" might protect or restrain patients with major depression from making a suicide attempt.

METHOD

Inpatients with DSM-III-R major depression were assessed for depression, general psychopathology, suicide history, reasons for living, and hopelessness. Of the 84 patients, 45 had attempted suicide and 39 had not.

RESULTS

The depressed patients who had not attempted suicide expressed more feelings of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and a greater fear of suicide than the depressed patients who had attempted suicide. Scores for hopelessness, subjective depression, and suicidal ideation were significantly higher for the suicide attempters. Reasons for living correlated inversely with the combined score on these measures, considered an indicator of "clinical suicidality." Neither objective severity of depression nor quantity of recent life events differed between the two groups.

CONCLUSIONS

During a depressive episode, the subjective perception of stressful life events may be more germane to suicidal expression than the objective quantity of such events. A more optimistic perceptual set, despite equivalent objective severity of depression, may modify hopelessness and may protect against suicidal behavior during periods of risk, such as major depression. Assessment of reasons for living should be included in the evaluation of suicidal patients.

Suicidal behavior in patients with schizophrenia and other psychotic disorders

OBJECTIVE

Patients with schizophrenia are known to be at high risk for suicide attempts and dying by suicide. However, little research has been conducted to determine whether the risk for suicidal behavior is elevated among patients with psychosis in general.

METHOD

This study evaluated 1-month and lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients (ages 18 to 55 years) with DSM-III-R psychotic disorders. Demographic, clinical, and diagnostic correlates of suicidal behavior were examined.

RESULTS

A high rate of suicidal behavior was found in the group: 30.2% reported a lifetime history of suicide attempts, and 7.2% reported a suicide attempt in the month before admission. The highest 1-month and lifetime rates were found in patients with schizoaffective disorder and major depression with psychotic features. Ratings of the medical dangerousness of the most recent suicide attempt on the basis of the extent of physical injury were higher in patients with schizophrenia spectrum psychoses. Agreement was high between emergency room assessments and semistructured interview assessments of suicidal behavior.

CONCLUSIONS

Rates of suicidal behavior were high across a broad spectrum of patients with psychotic disorders; patients with a history of a current or past major depressive episode (as a part of major depressive disorder or schizoaffective disorder) were at a greater risk for suicide attempts, but patients with schizophrenia, on average, made more medically dangerous attempts. Risk factors for suicidal behavior in patients with psychosis appear to vary compared to those for the general population.

Pursuit tracking impairments in schizophrenia and mood disorders: step-ramp studies with unmedicated patients

BACKGROUND

Eye tracking abnormalities are highly prevalent in schizophrenia, and are among the most promising phenotypic familial markers for the disorder. The neurophysiologic mechanisms underlying these disturbances and their diagnostic specificity for schizophrenia are not yet well characterized.

METHODS

This study assessed eye tracking deficits using foveopetal and foveofugal step-ramp tasks (ramps moving toward and away from central fixation after an initial step respectively) across a range of target velocities in anti-psychotic-naive schizophrenia patients, previously treated but currently unmedicated chronic schizophrenia patients, unmedicated patients with either bipolar or unipolar mood disorders, and healthy volunteers.

RESULTS

All patient groups demonstrated reduced pursuit gain in open loop and closed loop visual tracking conditions. There were no significant group differences in the latency or accuracy of catch-up saccades on foveofugal ramp tasks.

CONCLUSIONS

These findings indicate that open and closed loop pursuit eye movements are impaired during acute episodes of schizophrenia and mood disorders. The intact accuracy of saccades to moving targets in all patient groups indicates that an adequate representation of motion information is available to the saccade system. Therefore, pursuit disturbances in mood disorders and schizophrenia seem to result, at least in part, from a disturbance in sensorimotor integration in the pursuit system after the initial extraction of sensory motion information. No eye movement abnormalities observed during performance of step ramp tasks were specific to schizophrenia.

Landmark-based morphometric analysis of first-episode schizophrenia

BACKGROUND

The goal of this investigation was to utilize landmark-based shape analysis and image averaging to determine the sites and extent of specific structural changes in first-episode schizophrenia.

METHODS

Neuroanatomic structures identified on midsagittal magnetic resonance imaging (MRI) scans were compared between 20 patients with schizophrenia and 22 normal control subjects. The difference between averaged landmark configurations in the two groups was visualized as a shape deformation by a thin-plate spline and through averaged MRI images for both groups.

RESULTS

A shape difference was found to be statistically significant; by inspection, it is contrast between differences in two closely abutting regions, involving primarily the posterior corpus callosum and upper brain stem--the "focus" is the relation between them.

CONCLUSIONS

The findings are consistent with prior studies suggesting involvement in schizophrenia of the corpus callosum and the limbic structures contributing to the corpus callosum; the possibility of local pathology primarily involving the brain stem cannot be excluded. The methods of landmark-based shape analysis and image averaging utilized in this study can complement the "region-of-interest" method of investigating morphometric abnormalities by characterizing the spatial relationships among structural brain abnormalities in schizophrenia.

Prefrontal cortical dysfunction in depression determined by Wisconsin Card Sorting Test performance

OBJECTIVE

Neuroimaging studies have demonstrated reduced prefrontal cortical blood flow and metabolism in depression, but the neurobehavioral significance of these observations is not yet established.

METHOD

The Wisconsin Card Sorting Test, a widely used neuropsychological index of prefrontal cortical function, was administered to 79 patients with major depression who had been unmedicated for at least 28 days, to 47 patients with schizophrenia who had never received antipsychotic medication, and to 61 healthy comparison subjects.

RESULTS

Depressed patients demonstrated significant deficits on multiple Wisconsin Card Sorting Test measures compared with healthy individuals. These deficits were correlated with the severity of depression and were less severe than those demonstrated by patients with schizophrenia.

CONCLUSIONS

These results provide neuropsychological evidence for significant prefrontal cortical dysfunction in depression.

Toward a clinical model of suicidal behavior in psychiatric patients

OBJECTIVE

Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study.

METHOD

Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed.

RESULTS

Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters.

CONCLUSIONS

The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.

Racial and gender differences in expressed emotion and interpersonal control in families of persons with schizophrenia

Expressed Emotion (EE) has been shown to be predictive of course or severity in many illnesses, but the studies have been largely of white middle-class patients. This study examined gender and racial differences in parental EE level and communication patterns between the parent and patient with schizophrenia, using data from the NIMH Treatment Strategies in Schizophrenia study. Dialogues (n = 140) from 54 patient-parent dyads were coded into the Relational Control Coding System. Resultant data (n = 13,605 sequences) were analyzed with log-linear models. Results show that the relationship between control and EE level was stronger in African American families compared to Caucasians. Gender differences were as expected, with daughters less competitive and more deferential to their parents. Although the total number of high-EE parents with daughters was small, patterns in these families showed parents who responded submissively in contrast to the competitive symmetry in families with male patients.

Eye tracking abnormalities in schizophrenia: evidence for dysfunction in the frontal eye fields

BACKGROUND

Eye tracking deficits are robust abnormalities in schizophrenia, but the neurobiological disturbance underlying these deficits is not known.

METHODS

To clarify the pathophysiology of eye tracking disturbances in schizophrenia, we tested 12 first-episode treatment-naive schizophrenic patients and 10 matched healthy individuals on foveofugal and foveopetal step-ramp pursuit tasks.

RESULTS

On foveopetal tasks, the initiation of pursuit eye movements was delayed in schizophrenic patients, and their steady-state pursuit gain was reduced particularly at slower target speeds (8 and 16 deg/sec). In foveofugal step-ramp tasks, their primary catch-up saccades were normal in latency and accuracy, but their postsaccadic pursuit in the first 100 msec after the primary catch-up saccade was significantly reduced even relative to their slow steady-state pursuit, especially during and immediately after an acute episode of illness.

CONCLUSIONS

These observations indicate that motion-sensitive areas in posterior temporal cortex provide sufficiently intact information about moving targets to guide accurate catch-up saccades, but that the sensory processing of motion information is not being used effectively for pursuit eye movements. Low-gain pursuit after the early stage of pursuit initiation suggests that the use of extraretinal signals about target motion (e.g., anticipatory prediction) only partially compensates for this deficit. The pattern of low-gain pursuit, impaired pursuit initiation, and intact processing of motion information for catch-up saccades but not pursuit eye movements, was consistent in the schizophrenic patients tested at five time points over a 2-year follow-up period, and implicates the frontal eye fields or their efferent or afferent pathways in the pathophysiology of eye tracking abnormalities in schizophrenia.

Research and treatment strategies in first-episode psychoses. The Pittsburgh experience

BACKGROUND

Studies of first-episode patients allow investigation of the biological basis of psychotic disorders without the potential confounds of prior treatment and illness chronicity. Prospective studies of this population can clarify the impact of illness course and treatment on neurobiology.

METHOD

We summarise preliminary findings from our ongoing magnetic resonance imaging and spectroscopy studies of first-episode schizophrenia patients being conducted prospectively from index evaluations through a period of two years; during this period, patients were treated with either a conventional antipsychotic such as haloperidol, or the atypical risperidone.

RESULTS

Baseline neurobiological evaluations in first-episode schizophrenia patients have revealed evidence for structural and functional brain abnormalities consistent with a neurodevelopmental model of this illness. Our preliminary data support the value of risperidone as an antipsychotic drug of first choice among patients with early schizophrenic illness.

CONCLUSIONS

Focused studies of first-episode patients have the potential to unravel pathophysiology of schizophrenic illness. Such knowledge is critical for more effective early detection, intervention and even prevention of this enigmatic disorder.

Delay to first antipsychotic medication in schizophrenia: impact on symptomatology and clinical course of illness

The possible adverse clinical effects of untreated psychosis in schizophrenic patients, particularly early in the course of illness, have been a topic of considerable interest in recent years. We examined the timing of first administration of antipsychotic medication after the first onset of psychotic symptoms in 103 patients with DSM-III-R diagnoses of schizophrenia, schizophreniform or schizo-affective disorder. Patients with a delay of one or more years between the onset of the first psychotic symptom and the initiation of antipsychotic treatment demonstrated more severe negative symptomatology on admission to hospital and more severe positive symptoms and negative symptoms at discharge. These effects were present in both first-admission patients, in whom the delay to treatment immediately preceded hospitalization and chronic patients with a history of multiple hospitalizations. Patients with one or more years of untreated psychosis prior to their first antipsychotic treatment displayed a more severe poverty syndrome at the time of admission and discharge and a more severe reality distortion syndrome at discharge from the index hospitalization. These findings were not related to age, premorbid functioning, duration of illness, first- vs multiple-episodes status, or dosage of antipsychotic medication at time of admission or discharge assessment. Findings from the present study suggest that failure to initiate antipsychotic treatment early in the course of the illness may be associated with a recurrent pattern of poorer treatment response and more severe and persistent positive and negative symptomatology. These findings indicate the importance of early detection of illness and early initiation of antipsychotic treatment for the first psychotic symptoms of schizophrenia.

Superior temporal gyrus and the course of early schizophrenia: progressive, static, or reversible?

Accumulating evidence suggests alterations in brain structure, especially in the prefrontal and temporal cortex, in schizophrenia. Previous studies examining the progression of brain structural alterations in schizophrenia have led to conflicting results. Morphometric studies of the superior temporal gyrus (STG) volumes were conducted in a series of neuroleptic-naive first-episode schizophrenic patients, non-schizophrenic first-episode psychotic patients, and matched healthy controls. Three-dimensional MRI scans were carried out in these subjects before and after one year of treatment. Volume reductions were seen at baseline in the left superior temporal gyrus (adjusted for intracranial volume) in both of the patient groups. Pretreatment illness duration was inversely related to the volume of the left superior temporal gyrus; this relation was confined to males. One-year follow-up MRI investigations in a smaller subset of patients suggested that the STG volume reductions may be reversible. No significant changes were noted in the STG volumes in matched healthy controls who were also scanned at baseline as well as at one-year follow-up. These findings have implications for understanding the nature of the neuropathological processes in early schizophrenia, as well as the potential impact of early treatment.

Adverse effects of risperidone on eye movement activity: a comparison of risperidone and haloperidol in antipsychotic-naive schizophrenic patients

Risperidone is a novel and clinically effective atypical antipsychotic medication with a unique biochemical profile. To contrast the neurophysiological effects of this new medication with those of a typical antipsychotic medication, we performed quantitative measurements of saccadic eye movements in a series of antipsychotic-naive schizophrenic patients treated with either risperidone or haloperidol. Patients were tested before and after 1 month of treatment, and a matched group of healthy subjects was tested twice over a similar time interval. Risperidone, but not haloperidol, was associated with prolonged latency and decreased peak velocity and accuracy of saccadic eye movements that was detectable 4 weeks after treatment initiation. The adverse effects of risperidone may be due to the lack of development of acute tolerance to its powerful serotonergic (5-HT2A) antagonism, which could be responsible for the disruption of brainstem physiology in regions controlling saccadic eye movements.

Suicidal behavior in patients with major depression and comorbid personality disorders

We investigated the relationship of DSM-III-R personality disorder (PD) diagnoses and traits to suicidal behavior in patients with Major Depressive Disorder (MDD). Axis I and Axis II criteria and suicidal behavior were assessed using structured interviews of 102 psychiatric inpatients. Subjects with comorbid MDD and Borderline PD (BPD: n = 30) were more likely than other patients to have a history of multiple suicide attempts, and were equally likely to have made a highly lethal attempt. Number of BPD and other Cluster B (dramatic/erratic) criteria were better predictors of past suicidal behavior than were depressive symptoms. We conclude that patients with BPD symptomatology are at risk for serious suicide attempts. Moreover, severity of comorbid Cluster B PD psychopathology should be considered when assessing suicide risk in MDD patients even in those without a PD diagnosis.

Gender effects on the clinical presentation of alcoholics at a psychiatric hospital

Despite the clinical importance of gender effects on symptom patterns and comorbidity patterns in alcoholics, little is known about such effects in treatment facilities other than alcoholism treatment centers. This study evaluated the effect of gender on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. It demonstrated that major depression and accompanying depressive and anxiety-related symptoms are more prominent in female alcoholics than in male alcoholics, whereas antisocial personality disorder and antisocial symptoms are more prominent in male alcoholics presenting to a psychiatric hospital. The study also demonstrated that reversed neurovegetative symptoms are more severe in female than in male alcoholics.

Major depression and the risk of attempted suicide

We examined the risk of attempted suicide in 100 inpatients during a major depressive episode. We hypothesized that patients who attempt suicide have a vulnerability for suicidal behavior independent of severity or duration of depression, manifested by suicide attempts early in the course of a depressive episode. The first 3 months after the onset of an MDE and the first 5 years after the lifetime onset of major depressive disorder represented the highest-risk period for attempted suicide, independent of the severity or duration of depression. Familial, genetic, early-life loss experiences and comorbid alcoholism may be causal factors.

Selective effects of antipsychotic medications on eye-tracking performance in schizophrenia

The potential impact of antipsychotic medications on eye-tracking impairments in schizophrenia has received little systematic attention. To address this issue, eye-tracking performance was studied in 19 neuroleptic-naive schizophrenic patients, 22 previously medicated schizophrenic patients who had not received antipsychotic drugs for at least 28 days, and 52 nonpsychiatric control subjects. Impairments were similar but generally more severe in previously treated than in neuroleptic-naive patients. An attention-facilitation manipulation improved eye-tracking performance in all groups. Ten neuroleptic-naive and 14 previously treated cases were retested after at least 3 weeks of treatment with antipsychotic medication. Short-term treatment with neuroleptics improved certain attention-related aspects of eye tracking involving saccadic eye movements such as anticipatory saccades, but it did not alter pursuit eye movements.

A multisite investigation of the reliability of the Scale for the Assessment of Negative Symptoms

OBJECTIVE

The Scale for the Assessment of Negative Symptoms is a widely used instrument for measuring negative symptoms in schizophrenia, but few studies have examined its reliability. This study examined the interrater, internal, and test-retest reliabilities of the scale and its factor structure in the context of a multisite study.

METHOD

Two hundred seven patients with schizophrenia who were participating in the Treatment Strategies in Schizophrenia study were assessed with the Scale for the Assessment of Negative Symptoms following a symptom exacerbation and again 3-6 months later. All assessments were performed by trained psychiatrists who were treating the patients.

RESULTS

Interrater reliabilities ranged from low to high for the items on the Scale for the Assessment of Negative Symptoms but were statistically significant in most cases. Most correlations between individual items and subscale total scores were moderate to high, as were coefficient alphas for each subscale, indicating adequate internal consistency. Test-retest correlations were of moderate magnitude. Few differences in reliability statistics between sites were found, although differences in mean scale ratings between sites were present. A factor analysis indicated three factors corresponding to the Affective Flattening or Blunting subscale, the Avolition-Apathy and Anhedonia-Asociality subscales, and the Alogia and Inattention subscales.

CONCLUSIONS

The results suggest that the Scale for the Assessment of Negative Symptoms has good reliability and is a useful instrument for the measurement of negative symptoms in multisite clinical studies. The internal reliability of the Alogia, Avolition-Apathy, and Inattention subscales could be improved by replacing some items and including additional items.

Eye tracking dysfunction in schizophrenia: characterization of component eye movement abnormalities, diagnostic specificity, and the role of attention

To characterize oculomotor components and diagnostic specificity of eye tracking abnormalities in schizophrenia, we examined a large consecutively admitted series of psychotic patients and matched controls. The most common abnormality in schizophrenic patients was low gain (slow) pursuit eye movements (47% of cases). Pursuit and saccadic eye movement abnormalities were no more severe in schizophrenic Ss than in those with affective psychoses, except that high rates of catch-up saccades were unique to schizophrenic Ss (17% of cases). These findings indicate that impaired pursuit eye movements are a major cause of eye tracking impairments in schizophrenia, that tracking dysfunctions commonly occur in affective psychoses, and that markedly high rates of catch-up saccades during eye tracking may be specific to schizophrenia.

Eye tracking dysfunction in schizophrenia: characterization of component eye movement abnormalities, diagnostic specificity, and the role of attention

To characterize oculomotor components and diagnostic specificity of eye tracking abnormalities in schizophrenia, we examined a large consecutively admitted series of psychotic patients and matched controls. The most common abnormality in schizophrenic patients was low gain (slow) pursuit eye movements (47% of cases). Pursuit and saccadic eye movement abnormalities were no more severe in schizophrenic Ss than in those with affective psychoses, except that high rates of catch-up saccades were unique to schizophrenic Ss (17% of cases). These findings indicate that impaired pursuit eye movements are a major cause of eye tracking impairments in schizophrenia, that tracking dysfunctions commonly occur in affective psychoses, and that markedly high rates of catch-up saccades during eye tracking may be specific to schizophrenia.

Clinical significance of inpatient family intervention: conclusions from a clinical trial

OBJECTIVE

To test whether the statistically significant results of a randomized clinical trial of an inpatient family intervention were clinically significant for hospital practice, the authors reanalyzed outcome data using a measure of clinical significance based on the extent to which patients had recovered during the course of the intervention.

METHODS

A total of 169 hospitalized subjects and their families were randomly assigned to a psychoeducational inpatient family intervention or to a comparison group. Patient and family outcome measures were assessed at admission, discharge, and six and 18 months after admission. Analyses of statistically significant differences in outcome suggested that inpatient family intervention was effective for certain patient subgroups identified by gender and diagnosis. Global Assessment Scale scores two or more standard deviations above the pretreatment (admission) mean were used as indicators for clinically significant improvement.

RESULTS

The reanalysis confirmed that inpatient family intervention was associated with clinically significant improvement at discharge, especially for female patients and patients with chronic schizophrenia and bipolar disorder. These effects were maintained six months after admission before attenuating at 18 months.

CONCLUSIONS

Inpatient family intervention results in clinically meaningful outcomes for certain subgroups of patients and their families.

Mixture analysis of pursuit eye-tracking dysfunction in schizophrenia

Results of two recent studies suggest that a distinct subgroup of schizophrenic patients and their relatives have particularly deviant eye tracking. Such heterogeneity could be of considerable importance, as it may indicate significant pathophysiologic or etiologic heterogeneity in schizophrenia. An analysis of 101 consecutive-admission schizophrenic patients confirmed the existence of two distinct subgroups of patients with higher and lower levels of spatial [root mean square (RMS)] eye-tracking error. However, there was no heterogeneity in the disturbance of pursuit eye movements. Anticipatory saccades, which by definition add very large amounts of spatial tracking error, were more frequent in the "high" RMS error group. Rates of anticipatory saccades were similar in the "low" RMS error patient group and normal controls, and there was no heterogeneity in the expression of anticipatory saccades. Apparent heterogeneity in global indices of eye-tracking impairment in schizophrenia appears to be a measurement artifact reflecting the powerful influence of anticipatory saccades on global performance indices, rather than true heterogeneity in the expression of any specific eye movement abnormality.

Factor composition of the Suicide Intent Scale

An exploratory analysis of the Suicide Intent Scale was performed on a sample of 98 psychiatric inpatients who had made suicide attempts. The factor analysis was performed using a method for polychotomous data, and resulted in a two-factor solution. The Lethal Intent factor contained items pertaining to the subjective level of lethal intent, while the Planning factor contained items largely related to objective planning for the attempt. Preliminary analysis of these factors suggest that the Suicide Intent Scale can be used to evaluate two separate aspects of suicidal behavior.

Clinical correlates of cerebral ventricular enlargement in schizophrenia. Further evidence for frontal lobe disease

Numerous studies have shown evidence of cerebral ventricular enlargement in schizophrenia and its relationship to severity of clinical symptoms and psychosocial dysfunction. In this large prospective study, 88 noninstitutionalized DSM-III-R schizophrenic patients were administered a CT scan and rated for positive and negative symptomatology and premorbid adjustment. The CT scans from 14 healthy controls were used for comparison of cerebral ventricular measures. Patients had an enlarged ventricle to brain ratio of the anterior portion of the lateral ventricles, the frontal horns, compared with controls. Patients with larger frontal horns had more severe negative symptoms and poorer premorbid childhood adjustment. The area of the main body of the cerebral lateral ventricles, though not elevated in patients, was correlated with the total number of prior hospitalizations. These results support the hypothesis of a structural and functional "frontal" deficit in schizophrenia.

Bizarre delusions and DSM-III-R schizophrenia

OBJECTIVE

Bizarre delusions are assigned greater weight relative to other delusions in the DSM-III-R diagnosis of schizophrenia. The decision to emphasize bizarre delusions was based largely on historical tradition rather than empirical evidence. This study examined 1) the extent to which a history of bizarre delusions contributes to the diagnosis of schizophrenia and 2) whether schizophrenic patients with bizarre delusions constitute a clinically distinguishable subgroup.

METHOD

Two hundred fourteen consecutively admitted psychotic inpatients were assessed for bizarre delusions according to the DSM-III-R criteria. Clinical and demographic correlates of bizarre delusions were examined in subsets of patients diagnosed as schizophrenic according to DSM-III-R who also received CT scans and neuropsychological testing.

RESULTS

With the base prevalence rate for schizophrenia of 0.71, bizarre delusions had a sensitivity of 0.79, a specificity of 0.56, and a positive predictive power of 0.82 for the diagnosis of schizophrenia (N = 152) relative to other psychotic disorders (N = 62). Clinical, neurobehavioral, CT scan, and premorbid adjustment data on the schizophrenic patients indicated that beyond manifesting more severe positive symptoms, patients with bizarre delusions did not otherwise constitute a clinically distinguishable subgroup.

CONCLUSIONS

The data suggest that criterion A for the diagnosis of schizophrenia in DSM-IV could be improved by removing the special emphasis that was placed on bizarre delusions in DSM-III-R.

Premorbid and onset features of first-episode schizophrenia

Most descriptive studies of the psychopathology of schizophrenia have focused on the period following illness onset. Little attention has been paid to the assessment of psychopathology before onset of psychotic symptoms. In this study, 71 first-hospitalization patients diagnosed with schizophrenia, schizoaffective, or schizophreniform disorder using DSM-III-R criteria were assessed on measures of premorbid adjustment, clinical history, and presenting symptomatology. A pattern of progressive decline was characteristic of 21 percent of the cases--primarily males with a long-term history of psychotic symptoms before first hospitalization and a trend for more severe negative symptoms at hospital admission. Patients who had a stable pattern of good premorbid adjustment experienced symptom onset and first hospitalization at a later age than those with a chronically poor premorbid adjustment. Time from onset of first psychotic symptom to first hospitalization varied from less than 1 month to over 20 years and was not associated with symptom severity or age of first psychotic symptoms. Systematic characterization of the earliest manifestations of schizophrenia may be important in identifying subgroups of patients with a similar course of illness, and may ultimately facilitate diagnosis, treatment, and understanding of the pathophysiology of schizophrenia.

Neuropsychological and eye movement abnormalities in first-episode and chronic schizophrenia

It is well known that neurobehavioral deficits are associated with schizophrenia. Little is known, however, about whether these disturbances becomes more severe over the course of the illness. In the present study, 101 patients with schizophrenia, of whom 45 were first-episode cases, performed pursuit eye tracking tasks. A subset of 60 of these patients, including 27 first-episode cases, were administered a battery of neuropsychological tests. Patients with a history of prior psychotic episodes demonstrated more severe pursuit eye movement dysfunction than first-episode patients and more severe disturbances on neuropsychological tests sensitive to prefrontal and left temporal cortical dysfunction. Longitudinal studies of patients ascertained close to the point of illness onset are needed to determine whether these findings reflect a progressive deterioration in neurobehavioral functioning over the course of schizophrenia.

Evaluation of the stability of neuropsychological functioning after acute episodes of schizophrenia: one-year followup study

Few studies have evaluated the longitudinal stability of neuropsychological deficits in schizophrenia. In the present study, 39 inpatients with DSM-III-R schizophrenia were administered a comprehensive battery of neuropsychological tests after achieving sufficient clinical recovery to warrant discharge, and again 1 year after the first assessment during a nonacute period. Significant improvement in neuropsychological functioning from the first to the second assessment was observed on several tasks, including the following: Trails A and B, Digit Symbol, Judgment of Line Orientation, recognition memory on the Rey Auditory Verbal Learning Test, the Wisconsin Card Sort, and Finger Tapping. These improvements were unrelated to treatment history, and were similar in first episode and chronic cases. For many patients, the improvement in functioning brought test performance into line with normative scores from test standardization samples. These results indicate that considerable improvement in neuropsychological functioning can occur in schizophrenic patients over the months following an acute episode of illness, and that recovery of cognitive functioning can occur after substantial clinical recovery from an acute episode of illness has already been achieved.

Relationships between medication treatments and neuropsychological test performance in schizophrenia

Few investigations have assessed the neuropsychological effects of psychotropic medications on schizophrenic patients. In this study, 44 clinically stable schizophrenic inpatients were administered a battery of neuropsychological tests, and their performance was correlated with dosage of neuroleptic medication and benztropine. Neuroleptic dose was correlated with poorer performance on tests of psychomotor speed and attention, and with the number of perserverative errors on the Wisconsin Card Sort. Anticholinergic dose was associated with poorer verbal learning, verbal fluency, and motor speed. Both medication dosages were associated with poorer verbal recognition memory, but this association was strongly influenced by the performance of individuals on the highest medication doses. The findings, which were independent of clinical state and intelligence, indicate that higher doses of neuroleptic and anticholinergic medications are associated with poorer neuropsychological functioning in schizophrenia.

Substance use in borderline personality disorder

The authors investigated the prevalence of substance abuse in 137 inpatients with DSM-III borderline personality disorder. Ninety-two (67%) of these patients were given DSM-III substance use disorder diagnosis. The most frequently used substances were alcohol and sedative-hypnotics. When substance abuse was not used as a diagnostic criterion for borderline personality disorder, 32 (23%) of the 137 patients no longer met borderline criteria. These patients differed significantly from the rest of the patients in severity and course of illness. These data suggest that there might be a subgroup of borderline patients for whom substance use plays a primary role in the development of borderline psychopathology.

A randomized clinical trial of inpatient family intervention. IV. Followup results for subjects with schizophrenia

This is the last of a series of four papers, here focussing on schizophrenia, which report followup data up to 18 months from a randomized clinical trial of a psychoeducational family intervention (IFI), which was added to medication and limited to the inpatient phase of treatment, after which post-hospital care was not controlled. Our data suggested that patients with poor prehospital functioning (i.e., the chronic patients) may benefit from inpatient family intervention, but this therapeutic effect appears to be limited to females and does not appear until 18 months postadmission. Families of patients with schizophrenia also show benefit from having received IFI, the effect is seen earlier than with the patients, and is associated with achieving the goals of IFI. The results in the IFI group could not be accounted for by improved post-hospital medication compliance, but they may be related to this group's greater tendency to obtain further family treatment after discharge.

A randomized clinical trial of inpatient family intervention. V. Results for affective disorders

This paper reports the results at follow-up of a randomized clinical trial of combining family intervention with drug treatment during hospitalization for patients with affective disorder. The results suggest that female bipolar patients and their families benefited from family intervention, whereas unipolar patients and families did not. Patient outcome was positively correlated with the achievement of the goals of family intervention.

Gender and schizophrenia outcome: a clinical trial of an inpatient family intervention

Several studies document sex differences in premorbid and intermorbid role functioning, showing less functional deficit among females. The specific nature of sex differences in role functioning is still poorly understood. The purpose of the present study was to investigate sex differences in symptomatology and role functioning in a sample of 92 inpatients hospitalized for an episode of DSM-III-diagnosed schizophrenic disorder. Patients were randomized at hospital admission to either of two treatment conditions: (1) multimodal hospital treatment with the addition of an inpatient family intervention (IFI) or (2) multimodal hospital treatment without IFI. Results indicated (1) sex differences in levels of substance abuse and antisocial behavior (worse for males both at admission and followup)--dimensions of psychopathology unrelated to the core features of schizophrenia; (2) superior family and occupational functioning in females at followup; and (3) superior clinical response of females to IFI. Data on family response to IFI suggest some ameliorative effects of IFI on critical family attitudes toward female patients as well as greater family compliance with IFI treatment among the families of females. Sex differences in intermorbid family and occupational functioning and response to a family-based psychosocial intervention are discussed in light of data on rejecting family attitudes toward the patient and sex differences in symptomatology. The possible influence of sex-differentiated social role demands on response to IFI is also discussed.

A randomized clinical trial of inpatient family intervention, III: Effects at 6-month and 18-month follow-ups

This paper focuses on the follow-up results of a randomized clinical trial of inpatient family intervention (IFI) that emphasized psychoeducation. Results for the sample of 169 psychiatric patients suggested that adding family treatment to standard hospital treatment was effective; however, the statistical interactions indicated that this therapeutic effect was restricted to female patients with schizophrenia or major affective disorder. The effect of family treatment on male patients with these diagnoses was minimal or slightly negative. In a group of patients with other diagnoses, the Treatment by Sex effect was reversed: male patients did better with the family treatment.

Inpatient family intervention: a randomized clinical trial. II. Results at hospital discharge

Although family intervention is practiced in most psychiatric hospitals, to our knowledge, no adequately controlled studies of its efficacy exist. This study was designed to answer, in part, the question of the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients (1) with major psychiatric disorders, (2) in need of hospital treatment, and (3) for whom both treatments are judged clinically feasible. This article compares treatment results at the time of hospital discharge for 169 patients randomly assigned to the inpatient Family Intervention or comparison conditions. Inpatient Family Intervention had greater efficacy than the comparison treatment, mostly attributable to its effect on female patients, especially those patients (and their families) with affective disorder.

Goal Attainment Scaling. Relevance and replicability in follow-up of inpatients

First proposed by Kiresuk in 1968, Goal Attainment Scaling has been widely and enthusiastically accepted as an evaluation tool in service delivery and education. However, it has not been much used in controlled research, probably because its reliability and validity have been questioned by critics. The authors have used Goal Attainment Scaling as one of a number of outcome measures in a research project on the effect of family intervention on inpatients. In the course of doing so, they have developed guidelines for gathering information, constructing goal scales, selecting expected outcome levels, and categorizing subsequent outcome data. They believe that these guidelines have clinical integrity and that their use would improve the reliability of goal attainment scaling without detracting from its value as an individualized measure. With these modifications, Goal Attainment Scaling can be made more systematic and therefore more reliable without losing its intrinsic value as an individually targeted outcome measure.

A controlled evaluation of inpatient family intervention. I. Preliminary results of the six-month follow-up

Although family intervention is practiced in most psychiatric hospitals, there are no adequately controlled studies of its efficacy. This study was designed to answer, in part, the following question: What is the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients with major psychiatric disorders who are in need of hospital treatment and for whom both treatments are judged clinically feasible? This is our first report, presenting preliminary data on six-month follow-up for the first three quarters of the total sample of 144 patients (80 with schizophrenic disorder and 64 with major affective disorder).