Passive and active schizophrenia: toward a new descriptive micropsychopathology

The "experiences" reported by individuals affected by schizophrenia are fundamental components of the descriptive approach adopted by current diagnostic systems for mental disorders and by clinical diagnostic interviews and rating scales for the assessment of the symptoms of schizophrenia. However, the technical literature does not rely on a specific definition of experiences in schizophrenia. This article introduces a specific, restrictive, operationalized definition of the "experiential substrate" of schizophrenia, defined by the "self-giving" "passive experiences" of the disorder that break into the consciousness of the affected individual, and are distinguished from the "active" acts of judgment formulation and conviction/belief attainment. The experiential substrate of schizophrenia may be considered similar to the experiential substrate of pain. The operationalization of the definition of passive experiences can enable the experiential substrate of schizophrenia to be acknowledged as an independent domain with a specific role in the assessment of the disorder, a role that is substantially omitted or ignored by current research and practice. The term "descriptive micropsychopathology" is proposed for this new method aimed to describe passive experiences and active judgments as independent domains to enhance the reformulation of criteria for symptom assessment and, consequently, reformulation of the criteria for the assessment of the efficacy and effectiveness of interventions aimed at prevention, care, and rehabilitation in schizophrenia. A new measure focusing on the evaluation of the passive experiences of schizophrenia and on the disturbance they cause to patients is also described.

Assertive community treatment in the Netherlands: a randomized controlled trial

OBJECTIVE

Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services.

METHOD

Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59).

PRIMARY OUTCOME

sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756.

RESULTS

Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found.

CONCLUSION

The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.

The application of civil commitment law and practices to a case of delusional disorder: a cross-national comparison of legal approaches in the United States and the United Kingdom

Legal approaches to civil commitment in the United States and the United Kingdom are compared. A concise overview of the historical evolution of civil commitment in both countries precedes a discussion of the present scheme of commitment standards in each system. These current standards in U.S. and U.K. jurisdictions are then applied to a hypothetical case of delusional disorder. A discussion of the constructive use of civil commitment in patients with delusional disorder who may be dangerous focuses on its value as a preventive measure against potential harm to self or others, as well as the pros and cons of coercive assessment and treatment. Despite the many differences in approach to commitment, the authors concur that in both countries the patient with delusional disorder was committable before the commission of a serious criminal offense.

Psychopathology and outcome of first-admission schizophrenic patients: hypochondriac-cenestopathic symptoms as predictors of an unfavorable outcome

The outcome of first-admission schizophrenic patients at Jichi Medical School Hospital was investigated to identify outcome predictors of schizophrenia among the symptoms at the time of the first hospitalization. The subjects were 62 schizophrenic patients, 29 females and 33 males, consecutively discharged from the Department of Psychiatry, Jichi Medical School Hospital, between June 1983 and May 1988. The mean interval between first admission and follow-up was 13 years. Eguma's Social Adjustment Scale was used to measure social outcome. The subjects were divided into two groups according to their rating on Eguma's Scale; a favorable outcome group and an unfavorable outcome group. Information on premorbid status and psychopathology at the time of the first hospitalization was obtained from clinical records and analyzed by comparing them between the two groups. Of the 62 patients, 56 were followed-up. Nine of the 56 patients followed-up had died. While 47 patients were alive; 39 were receiving psychiatric treatment and eight were not. The 47 patients who were still living were divided into two groups; a favorable outcome group (n = 22), and an unfavorable outcome group (n = 25). No significant differences in premorbid status were found. Comparison of psychopathology at the time of the first hospitalization between the outcome groups revealed significant differences in lack of spontaneity and hypochondriac-cenestopathic symptoms. Lack of spontaneity may reflect negative symptomatology, while hypochondriac-cenestopathic symptoms may reflect a serious disturbance of ego function. There is a strong possibility that evaluation of body-related symptoms in schizophrenia will be helpful in predicting outcome.

Effect of voluntariness of participation in treatment on short-term outcome of inpatients with schizophrenia

OBJECTIVE

The purpose of this study was to examine associations between the voluntary or coercive nature of patients' participation in inpatient treatment and the short-term outcome of inpatient treatment for patients with schizophrenia.

METHODS

Eighty-eight adult patients with schizophrenia and delusional disorders who were consecutively admitted to a 320-bed psychiatric hospital in southern Germany over a three-month period in 2002 were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) at admission and discharge, a mean of 36.2 days later. The patients were grouped by whether their participation was voluntary or involuntary in each of five aspects of inpatient treatment: admission, hospital stay, medication, discharge, and intention to continue treatment after discharge. Outcome was defined as the change between admission and discharge in scores on the PANSS and the GAF and change in those scores per inpatient day.

RESULTS

The outcome measures were not significantly related to the voluntariness of patients' participation in any aspect of treatment.

CONCLUSIONS

The short-term outcome of inpatient treatment is independent of whether treatment is voluntary.

The Effect of a Structured Intervention on Caregivers of Patients With Dementia and Problem Behaviors

The objective was to assess the effect of a structured intervention on caregiver stress and the institutionalization rate of patients with dementia and problem behaviors. Caregivers contacting the Federazione Alzheimer Italia (AI) to receive help, advice, or information in relation to problem behaviors of outpatients were enrolled. Eligible caregiver-patient dyads were randomized to receive either a structured intervention or the counseling AI usually provides (control group). After basal assessment, families were reassessed at 6 and 12 months. Problem behavior (particularly agitation) was the only variable significantly correlated (P = 0.006) with the baseline caregivers' stress score. Thirty-nine families completed the 12-month follow-up; the mean problem behavior score was significantly lower in the intervention than the control group (p < 0.03); the time needed for care of the patient increased by 0.5 +/- 9.7 hours/day in the control group and decreased by 0.3 +/- 4.1 in the intervention group (p = 0.4, Wilcoxon test). The main determinant of institutionalization seemed to be the level of caregiver stress (p = 0.03). In patients of the intervention group, there was a significant reduction in the frequency of delusions. This pilot study suggests that caregiver stress is relieved by a structured intervention. The number of families lost to follow-up, the relatively short duration of the study, and the ceiling effect due to the severity of the clinical characteristics of patients probably all partly dilute the observed findings.

Associations between psychotic symptoms and dependence in activities of daily living among older adults with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is associated with dependence in activities of daily living (ADL). In addition to the cognitive impairment resulting from AD, the presence of psychotic symptoms may further increase this dependence. The objective of this study was to quantify the additional contribution of psychotic symptoms to dependence in ADL.

METHOD

We analyzed data from 558 individuals with AD referred to a memory clinic. Information on ADL, psychotic symptoms, depression symptoms, and cognition was collected with standardized instruments.

RESULTS

The frequency of psychotic symptoms was correlated with dependence in ADL (r = -.44, p < .001). The independent contribution of psychotic symptoms to ADL (basic and instrumental) after consideration for cognitive impairment and depression symptoms was assessed with hierarchical regression models. Twenty-five percent of basic ADL variance was explained by cognition; psychotic symptoms accounted for an additional 7% of the variance (b = -0.12, p < .001). Cognitive impairment explained 31% of instrumental ADL variance; psychotic symptoms accounted for an additional 6% (b = -0.21, p < .001).

DISCUSSION

Psychotic symptoms are associated with dependence in ADL after controlling for cognitive impairment and depression symptoms. Future research should investigate possible causal linkages between psychotic symptoms and dependence in ADL. This may have implications regarding interventions to maintain independent living in people with AD.

[Homicide on first day after commitment to the closed ward of psychiatric clinic--report of a successful rehabilitation against all odds]

The Swiss penal code provides quite a sophisticated system of rules concerning the assessment and management of mentally ill offenders--there is, however, a substantial lack of treatment places. This means a challenge for hospitals of general psychiatry if these patients should not be referred to common law prisons. We report of a young man who killed another patient on the day of his referral to a psychiatric clinic. The treatment and his rehabilitation was performed successfully in a clinic of general psychiatry--in spite of the scepticism of the legal authorities.

[Autocastration of a young schizophrenic man]

OBJECTIVE

Self-mutilation of the genitals in man is a rare phenomenon mainly occurring in young males. The importance of conflicts about the male role, difficulties with the male identification in childhood and feeling of guilt for sexual offences are discussed in the literature. The influence of developmental crisis on this symbolic form of automutilation will be discussed in our case report.

METHOD

We present a case of a young schizophrenic man whose illness started in adolescence. He committed genital automutilation already in early adolescence, as a young male he autocastrated himself.

DISCUSSION

We demonstrate the connection of specific problems of development in adolescence and psychopathology. Autocastration will be discussed as a "psychotic" solution of the adolescent conflict of dependence.

CONCLUSIONS

Developmental conflicts may be important pathoplastic factors who may lead to severe psychopathology and misbehavior. Additionally to a psychopharmacological treatment a specific adolescent- and conflictoriented psychotherapy for solving the developmental conflicts in young schizophrenic patients should be established.

[Olfactory delusional syndrome and alcoholism]

The olfactory delusional syndrome belongs to the rare delusional diseases. It is characterized by the persuasion of bothering other people by sending out an odour. This case report is about a 52 year old male suffering of alcoholism in addition. Aspects of this special comorbidity are discussed. Neuroleptic treatment with Risperidone led to a partial remission of the delusional syndrome.

Delusions in first-admitted patients: gender, themes and diagnoses

Whether there is a specific link between certain delusional symptoms and particular etiologies has not yet been completely clarified. In this study, 639 first ever admitted deluded patients were investigated in order to find out whether age and gender are associated with certain delusional contents, whether age at first admission may be linked to certain etiologies and whether it is possible to detect indicators particularly related to basic dysfunctions. At first admission, delusional female patients were older than men with a significant predomination of delusions of persecution, while men presented significantly more frequently delusions of jealousy and grandiosity. Within delusions of persecution, of religious or metaphysical content and of grandiosity, women were even significantly older than men. Religious or metaphysical and grandiosity contents occurred significantly more frequently in ICD-8 schizophrenia, indicating that these themes seem to be particularly linked to ICD-8 schizophrenia. Additionally, some target symptoms not included in the delusional symptomatology were investigated to test the relationship between delusions and schizophrenia. Overall, the results of the present investigation indicate that delusions are not specific for schizophrenia, and therefore, other symptomatological criteria should be applied for the nosographic attribution.

Clinical predictors of discrepancy between self-ratings and examiner ratings for negative symptoms

Little is known about the awareness of negative symptoms or its correlates. The aim of this study was to examine whether a number of clinical variables can predict the discrepancy between ratings of negative symptoms made by schizophrenic patients and by an examiner. This discrepancy could provide a measure for the awareness of negative symptoms. Eighty-six schizophrenic patients used a self-rating scale for negative symptoms with items derived from the Scale for the Assessment of Negative Symptoms (SANS). A psychiatrist assessed all patients using the SANS and other instruments, including the Present State Examination (PSE) item "insight into psychotic condition." Nurses assessed all patients using the Rehabilitation Evaluation Hall and Baker (REHAB), a scale for the measurement of psychiatric disability. All measurements were repeated after 2 months. A sensitive index for the underestimation of the severity of negative symptoms was developed, the discrepancy score. Multiple regression analysis was used to examine the predictability of discrepancy scores. Since scores for SANS items were used to calculate discrepancy scores, all regression analyses were performed with the SANS summary score as a covariate. The first step was to assess the independent contribution of each variable to the prediction of discrepancy scores. The second step was to examine the predictive quality of the 19 variables together. The variables themselves failed to make an independent contribution to the prediction of discrepancy scores at both assessments. REHAB scores, for instance, contributed to the prediction of discrepancy scores at the first assessment, but not at the second. The results of the second step showed that the best model for the prediction of discrepancy scores included the variables of depression (negative association) and anxiety (positive association). The absence of an association with the PSE item suggests that the awareness of negative symptoms is not related to insight into positive symptoms. An important limitation of our study is the arbitrary method of discrepancy quantification.

Reverse Othello syndrome subsequent to traumatic brain injury

Delusional syndromes that occur following head injury are frequently ascribed directly to the consequences of organic insult and seen as empty of psychological significance. The presence of an organic factor, however, does not necessarily indicate that delusional ideation is a direct product of that factor. In this article a detailed report is given of Reverse Othello syndrome (a delusional belief in the fidelity of a romantic partner) appearing in a 49-year-old male following extremely severe traumatic brain injury. This case report highlights the interaction and interpenetration of a complex array of biological, psychological, and social factors in the crystallization of a delusion system. It is argued, following Jaspers, that the emergence of erotically themed delusions following trauma may represent an active attempt to regain intrapsychic coherence and to confer meaning on otherwise catastrophic loss or emptiness.

Internal consistency, temporal stability and neuropsychological correlates of three cognitive components of the Positive and Negative Syndrome Scale (PANSS)

Comprehensive models of schizophrenia have increasingly included symptoms of cognitive dysfunction as an important feature of schizophrenia. Factor analytic studies of the Positive and Negative Syndrome Scale (PANSS) have consistently established cognitively disorganized symptoms as a separate domain from positive and negative symptoms. However, the individual symptom composition of the cognitive domain varies from model to model. The present study explores the temporal stability, internal consistency, concurrent validity, and discriminant validity for three published PANSS factor analytically derived cognitive components (Bell et al., 1994a, Psychiatry Res., 52, 295-303; Dollfus et al., 1991. Eur. Psychiatry, 6, 251-259; Kay and Sevy, 1990. Schizophr. Bull., 16, 537-544). Analyses were conducted using PANSS data from 120 patients with DSM-IV diagnoses of schizophrenia or schizoaffective disorder. Results indicate that the Bell et al. and Kay and Sevy models have similar psychometric properties including adequate temporal stability, internal consistency, and discriminant validity. The Kay model demonstrated somewhat better concurrent validity with cognitive test measures, while the Dollfus model demonstrated relatively poor psychometrics. The symptom composition of a narrowly defined cognitively disorganized subtype and a more broadly defined cognitively impaired subtype are discussed in terms of their value for schizophrenia research.

Lack of insight among outpatients with schizophrenia

OBJECTIVE

This study investigated the prevalence of lack of insight among outpatients with schizophrenia and the relationship between lack of insight and other variables, including whether patients received professional residential supervision.

METHODS

A total of 87 stable outpatients with schizophrenia were drawn from community programs in a public-private mental health system. Subjects' clinical symptoms and insight about their illness were assessed using the Positive and Negative Syndrome Scale, a battery of neuropsychological tests, and the Social Functioning Scale.

RESULTS

The illness insight of 43 subjects, or 49.5 percent, was at least moderately impaired. Twenty-one subjects, or 25 percent, had severe insight deficits. In a multiple regression analysis, 40 percent of the variance in lack of insight was predicted by ratings of the severity of delusions, difficulty with abstract thinking, lack of social activities, and absence of anxiety. Patients who received professional residential supervision had more impaired insight than those living independently or with family.

CONCLUSIONS

Insight deficits are common among stable outpatients engaged in community-based care. These deficits have implications for patients' use of limited services such as residential supervision.

[Description of a case of Cotard's syndrome]

The authors report the case of a male 61-year-old patient with Cotard's syndrome. Onset occurred three years ago with depressive symptoms that did not show the specific features of the syndrome, but failed to respond fully to treatment with tricyclic antidepressants. A probable later recurrence was characterised by elements typical of Cotard's syndrome. Treatment with tricyclic and serotoninergic antidepressants was ineffective. Encephalic NMR showed multiple ischemic foci and signs of cortical atrophy. Three years after the onset of depressive symptoms Cotard's syndrome is virtually unchanged and shows ingravescent mental deterioration.

Work and meaning: disturbance of volition and vocational dysfunction in schizophrenia

R. is a 40-year-old, divorced, White male with a diagnosis of schizophrenia, paranoid type, chronic. Shortly after his entrance into our work rehabilitation program, R. engaged one of the authors (P.L.) in a conversation about the nature of his illness. He reported that his most disabling and pervasive symptom was a persistent inability to pursue any goal in his life. R. recognized that he had other symptoms of psychiatric illness but stated that these did not account for his disability. He explained that the voice of God that counseled him when he felt overwhelmed and his fear that God was about to kill him as punishment for his sins put life in perspective and, consequently, were sometimes as comforting as they were distressing. R. explained that what had altered his life was a process, invisible to others, that left him unable to plan out and pursue a life course. He did not know whether it was a lack of knowledge or lack of motivation and energy that left him without the inner direction he needed. All he knew was that it was "schizophrenia," and it left him unable to work or to function like other people. What R. was describing as the foundation of his illness and his disability appears to be a disturbance of volition. Interestingly, self-understanding is more consistent with several of the early formulations of schizophrenia than it is with current formulations. To explore the merits of R.'s belief about his illness we offer a review of the role that disturbance of volition has played in historical conceptualizations of schizophrenia, the current nosology, and in theories of the negative or deficit syndrome. The history of R.'s illness is then presented. Lastly, we discuss what we learned from R.'s participation in a paid work program.

Morbid jealousy in alcoholism

BACKGROUND

Morbid jealousy is an incompletely understood syndrome. The association between morbid jealousy and alcoholism is unclear.

METHOD

Morbid jealousy was assessed in 207 male patients with alcohol dependence (DSM-III-R) using a semi-structured interview schedule administered both to patients and their spouses.

RESULTS

Thirty-four per cent (71 out of 207) suffered from morbid jealousy. Morbid jealousy had different manifestations. Some patients expressed it only when intoxicated, others even when sober and in some the jealousy took the form of a delusional disorder.

CONCLUSIONS

Alcoholism appears to have an aetiological role in the development of morbid jealousy. Detecting morbid jealousy when it is expressed only under the influence of alcohol has preventive implications.

A behavioral nosology for tinnitus

Studies of the physiological and psychological characteristics of tinnitus and its treatment have yielded a variety of conclusions. The variation in results may reflect heterogeneous patient populations. Although the sources of variation are many, one may be derived from combining patients of several severities of tinnitus into a single group. A nosology is proposed for tinnitus severity to be classified by the patient's behavioral responses. Classifying patients allows direction to specific treatment modalities and will facilitate research. The concept of phantom auditory pain and a rational basis for the use of antidepressant therapy are discussed.

Stability trends and longitudinal correlations of negative and positive syndromes within a three-year follow-up of initially hospitalized schizophrenics

Our study investigates whether the distinction between positive and negative symptoms in schizophrenia--as discussed in the literature--can be confirmed by a factor analysis and whether such a distinction proves stability over time. In a further step, symptom factors are correlated to different external variables for the purpose of validation. Processed data cover 36 months obtained from a prospective 5-year follow-up study of 163 initially hospitalized schizophrenics. The results permit for dividing the symptoms into a total of five factors--two representing positive and negative symptoms and one representing the general neurotic syndrome. This factor structure proved to be stable over time. Correlations between symptom factors and external variables justify a trait-interpretation of the negative factor anhedonia.

Cognitive behavioural therapy for drug-resistant psychosis

A small controlled trial of cognitive behaviour therapy for drug-resistant psychosis is reported. The study was designed as a pilot study for a future larger and longer randomized controlled trial. The therapy was offered to patients with a diagnosis of schizophrenia or schizo-affective psychosis who presented unremitting positive symptoms. An average of 16 sessions were delivered over a six-month period. The results of this pilot study are promising. Rates of engagement in therapy were high. The treatment group also improved significantly on a number of key symptom measures when compared with the controls. These were reductions in delusional conviction, general symptomatology and depression scores. Future studies should offer therapy over a longer period, targeting social as well as symptom change, and considering factors which will enhance maintenance of improvement.

Prognostic value of initial subtype in schizophrenic disorders

The prognostic value of the subtype diagnosis at the initial episode was investigated in 148 narrowly defined schizophrenic patients. Every initial episode was classified according to multiple criteria: DSM-III-R, ICD-10, the positive/negative dichotomy, and Schneider's first rank symptoms. Patients were followed up on average 23 years later (range 10-50 years). Different aspects of long-term outcome were evaluated (global functioning, social adjustment, negative social consequences). In 93% of the patients persisting alterations were found at the end of the observation time. The influence of the predominant clinical features at the initial episode on various aspects of long-term outcome was found to differ depending on which of the four diagnostic systems was used. The highest power for discrimination was found for the subtypes of DSM-III-R, while the presence of first rank symptoms had no prognostic value. It was found that patients with an initial paranoid or positive episode had a significantly better long-term outcome than patients initially having a disorganised/hebephrenic or catatonic episode. The frequency of negative social consequences was not influenced by the initial subtype, with the exception of permanent hospitalisation.

Characteristics of men with alcoholic hallucinosis

The goal of this study was to evaluate the characteristics of primary alcoholics with alcoholic hallucinosis. Six hundred and forty-three primary alcoholic men were recruited from a 28-day Alcohol and Drug Treatment Program at the San Diego VA Medical Center. Subjects only experiencing perceptual abnormalities during alcohol withdrawal, drug-related hallucinosis, as well as those having abnormal sensations that did not meet criteria for hallucinations were excluded from the present study. The remaining 532 subjects were divided into Group 1 (n = 48), which consisted of subjects with a DSM-IIIR and ICD-10 diagnosis of alcoholic hallucinosis, and Group 2 (n = 484) which consisted of those without any history of hallucinations. A comparison of the two groups revealed that Group 1 men were younger at the onset of alcohol problems, consumed more alcohol per occasion, developed more alcohol-related life problems, and had higher rates of drug experimentation as well as more different types of drugs used. This study suggests that primary alcoholics who consume more drugs and/or alcohol might be at an increased risk for developing alcoholic hallucinosis.

On the perception of madness

Since the beginning of recorded history, mental illness has been recognised as being primarily in the province of the healing profession. This view has continued, despite the fact that psychiatry left the mainstream of medicine with the development of asylums during the 19th century. With the advent of deinstitutionalization however, psychiatrists, particularly in Australia, have increasingly left public practice. As a result, the treatment of the severely and chronically mentally ill, especially those with behavioural disorder, has become neglected. It is argued that moves toward the mainstreaming of acute psychiatry to general hospitals offer a new opportunity for the profession to reassert itself in this essential but difficult area of psychiatric practice.

A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome

Despite neuroleptic medication, many schizophrenic patients continue to experience residual positive psychotic symptoms. These residual symptoms cause distress and disability. We report a controlled trial of two cognitive-behavioural treatments to alleviate residual hallucinations and delusions. Forty-nine patients were recruited into the trial, of whom 27 entered the trial and completed post-treatment assessment, and 23 were reassessed at six-month follow-up. Patients were randomly allocated to either coping strategy enhancement (CSE) or problem solving (PS). Half the patients were allocated to a high-expectancy positive demand condition and half to a counter-demand condition to evaluate expectation of improvement. Patients receiving either cognitive-behavioural treatment showed significant reductions in psychotic symptoms compared with those in the waiting period, who showed no improvement. There was some evidence, although equivocal, that patients receiving CSE improved more than those receiving PS. There was no evidence that improvements generalised to negative symptoms or social functioning, nor was there evidence that expectancy of treatment benefit contributed to the treatment effect.

Cannabis and psychotic illness

In-patients with psychotic symptoms and cannabis-positive urine analysis were assessed by PSE within one week of admission and again at one and six months. Concurrently admitted psychotic patients with drug-free urine analysis were controls. At one week the two groups differed significantly on only five PSE items: changed perception, thought insertion, non-verbal auditory hallucinations, delusions of control, and delusions of grandiose ability. One item (delayed sleep) differed at one month, and none at six months. The symptom cluster at one week is consistent with acute cannabis intoxication. Subjects and controls were mostly single, poorly educated, unemployed people with histories of psychotic disorders, and given major tranquillisers on admission. Compared with controls, subjects were younger, less likely to have psychiatric histories, more often male, Afro-Caribbeans with a history of convictions and compulsory admissions. The commonest diagnosis was schizophrenia. Use of the label 'cannabis-induced psychosis' may obscure a diagnosis of paranoid schizophrenia. A short-lived psychotic episode does occur in clear consciousness after cannabis intoxication, but chronic cannabis-induced psychosis was not found.

Patients on Warrants of the Lieutenant Governor in Alberta: a statistical summary with comments on treatment and release procedures

Files on all 48 Alberta patients under Warrants of the Lieutenant Governor were reviewed in late 1984, early 1985. Few were on Warrant as a result of unfitness to stand trial and all carried a primary diagnosis involving major mental disorder. More than half were considered paranoidal. Two-thirds of the population had killed someone or attempted to do so. Only eight had not previously been inpatients in psychiatric hospitals. Nearly half of the patients offended against relatives. Close to two-thirds had a previous criminal record. The Alberta Hospital's Forensic Service is described as is the province's Board of Review. Two brief case studies help portray the system of gradual release. The authors comment on the design of services for this group of patients known to be hard to treat and administer.

Effects of contingent social reinforcement with delusional chronic schizophrenic men

4 male, chronic schizophrenic inpatients were subjects in an experiment aimed at investigating whether contingent verbal reinforcement could decrease delusional verbalizations. The reinforcement connoted both approval and mild punishment, and two different schedules of reinforcement, fixed and variable ratios, were employed. A significant conditioning effect was observed, but neither fixed ratio nor variable ratio was successful in providing resistance to extinction. Results were discussed in the light of the immediacy hypothesis which suggests that immediate stimuli govern the behavior of schizophrenics.