A standardized psychiatric assessment scale for rating chronic psychotic patients

No evidence for left superior temporal dysfunction in asymptomatic schizophrenia and bipolar disorder. PET study of verbal fluency

BACKGROUND

Positron emission tomography (PET) studies have revealed functional left superior temporal gyrus (STG) abnormalities in symptomatic schizophrenia during word generation.

AIMS

To discover if this dysfunction is present in asymptomatic schizophrenia. To determine whether, without concurrent symptomatology, schizophrenia and bipolar affective disorder (BPD) are distinguishable by differing regional cerebral blood flow (rCBF) patterns during word generation.

METHOD

A PET verbal fluency protocol was applied to six patients with BPD in remission and six patients with asymptomatic schizophrenia. Analysis included 10 control subjects from a contemporaneous study.

RESULTS

All groups showed relative reduction of rCBF in both superior temporal cortices. There were no quantitative differences in any group comparison. All groups exhibited negative covariation between rCBF in left prefrontal and right (but not left) temporal regions.

CONCLUSIONS

Abnormal patterns of left STG function cannot be regarded as a trait marker for schizophrenia. Functional abnormalities may reflect aspects of mental state.

Hallucinations and delusions. 2: A dual diagnosis case study

This article, the second of two parts, describes how evidence-based psychological interventions were used to help a client suffering from treatment-resistant delusions and substance misuse, allied to a chaotic lifestyle, that had previously presented a substantial challenge to services. The first part (Vol 8(15): 998-1002) Investigated how the neurobiological, social and environmental factors involved in the course and treatment of schizophrenia have helped to establish a pathway to recovery or remission that does not involve pharmacological therapy alone.

Psychological methods of treating hallucinations and delusions: 1

This article, the first in a two-part series, describes how the neuro-biological, social and environmental factors involved in the course and treatment of schizophrenia have helped to establish a pathway to recovery or remission that does not embrace pharmacological therapy alone. Research into drug-resistant symptoms and poor adherence rates (Curson et al, 1985) demands effective alternatives and additions to more traditional approaches to treatment such as medication. The second part of the article describes how evidence-based psychological interventions were used to help a client suffering from treatment-resistant delusions, allied to a chaotic lifestyle and substance misuse, that had previously presented a substantial challenge to the mental health services.

Family interventions in schizophrenia: an analysis of non-adherence

OBJECTIVE

The aim of this study was to identify baseline factors which may make it possible to predict non-adherence to prescribed treatment.

METHOD

A total of 87 schizophrenic patients in a catchment area of Valencia (Spain) were randomly assigned to two family strategies. The characteristics associated with lack of adherence to the programmes were analysed in both the patients and their families.

RESULTS

Older patients, those with a higher number of previous hospital admissions, those living in small households and those having relatives with little knowledge of schizophrenia at the time of the initial assessment were the main factors associated with a higher risk of dropping out of the interventions.

CONCLUSIONS

The findings of this study offer some guidance on suggesting intervention strategies that might reduce drop-out rates in these types of programmes.

Designing and implementing a 'dual diagnosis' module: a review of the literature and some preliminary findings

People with a learning disability experience the full range of mental health problems, with prevalence greater than in the general population. The literature suggests that the move to community care has highlighted their special needs, as they face a complexity of life experiences and risks. Nurses play a key role, and must be equipped with appropriate knowledge and expertise to respond to the mental health problems of people with a learning disability ('dual diagnosis'). Major national initiatives support research and propose access to appropriate education for care professionals. In order to respond to locally identified educational needs a 'dual diagnosis' module was developed for nurses working with people with a learning disability who experienced mental health difficulties. The aims were to increase knowledge, to consider implications for learning disability nursing, to increase awareness of research and policy issues, and ultimately to enhance practice. Preliminary findings suggest that participants have moved from an entry position of professional bias and lack of knowledge and skill, to a changed perspective and enhanced practice relating to the mental health needs of clients with a learning disability. These changes are, however, speculative and may be attributable to variables other than module completion. Implications for further research and development are suggested.

Comparison of set-shifting ability in patients with chronic schizophrenia and frontal lobe damage

Neuropsychological studies of patients with schizophrenia have consistently identified deficits on tests sensitive to frontal lobe function. One paradigm that has been widely used is that of attentional set-shifting using the Wisconsin Card Sorting Test (WCST). In the present study, patients with chronic schizophrenia and with frontal lobe lesions were assessed on a computerised set-shifting task that provides a componential analysis of the WCST by distinguishing between intra-dimensional and extra-dimensional set-shifting. Out of 51 patients with schizophrenia, those with high IQ (n =24) were compared with patients with lesions in prefrontal cortex (n = 22) and with normal control subjects (n= 18). These three groups were well matched for age, sex and National Adult Reading Test (NART) IQ. The schizophrenic group showed a significantly higher rate of attrition at the intra-dimensional shift stage of learning compared with the other two groups. At the extra-dimensional shift stage, both the schizophrenic and frontal lesioned groups showed greater attrition than controls. Further, patients with schizophrenia who were able to learn the intradimensional reversal stage required more trials and made significantly more errors at that stage than the other two groups. In comparison with high IQ patients with schizophrenia, those with low IQ performed at a lower level but showed a qualitatively similar pattern of performance, providing further evidence that the set-shifting deficits were not simply explained by any global intellectual decline. Patients with schizophrenia who dropped out at the extradimensional shift stage had higher negative symptom scores compared with patients dropping out at previous learning stages, while patients failing at the intra-dimensional shift stage had lower scores for bradyphrenia (slowness of thought). The results suggest that patients with chronic schizophrenia fail to 'learn set' and are impaired at both set-shifting and concept formation. The relevance of these findings to understanding the nature of prefrontal cortical deficits in chronic schizophrenia is discussed. The implication of these findings to the rehabilitation of these patients is considered.

Symptom classification of schizophrenia changes with the duration of illness

Our starting hypothesis was that schizophrenic symptomatology changes over time. This hypothesis explains conflicting reports on schizophrenic symptom structures as a consequence of different durations of illness in the samples studied to date. Therefore a sample of 258 schizophrenic in-patients (with ICD-10 diagnoses F20) was categorized according to illness duration. A factor analysis was performed on the 8 items of the Manchester Scale for three subgroups (duration < 10 years, 10> or =20 years and > or = 20 years). For those patients whose illness duration was less than 10 years, 'formal thought disorder' was not related to any other mental state, whereas for those whose duration was 10 years or longer, it was correlated with 'negative symptoms'. In the < 10 years group, 'anxiety and depression syndrome' and 'positive symptoms' formed one complex, but these symptoms were separated into two distinct syndromes in the > or = 20 years group. Thus we were able to demonstrate that the classification of symptoms changes with increasing duration of illness.

Four behavioural syndromes of schizophrenia: a replication in a second inner-London epidemiological sample

In a previous large epidemiological survey of patients with strictly defined schizophrenia in the London borough of Camden, we extracted four behavioural syndromes (Social withdrawal, Thought disturbance, Anti-social behaviour and Depressed behaviour) by factor analysis of MRC Social Behaviour Schedule (SBS) data. These syndromes had significant differential relationships to symptoms assessed using the Manchester Scale (MS), symptom-derived syndromes, and social functioning variables. A second inner-London epidemiological survey of schizophrenia in South Westminster using identical methodology found the same four behavioural syndromes with identical core component items. The same four behavioural syndromes were extracted, whether applying strict Feighner diagnostic criteria (n=112) or broader DSM-III-R criteria (n=198). The four syndromes extracted from the Feighner positive sample showed relationships to symptoms and social functioning variables similar to those found in the original Camden study. However, the symptom-derived factors were not the same and did not conform to the three recognised symptom-based syndromes of schizophrenia. This successful replication suggests that assessment of the four behavioural syndromes of schizophrenia offers a different perspective on disability and a potentially relevant measure in clinical practice, clinical trials and studies of the neuropsychology and pathophysiology of schizophrenia.

Dopamine D1 receptor gene polymorphism and schizophrenia in Japan

We studied the relationship between schizophrenia and the DdeI polymorphism in the 5' untranslated region (5'UTR) of the dopamine D1 receptor (DRD1) gene. This polymorphism is an A (A1 allele) to G (A2 allele) transition in the 5' UTR of exon 2 at bp -48 (A-48G). One hundred forty-eight schizophrenics and 148 control subjects were investigated. No significant differences in genotypic counts and allele frequencies between schizophrenics and controls were found. Although a significant difference between the patients classified as disorganized type and the controls was discovered both in genotypic counts and allele frequencies, neither association proved significant when a Bonferroni correction was used. Moreover, there were no differences in scores of main symptoms of schizophrenia based on the Manchester Scale between patients with A1/A1 genotype and those with A1/A2 genotype. These findings suggest that this gene may not be involved in the pathogenesis of schizophrenia.

Impairment of willed actions and use of advance information for movement preparation in schizophrenia

OBJECTIVES

To assess willed actions in patients with schizophrenia using reaction time (RT) tasks that differ in the degree to which they involve volitionally controlled versus stimulus driven responses.

METHODS

Ten patients diagnosed with schizophrenia and 13 normal controls of comparable age were tested. Subjects performed a visual simple RT (SRT), an uncued four choice reaction time (CRT), and a fully cued four choice RT task. A stimulus 1(S1)-stimulus 2(S2) paradigm was used. The warning signal/precue (S1) preceded the imperative stimulus (S2) by either 0 (no warning signal or precue) 200, 800, 1600, or 3200 ms.

RESULTS

The patients with schizophrenia had significantly slower RTs and movement times than normal subjects across all RT tasks. The unwarned SRT trials were significantly faster than the uncued CRT trials for both groups. For both groups, fully cued CRTs were significantly faster than the uncued CRTs. However, the S1-S2 interval had a differential effect on CRTs in the two groups. For the normal subjects fully cued CRTs and SRTs were equivalent when S1-S2 intervals were 800 ms or longer. A similar pattern of effects was not seen in the patients with schizophrenia, for whom the fully cued CRT were unexpectedly equivalent to SRT for the 200 ms interval and expectedly for the 1600 ms S1-S2 interval, but not the 3200 or 800 ms intervals.

CONCLUSIONS

Patients with schizophrenia were able to use advance information inherent in SRT or provided by the precue in fully cued CRT to speed up RT relative to uncued CRT. However, in the latter task, in which the volitional demands of preprogramming are higher since a different response has to be prepared on each trial, patients showed some unusual and inconsistent interval effects suggesting instability of attentional set. It is possible that future studies using RT tasks with higher volitional demands in patients with predominance of negative signs may disclose greater deficits in willed action in schizophrenia.

Criteria defining refractory schizophrenia

To date there has been no agreement with regard to the criteria that define refractory schizophrenia. In this study, we intended to clarify the criteria which psychiatrists use to judge schizophrenic patients as being refractory in Japan. Based on 258 schizophrenic in-patients (ICD-10) and their likelihood of discharge, level of psychosocial functioning, mental state and use of medication, the common features of patients who are viewed as non-dischargeable because of their severe mental state, compared to those of dischargeable patients, were extracted and used as the criteria. The criteria proposed necessitate (i) diagnosis of schizophrenia by standard operational criteria, (ii) continuous hospitalization for at least the past 2 years, (iii) a level of psychosocial functioning of < or = 40 as measured by the Global Assessment Scale, and (iv) an intensity score of 'marked' or 'severe' on at least three of the six Manchester Scale items (flattened affect, psychomotor retardation, delusions, hallucinations, incoherence of speech and poverty of speech).

Pharmacological treatment of schizophrenia resistant to first-line treatment: a critical systematic review and meta-analysis

Schizophrenia resistance to conventional antipsychotics is a common phenomenon. In 5-25% of cases, satisfactory treatment response is not achieved, and intolerance to conventional antipsychotics occurs in 5-20% of patients. Numerous reasons for refractoriness have been proposed. However, up to now only a few pharmacological agents have been found useful in the treatment of schizophrenia resistant to conventional antipsychotics. This paper critically reviews quality-assessed trials on the pharmacological treatment of refractory schizophrenia. Randomized blinded trials of conventional antipsychotics at high doses, atypical antipsychotics, lithium, propranolol, and agents not traditionally used in the treatment of schizophrenia are reviewed. On the basis of the methodologically sound studies included, we conclude that only clozapine has proved to be clinically effective in the treatment of refractory schizophrenia. In the short term, the odds ratio for clinical improvement on clozapine treatment when compared to conventional treatment is calculated to be 2.4 (95% confidence interval [CI] 1.7-3.5) and the number of patients needed to treat (NNT) is 7 (95% CI 5-13). In single inconclusive trials, olanzapine and risperidone have been found as effective as clozapine. In order to establish the usefulness of other pharmacological treatments, more randomized clinical trials are needed.

Evaluating clinical outcome and staff morale in a rehabilitation team for people with serious mental health problems

Tameside and Glossop rehabilitation team (in England) have developed a progressive and targeted service for people with serious mental health problems through the systematic implementation of research-based evidence in practice and service configuration. This study was undertaken to provide a method of auditing the clinical outcome of the service and monitoring staff morale in a manner which could be integrated in the day to day delivery of services, and which could inform future service developments. Changes in the functioning of the total population of rehabilitation team clients were assessed over a 1-year period by Health of the Nation Outcome Scales (HoNOS) ratings at 6-monthly intervals. Factors causing stress and stress levels among all staff were assessed using the Mental Health Stress Questionnaire. The findings give clear indications of areas of the service which needed improving or changing, and identify ways in which the ongoing process of data collection might be refined.

Two factors of experienced deficits in schizophrenia and their relationships with positive, negative, and depressive symptoms

Eighty inpatients and 20 outpatients with ICD-10 schizophrenia were assessed with the Manchester Scale (MS) and the scale for the assessment of Subjective Experience of Deficits in Schizophrenia (SEDS). A factor analysis on MS scores yielded a three-factor solution: negative symptoms, positive symptoms, and anxious-depressive factor. On the other hand, a factor analysis on SEDS scores provided a seven-factor solution. The first factor, "awareness of social incompetence (ASI)," positively correlated with the anxious-depressive factor. ASI may reflect a negative cognitive attitude of persons who easily become depressive. The second factor, "subjective cognitive disturbance (SCD)," positively correlated with the positive-symptoms factor. SCD might represent a subtle disturbance, which can also produce positive symptoms. We found no factor on SEDS that correlated with the negative-symptoms factor. It was noted that a selection and comparison of items and the cultural background of subjects should be considered.

Apolipoprotein E regulatory region genotype in schizophrenia

Clinical observations indicate that a proportion of patients with schizophrenia experience cognitive impairment, which suggests that a neurodegenerative basis might be involved in the etiology of schizophrenia. Apolipoprotein E (ApoE), which has been confirmed to be genetically associated with Alzheimer's disease, is thus highlighted as a candidate gene for schizophrenia. Recently, novel functional polymorphisms in the ApoE transcriptional regulatory region have been found. To investigate whether these polymorphisms are associated with the risk of schizophrenia, we genotyped 144 patients with schizophrenia and 134 controls for two polymorphisms (-491A/T and -219G/T). No significant positive associations between both polymorphisms and schizophrenia were observed. Our findings exclude the regulatory region of the ApoE gene as a locus that might confer increased susceptibility to schizophrenia.

Familial associations of subsyndromes of psychosis in affected sibling pairs with schizophrenia and schizoaffective disorder

Attempts to describe the clinical heterogeneity of schizophrenia have consisted of categorical subtyping and a dimensional approach using factor analysis. The latter has yielded three dimensions or subsyndromes: positive, negative and disorganisation. The aim of this study is to explore to what degree these subsyndromes are correlated within 114 sibling pairs (185 individuals) with DSM-III-R schizophrenia or schizo-affective disorder who were assessed for the lifetime presence or absence of the positive, negative, affective and disorganisation subsyndromes. Ratings were based on the core symptoms of each subsyndrome using a modified Krawieka scale. First rank symptoms were also included in the analysis. Coincidence was assessed by application of the binomial theorem to the frequency of occurrence of subsyndromes in this set of siblings. The disorganisation subsyndrome was shared above chance expectation (chi2=9.15, P < 0.01 for all sibling pairs). The significant results for the disorganisation subsyndrome suggest that it may be a suitable phenotypic marker for genetic linkage studies.

Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia

OBJECTIVES

To investigate whether intensive cognitive behaviour therapy results in significant improvement in positive psychotic symptoms in patients with chronic schizophrenia.

DESIGN

Patients with chronic schizophrenia were randomly allocated, stratified according to severity of symptoms and sex, to intensive cognitive behaviour therapy and routine care, supportive counselling and routine care, and routine care alone.

SETTING

Adjunct treatments were carried out in outpatient clinics or in the patient's home.

SUBJECTS

87 patients with persistent positive symptoms who complied with medication; 72 completed treatment.

OUTCOME MEASURES

Assessments of positive psychotic symptoms before treatment and 3 months after treatment. Number of patients who showed a 50% or more improvement in symptoms. Exacerbation of symptoms and rates of readmission to hospital.

RESULTS

Significant improvements were found in the severity (F=5.42, df =2,86; P=0.006) and number (F=4.99, df=2,86; P=0.009) of positive symptoms in those treated with cognitive behaviour therapy. The supportive counselling group showed a non-significant improvement. Significantly more patients treated with cognitive behaviour therapy showed an improvement of 50% or more in their symptoms (chi2=5.18, df=1; P=0.02). Logistic regression indicated that receipt of cognitive behaviour therapy results in almost eight times greater odds (odds ratio 7.88) of showing this improvement. The group receiving routine care alone also experienced more exacerbations and days spent in hospital.

CONCLUSIONS

Cognitive behaviour therapy is a potentially useful adjunct treatment in the management of patients with chronic schizophrenia.

Nithsdale schizophrenia surveys. 17. Fifteen year review

BACKGROUND

In recent years there has been a shift to 'community care' and the introduction of several 'atypical' antipsychotic drugs. We report the impact of these changes.

METHOD

In Nithsdale, Dumfries and Galloway, Scotland, the population of patients with schizophrenia was identified in 1996. This census replicated a study carried out in 1981. The population with schizophrenia were compared on clinical and social variables. The whereabouts in 1996 of the 1981 population was determined.

RESULTS

In comparison with the 1981 population, more patients in 1996 had positive, negative and non-schizophrenic symptoms. More showed tardive dyskinesia. Social adjustment had not changed. They had spent less time in hospital; fewer (13%) were living with their parents; and fewer (8%) were employed. By 1996, 35% of the 1981 cohort had died (standardised mortality rate male-154; female-162).

CONCLUSIONS

The mental health of a community of people with schizophrenia living in a rural area in 1996 was poorer than in 1981.

Red cell membrane fatty acids, cytosolic phospholipase-A2 and schizophrenia

Forty subjects with schizophrenia and 40 age- and sex-matched controls were recruited, and blood samples were obtained for analysis of red cell membrane fatty acid composition by capillary gas chromatography. A blood sample was also taken from the same population to test for allelic association between schizophrenia and a polymorphism close to the promoter site of the cytosolic phospholipase-A2 gene which is mapped to chromosome 1q25. The schizophrenic population was heterogeneous with regards age, symptoms severity and treatment. A significantly higher percentage concentration of dihomogamma-linolenic acid (DGLA) was found in the red cell membranes of schizophrenics compared to matched controls. All other fatty acids examined showed no difference from the normal population. No correlation was found between any demographic factor, treatment variable, diet, drug use, alcohol or tobacco consumption which could explain the biochemical findings. A negative correlation was found between the concentration of DGLA in red blood cell (RBC) membranes and severity of symptoms of schizophrenia. In particular, there was a significant correlation (r = -0.41, p = 0.009) between DGLA percentage concentrations and 'disorganised' symptoms. No association was found between schizophrenia and alleles of the polymorphism near the phospholipase-A2 gene or between fatty acid concentrations and the presence of any particular alleles. This study therefore finds support for membrane phospholipid abnormalities in patients with schizophrenia and particular symptom clusters, but does not replicate a previous report of an allelic association between a polymorphism close to the site of the cytosolic phospholipase-A2 gene and schizophrenia.

Effects of trihexyphenidyl on MMSE and CAMCOG scores of medicated elderly patients with schizophrenia

The purpose of this study was to assess the effects of an anticholinergic (trihexyphenidyl) antiparkinsonian medication on the Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG) scores in long-term institutionalized elderly patients with schizophrenia. Seventeen schizophrenic (DSM-III-R) inpatients on long-term medication who had received trihexyphenidyl for at least 6 consecutive months were compared for MMSE scores, CAMCOG scores, and other demographic and clinical variables with 14 patients not receiving any anticholinergic agent for the same time period. Results showed that age, years of education, illness duration, length of current hospital stay, the Manchester Scale scores, and chlorpromazine daily equivalent dose in mg were not different in the two groups compared. Extrapyramidal signs such as tremor, rigidity, and bradykinesia were more frequent in trihexyphenidyl receivers. The scores of MMSE (p < .007) and CAMCOG (p < .005) and CAMCOG subscales of orientation (p < .03), language (p < .01), and memory (p < .002) were significantly lower among trihexyphenidyl receivers, as was the Social and Occupational Functioning Assessment Scale score (p < .05). In addition, the MMSE and CAMCOG scores were significantly lower for patients receiving 10 mg of trihexyphenidyl a day compared with those receiving 5 mg/day and nonusers. It is suggested that trihexyphenidyl in usual clinical doses may impair total MMSE and CAMCOG scores as well as some of the CAMCOG subscales in this patient population. However, only a prospective study, preferably double-blind and controlled, with measures of change will validate this conclusion.

Association study of a functional catechol-O-methyltransferase gene polymorphism in Japanese schizophrenics

Catechol-O-methyltransferase (COMT) is an enzyme which inactivates catecholamine neurotransmitters by methylation, and is considered a candidate for involvement in schizophrenia. A functional COMT gene polymorphism influencing the enzyme activities, the high activity (val-108) and the low activity allele (met-108), was recently confirmed. We investigated a genetic association between schizophrenia and the COMT gene polymorphism in 150 Japanese schizophrenics and controls. We detected the low activity met-108 allele more frequently in schizophrenics than in the controls, and found that subjects sharing the met-108 allele (val/met and met/met) are significantly more common in the patients than in the controls. The results suggest that the low activity met-108 allele may be involved in susceptibility for schizophrenia.

Social skill as determinant of social networks and perceived social support in schizophrenia

Factors influencing supportive social networks of people with schizophrenia are little understood. Data from 46 outpatients with schizophrenia were analysed using structural equation modelling to test plausible sets of inter-relationships between social skill, social networks, and social support. The data supported a tentative model about the causal relationships between variables. Paths showed that people with greater social skill had larger social networks, but did not necessarily perceive greater support from these networks. Negative symptoms accounted for some of the effect of social skill on social networks. Whereas groups of single-admission and multiple-admission participants did not differ in terms of social skill, social networks, or support, the age of the participants influenced their social skill and the size of their social networks. Younger participants had greater social skill and larger social networks. The results appear to suggest the importance of early intervention for young people with first-episode psychosis.

Social adjustment in schizophrenia: factors predictive of short-term social adjustment in a sample of schizophrenic patients

A sample of 60 Spanish schizophrenic patients was studied in order to ascertain the relationship between their relatives' expressed emotion (EE) and social adjustment after 2 years of follow-up. The average extent of the disability did not increase over time, and differences in dysfunction rates between the various specific social roles were identified. No differences in social outcome were detected between patients with high EE and low EE families. Three factors which predict social adjustment outcome were obtained using logistic regression analysis, namely clinical conditions, baseline social adjustment and the occurrence of a psychotic relapse during the follow-up period.

One-year, low-dose neuroleptic study of in-patients with chronic schizophrenia characterised by persistent negative symptoms. Amisulpride v. haloperidol

BACKGROUND

Amisulpride is a potent substituted benzamide antipsychotic drug claimed to improve the negative symptoms of schizophrenia, particularly at low dosage.

METHOD

Sixty long-term in-patients with schizophrenia and selected for predominant negative symptoms were randomised to receive either haloperidol or amisulpride. Over a year there was systematic dose reduction, as symptoms allowed.

RESULTS

There were no significant differences between the treatment groups in the proportion receiving low-dose treatment, the control of positive symptoms, or ratings of social behaviour, side-effects or tardive dyskinesia. For negative symptoms, there were consistent but non-significant trends in favour of amisulpride. The amisulpride patients required significantly less anticholinergic medication.

CONCLUSIONS

In chronically-hospitalised in-patients with schizophrenia characterised by persistent negative symptoms, amisulpride was a well-tolerated maintenance antipsychotic medication. The drug had only a limited effect in reducing negative symptoms, which were relatively stable, enduring phenomena in this sample, despite dosage reduction.

Factor structure of symptoms in functional psychoses

Global ratings from the Scale for the Assessment of Positive Symptoms and Scale for the Assessment of Negative Symptoms were subjected to principal-component analysis (PCA) in 80 schizophrenia patients, 76 patients with schizophreniform disorder, 80 patients with schizoaffective and mood disorders, and 78 patients with delusional, brief reactive, and atypical psychoses. The resulting factors were correlated with depressive, manic, and catatonic syndromes, and subjected to a multivariate analysis of variance across DSM-III-R diagnoses. PCAs revealed that psychosis, disorganization, and negative factors were also present in each of the nonschizophrenic groups. The disorganization factor tended to be related to the manic syndrome, and the negative factor to depressive and catatonic syndromes. Overall, the three factors had little diagnostic relevance in functional psychoses, although the negative factor was relatively more characteristic of schizophrenia. The data suggest that positive, negative, and disorganization factors are not specific to schizophrenia; this is consistent with a dimensional view of psychopathology in functional psychoses.

Is Wisconsin Card Sorting Test performance related to 'working memory' capacity?

The Wisconsin Card Sorting Test (WCST) is a multifactorial and complex test, and it involves so many different kinds of functions that it is difficult to understand why patients fail. Capacity of 'working memory' is possibly involved in the WCST performance and is considered a relevant factor responsible for the schizophrenics' poor performance. The present study was specifically designed to assess the relationship between 'working memory' measurements and WCST performances of schizophrenics. Furthermore, we investigated the relationship between the cognitive dysfunction and the clinical symptomatology. The following tests were administered to 30 schizophrenics and 25 healthy subjects: WCST, Digit Span Test (Backward and Forward), Digit Symbol Substitution Test and Visuo-Spatial 'working memory' Test, a card test appropriately devised. Clinical assessment included the Italian version of the scale of Krawiecka Manchester Scale (K-MS) and the Outcome scale by Strauss and Carpenter (1972). The 30 patients differed significantly in all the neuropsychological variables from the controls. WCST indexes did not correlate significantly with any of the 'working memory' measures (visuo-spatial and verbal) in the samples studied. No relationship was seen between the neuropsychological performances and clinical symptomatology as evaluated by the K-MS scale. WCST indexes and DSST significantly correlated with the outcome measure. The results do not support the hypothesis that executive dysfunction as evaluated by WCST is attributed to 'working memory' impairment, rather they could suggest that these two neuropsychological functions identify different neurocognitive constructs.

Disability in schizophrenia and mood disorders in a developing country

The aim of this study was to investigate how the prevalence and severity of psychiatric disabilities in patients with chronic schizophrenia compares with that in patients with chronic mood disorders. A total of 128 patients, 80 with chronic schizophrenia and 48 with chronic mood disorders as confirmed by DSM-III-R, were examined using the World Health Organization Psychiatric Disability Assessment Schedule (WHO/ DAS). There were no significant differences in the prevalence and severity of disabilities between the two disorders. Two-thirds of the patients with chronic schizophrenia and over half the patients with chronic mood disorders had dysfunctional behaviour and experienced significant disabilities. The prevalence of disabilities among these Malaysian patients was not markedly different from that seen in developed countries, suggesting that the prognosis in developing countries may not be as favourable as previously thought.

Characteristics of the new long-stay population in an inner Melbourne acute psychiatric hospital

OBJECTIVE

There has been an accumulation of so-called 'new long-stay' (NLS) patients in psychiatric hospitals. To date, no Australian studies have characterised this patient group. We aimed to study the demography, and clinical and social functioning of the NLS population at Royal Park Hospital (RPH) together with patients' attitudes to treatment and views on future placement.

METHOD

All 30 NLS patients at RPH were identified. Twenty-seven consenting patients were assessed using the following standardised instruments: Manchester Scale for psychopathology, Life Skills Profile (LSP), Physical Health Index and Patient Attitude Questionnaire. Information on past psychiatric history, past treatment and current treatment was collected. Insight and compliance were assessed.

RESULTS

The majority of patients were single men with a diagnosis of schizophrenia. Forty-one percent were detained in hospital involuntarily and 56% were considered dangerous to themselves or others. The patients were characterised by high levels of positive and negative symptoms. They were most impaired with respect to 'social contact' relative to the other subscales of the LSP. While 10 (48%) patients expressed a desire to leave hospital, only one patient considered that anyone would cohabit with them. Over two-thirds considered they had been unwell and that medication had helped. Staff rated one-third as having major problems with compliance. About two-thirds of patients had disability secondary to comorbid physical illnesses.

CONCLUSION

Like other NLS patients studied in the United Kingdom and Ireland, this group had significant handicaps secondary to psychiatric illness, concomitant physical illness and disability and behaviour unacceptable in community settings. They were also characterised by significant social isolation. These factors may be important determinants of rehabilitation failure and need to be addressed in the process of de-institutionalisation as well as in longitudinal studies examining these and other factors predicting NLS status.

Service provision for people with schizophrenia. I. Clinical and economic perspective

BACKGROUND

The aim of this study was to provide information on patients current service use which could inform future decisions on service planning and resource allocation.

METHOD

Individuals with a diagnosis of schizophrenia, who had received in-patient care in the previous five years, were identified from the Lothian Case Register. Information was obtained from 193 subjects. Patients' service use over a six-month period was examined. The costs incurred in service provision were determined.

RESULTS

Patients differed markedly in their use of services. This was not found to be related to their mental state. Average care costs were high. In-patient care accounted for most of the overall expenditure.

CONCLUSIONS

There is considerable variation in the services used by patients with schizophrenia and in the costs incurred in service provision. When planning services it is therefore important that detailed information on the patient population is available if resources are to be allocated cost-effectively.

Appraisal, psychological adjustment and expressed emotion in relatives of patients suffering from schizophrenia

BACKGROUND

It is argued that coping theory may be useful in attempting to understand how relatives adopt to the demands of living with a schizophrenia sufferer.

METHOD

In a prospective study, univariate and multivariate relationships were explored between appraisal variables (appraisal of symptom threat (primary appraisal) and perceived symptom control (secondary appraisal)) and (a) expressed emotion, and (b) psychological distress in relatives of schizophrenic patients. The profile of relatives who showed sustained distress over time was also examined.

RESULTS

The appraisal variables were found to be related to both the concurrent distress (GHQ scores), EE ratings of relatives at the time of the patients' relapse and hospitalization, as well as the subsequent GHQ scores of relatives when the patient was discharged back home. Relatives who showed sustained distress were likely to show high EE and have a longer caring history.

CONCLUSIONS

The study gives some support to the theory that appraisal processes underlie how relatives react to having a family member with schizophrenia, and may have implications both for identifying those at risk of poor adaptation, and for understanding strategies that improve well-being.

Audit of out-patients on ‘higher dose’ antipsychotics

Standards developed from the Royal College of Psychiatrists' consensus statement on the use of high-dose antipsychotics were audited. The baseline survey and two completed audit cycles are described showing improvement in the monitoring and management of out-patients on higher dose depot antipsychotics. Initially the main problem was poor attendance at hospital appointments. Practice was changed by (a) medical staff becoming more assertive and visiting non-attenders at home; (b) a phlebotomist visiting patients at home. Deinstitutionalisation has relocated many patients with chronic psychoses into the community, but services, including the ancillary services, have sometimes been slow to follow. This audit found that the most effective change was the provision of services to patients in their own home.

Qualitative cerebral morphology in schizophrenia: a magnetic resonance imaging study and systematic literature review

Patients with schizophrenia have larger lateral ventricles, less cerebral substance and smaller mesial temporal lobe structures than groups of normal controls, but it has proved difficult to link these volumetric abnormalities with clinical features of the illness. Such quantitative techniques may overlook qualitative abnormalities of importance. We therefore compared a neuroradiologists' clinical assessment of gross structural abnormalities, generalised 'atrophy' and high intensity signal (HIS) foci, as detected on the first and second echo of a long TR sequence, in 42 patients with schizophrenia (22 treatment responsive, 20 treatment resistant) and 50 normal controls. The schizophrenic group included two (5%) subjects with gross lesions, two (5%) with cerebellar atrophy, 21 (52%) with at least a mild degree of cerebral atrophy, and 15 (38%) with one or more HIS foci; the comparable figures in the controls being 2, 0, 2 and 14%, respectively. Controlling for age, patients with schizophrenia had a substantially elevated rate of cerebral atrophy (odds ratio (OR) = 11.7, p < 0.0001). Treatment-resistant schizophrenics showed a tendency (OR = 2.8, p = 0.06) to greater atrophy than those who were treatment responsive, whereas our previous volumetric study showed no such difference. In contrast, the presence of HIS foci was only related to age. The degree of atrophy was correlated with the number of HIS foci (r = 0.31, p = 0.014). Taken together with previous studies, these findings demonstrate the value of qualitative examination of MRI images in patients with schizophrenia.

Observations on switching patients with schizophrenia to risperidone treatment. Risperidone Switching Study Group

This study examined one possible strategy for switching patients to treatment with risperidone involving immediate cessation of current neuroleptics and gradual withdrawal of anticholinergic treatments. All patients received risperidone monotherapy for at least 4 weeks. Side-effects and symptoms were rated and successful switching was defined as completion of the study with no consistent worsening in any rating scales. Of the 41 patients entered, five withdrew for reasons unconnected with the study. Of the remaining 36 patients, 64% (23 patients) were switched successfully. Overall, the rating scales showed significant improvements (mean score on Krawiecka scale, 11.0 to 6.6, P < 0.001), and side-effects decreased (mean score on Simpson & Angus scale, 5.1 to 2.9, P = 0.004). The strategy appeared to be successful for most patients, especially those who had previously received depot medication. However, more gradual withdrawal of previous treatments, including anticholinergics, may be advisable in some cases.

Grey matter correlates of syndromes in schizophrenia. A semi-automated analysis of structural magnetic resonance images

BACKGROUND

Symptoms in schizophrenia cluster into syndromes, each of which may be associated with a particular pattern of cerebral blood flow. We sought to investigate whether these syndromes are also related to neuroanatomical changes.

METHOD

A semi-automated method was used to examine structural magnetic resonance images in 12 patients with schizophrenia. The relationship between the relative regional grey matter volume and ratings of the syndromes of psychomotor poverty, disorganisation and reality distortion was investigated.

RESULTS

There was a significant negative correlation between psychomotor poverty score and the relative volume of the left ventro-medial prefrontal grey matter, and a significant positive correlation between disorganisation and the relative volumes of the hippocampus, and the parahippocampal/fusiform gyrus bilaterally.

CONCLUSION

The correlation between psychomotor poverty and left prefrontal grey matter volume resembles that previously seen with prefrontal blood flow in the same patient, suggesting that this functional abnormality is related to an underlying anatomical change.

Wisconsin card sorting test and Stroop test performance in schizophrenia: a shared construct

The Wisconsin card sorting test (WCST) and Stroop test were administered to 25 schizophrenic patients in order to better identify and understand more specific processing mechanisms involved in executive dysfunctions and to investigate their hypothetical involvement in symptom formation. Data show that for as much as the two tests employed measured executive functions in terms of mental control and cognitive flexibility, our findings seemed to indicate shared or interconnected mechanisms. No correlations were seen between the psychopathological evaluation and any of the neuropsychological indexes. The use of the Stroop task could provide a more readily cognitive analysis in terms of specific processing mechanisms, at the basis of WCST impairment in schizophrenia.

A controlled trial of amantadine hydrochloride and neuroleptics in the treatment of tardive dyskinesia

An 18-week, double-blind, crossover study of amantadine and neuroleptics in the treatment of tardive dyskinesia (TD) is described. A fixed-dose regimen was used, and objective rating scales for TD, extrapyramidal symptoms, and mental state were employed. The results indicate that amantadine is significantly better than placebo in the management of TD and that there is little risk of exacerbating psychosis. Further investigation of this potentially useful medication is warranted.

The Hampstead Schizophrenia Survey 1991. II: Incidence and migration in inner London

BACKGROUND

The previous paper reports a high prevalence of schizophrenia (broad definition) in an inner London area. In this paper we test hypotheses for this finding and examine the characteristics of people with schizophrenia who move frequently.

METHOD

People with schizophrenia in the Hampstead area were identified by key informant methodology, at two censuses five years apart. This allowed identification of incident cases during these five years and identification of people who had moved into and out of the area.

RESULTS

The incidence of DSM-III-R schizophrenia in Hampstead between 1986 and 1991 was at least 0.21 per 1000 of the population aged 15 to 54. There was a significant movement of people with schizophrenia to this inner London area from outer London between 1986 and 1991. People with schizophrenia who were relatively mobile were significantly more likely to be male, to suffer with prominent hallucinations, and to have no contact with a GP.

CONCLUSIONS

The high prevalence of broad schizophrenia in this inner London area is, in part, due to geographical drift. A significant excess of the people with schizophrenia who move frequently are men with positive symptoms.

Psychosocial dimensions of family burden among two groups of carers looking after psychiatric patients

In this study we examined the relationship between level of family burden and extent of psychological distress among family members of 52 psychiatric patients. Our sample consisted of 31 chronic and 21 subchronic patients with a diagnosis of schizophrenia. The paper focused on the influence of psychosocial factors, such as the sense of personal control and coping strategies upon the extent and the perception of burden. The carers of chronic patients more frequently used a passive way of coping with everyday problems. Passivity and variability on behalf of the carers were significantly correlated with areas of objective burden. Consistent with a stress-process model, we found that the factor of mastery correlated significantly with family burden and distress scores. The findings of the study are discussed in the context of community family interventions.

From Leros asylum to community-based facilities: levels of functioning and quality of life among hostel residents in Greece

The pattern of mental health care in Greece is undergoing a major transformation. The Leros Projects I and II supported the development of 13 community hostels located throughout the Greek mainland. These hostels provide residential care to more than 100 former psychiatric inpatients, mainly from Leros asylum. The present study evaluates the impact of the resettlement process on the residents' perceived quality of life (QoL) together with an examination of the residents' psychiatric and behavioural functioning four years after the move from hospital. The target sample (n = 99) comprised of individuals who may be considered 'chronic' psychiatric patients with a long history of institutionalisation and many are socially deprived with few family ties. The residents' functioning profile indicates a range of different levels of abilities. The QoL findings show that the majority of residents (70%) perceived the movement from the traditional hospital regime to the community hostels as being a positive change and expressed their satisfaction (74%) with the new living situation. This study demonstrates that even the most dependent, chronic psychiatric patients in Greece can be maintained in community settings and are able to articulate generally reliable and valid responses concerning the impact of service changes.

Construct validity of negative symptoms: an empirical and conceptual review

The construct validity of negative symptoms is reviewed, and findings on deficit negative symptoms are also incorporated. A valid negative symptom construct should: (a) have replicable relationships with observable phenomena and other constructs; (b) have good reliability, temporal stability, and homogeneity; and (c) predict prognosis and response to treatment, possess convergent and discriminant validity, and be useful to clinicians. Although a number of well-replicated findings provide support for the validity of the construct, modification is warranted. Specifically, the data suggest that there is a highly correlated set of negative symptoms, which includes flat affect, alogia, anhedonia, and avolition. Primary and enduring symptoms from this set have good predictive and discriminant validity and can be studied in the context of the deficit syndrome, as well as with current negative symptom rating scales. Future studies should examine whether deficit negative symptoms are better conceptualized as a dimension or a category, elucidate the relationship between deficit symptoms and additional clinical and behavioral variables (e.g., response to newer neuroleptic medications and diminished emotional responding), and explore differences between the pattern of correlates of deficit symptoms and those of the positive and thought disorder symptoms.

Cognitive function and duration of rooflessness in entrants to a hostel for homeless men

BACKGROUND

Four previous studies of homeless adults have yielded conflicting results regarding the presence of cognitive impairment.

METHOD

A consecutive series of 80 roofless entrants to a hostel for homeless men were sampled and 62 (76%) completed a range of assessments, including measures of mental state, cognitive functions and substance use.

RESULTS

Estimated premorbid IQ (mean = 96), current IQ (mean = 84) and cognitive speed were significantly lower than the norm. There was a significant IQ drop in all diagnostic groups. IQ drop, but not current IQ, correlated with duration of rooflessness. Those with schizophrenia or alcohol problems were roofless for longest. Alcohol misuse did not correlate with IQ drop, excepting alcohol withdrawal symptoms in those with schizophrenia.

CONCLUSION

The hypothesis that low IQ is a risk factor for rooflessness is supported. However, length of rooflessness was more closely related to IQ drop than to current IQ, suggesting that some third factor may be affecting both rooflessness and intellectual functioning. Roofless men with schizophrenia or alcohol problems may be especially at risk of long-term rooflessness.

Psychotic experiences induced in deluded patients using distorted auditory feedback

The effect of hearing immediate auditory feedback of their own voice distorted in pitch was examined in 21 patients with a diagnosis of schizophrenia. Patients frequently reported that they heard a voice "speaking when I speak" and often attributed this "other" voice to an external agent: "I think it's an evil spirit speaking when I speak." The frequency of making these ''other''attributions was significantly related to degree of pitch distortion (rho = 0.62, P <.01) and to current severity of delusions (rho = 0.62, P <.01). However, the relationship with hallucinations was not significant (rho = 0.40) and there was no relationship with negative features such as psychomotor retardation. We conclude that the "hallucination-like" reports elicited by our paradigm resulted from an interaction between an unusual perceptual experience (distorted auditory feedback) and an abnormal mechanism for belief formation present in deluded patients. This formulation suggests a close relationship between delusions and hallucinations.

Facial and other non-verbal communicative behaviour in chronic schizophrenia

Facial behaviour may be an important determinant in clinical ratings of psychopathology. A standardized objective technique was used to quantify measures of facial behaviour in 21 chronic schizophrenic subjects, in comparison with control groups of depressed, demented and Parkinsonian subjects. Facial behaviours were counted and timed from video recordings of each subjects' face during a clinical interview. Separate measurement of behaviours were obtained while subjects were speaking and silent. For most variables, the amount of facial behaviour was significantly less in schizophrenic subjects than in control groups. The groups differed significantly on a number of measures, but schizophrenics could not be reliably identified by a single facial behaviour variable. However, using a discriminant function analysis with measures for eye contact while speaking and silent, broad smiles and small smiles, discrimination between groups was good, with over 80% correctly classified as either schizophrenic, or not schizophrenic. These techniques may increase our understanding of psychopathological signs and the mechanisms that underly them.

Validation of three dimensions of schizophrenic symptoms in a large unselected sample of patients

A principal components analysis was conducted upon current symptoms and signs rated in a sample of 329 essentially unselected patients with schizophrenia. Three dimensions emerged clearly and closely resembled those previously described in smaller, more selected samples. The clearly defined psychotic dimensions were related in turn to: (i) other mental state variables; (ii) physical treatments administered; (iii) movement disorder; (iv) demographic and historical features; and (v) cognitive function. The correlates of the three dimensions were very different. The clarity of separation achieved in this investigation provides strong support for the view that the three psychotic dimensions of 'poverty', 'hallucinations and delusions' and 'disorganization' are valid and may well have different underlying pathophysiologies.

Clinical usefulness of an aftercare worker for psychotic patients discharged from half-way houses in Hong Kong

BACKGROUND

The aim was to assess the clinical usefulness and economic viability of an aftercare worker for psychotic patients discharged from half-way houses in Hong Kong.

METHOD

A sample of 32 chronic psychotic patients was provided with a full-time aftercare worker. A matched control group received no such service.

RESULTS

The experimental group was found to have greater and better employment prospects, better mental status with less hospitalisation and less law-breaking behaviour than the control group. Some of these benefits were converted into economic terms and the tangible costs incurred in the project were calculated.

CONCLUSIONS

The provision of an aftercare service is clinically useful and economically viable.