A standardized psychiatric assessment scale for rating chronic psychotic patients

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.

Rehabilitation and staffing levels in a 'new look' hospital-hostel

The present study examined the utility of a new hospital-hostel with low staffing levels. Results showed that the hostel was able to maintain 9 of the 10 initially transferred patients and has been able to provide some improvements in their quality of life. However, unlike highly staffed hospital-hostels, it was not able to decrease patients' disabilities. Implications of this are discussed in relation to staffing levels and practices.

A double-blind comparison of raclopride and haloperidol in the acute phase of schizophrenia. The British Isles Raclopride Study Group

This is the first comparative double-blind study of raclopride. Ninety-one patients with acute schizophrenia received either raclopride 2-8 mg twice daily or haloperidol 5-20 mg twice daily for 4 weeks. Both neuroleptics produced clinical improvements. There were no significant between-drug differences in overall efficacy measurements as assessed by the schizophrenia change sub-scale of the Comprehensive Psychopathological Rating Scale and the Krawiecka (Manchester) Rating Scale. Assessment by the Clinical Global Impression scale found haloperidol to be more effective. There were significantly fewer extrapyramidal symptoms with raclopride and a significantly lower incidence of acute dystonia. The results suggest that raclopride has an antipsychotic effect with a low incidence of extrapyramidal side effects.

Can we measure need in the homeless mentally ill? Using the MRC Needs for Care Assessment in hostels for the homeless

Hostels for the homeless contain many who are disabled by chronic mental illness but have little access to rehabilitation services. One approach to solving this problem might be to measure the needs of hostel residents in a standardized way and use this information as a basis for planning interventions. This study attempted to use the MRC Needs for Care Assessment Schedule to measure the needs of 46 mentally ill residents of Oxford hostels. It aimed to determine if a standardized assessment could be used in these difficult settings and if the needs it identified could form a useful basis for planning future interventions. Although it was possible to use the schedule, and although the pattern of need identified appeared broadly to reflect conditions in the hostels, it was not felt that the information produced was of sufficient quality to assist in planning services. The authors postulate that underlying this deficiency is the failure of the schedule to take sufficient account of the views of staff and residents.

Multidimensional ordering of psychopathology. A factor-analytic study using the Comprehensive Psychopathological Rating Scale

The aim of the study was to search for a multidimensional order in the psychopathology of the functional mental disorders in general. A heterogeneous group of 192 patients was investigated by means of a semistructured interview based on the Comprehensive Psychopathological Rating Scale. Principal component factor analysis revealed 5 clinically meaningful dimensions interpretable as representing dysregulation of emotion and motivation, perceptual and behavioural disintegration and dysregulation of autonomic functions.

Syndromes of chronic schizophrenia and some clinical correlates

Subtypes of the features of chronic schizophrenia were investigated. As in previous research, three discrete syndromes were found. These were then related to demographic, psychological, and movement-disorder variables. Possible pathophysiological mechanisms are discussed in terms of known neostriatal functions.

The influence of family expressed emotion on the course of schizophrenia in a sample of Spanish patients. A two-year follow-up study

A sample of 60 Spanish schizophrenic patients was studied to ascertain the relationship between their relatives' expressed emotion (EE) and relapse at follow-up. The relatives' EE and patients' relapse were operationalised following Leff & Vaughn's criteria. At nine months a significant association was not found between the relatives' EE and relapse, but this association became significant on reclassifying the relatives' EE scores after decreasing to four points the cut-off point for critical comments. At 24 months no association was found between EE and relapse. There was a tendency for patients who interrupted their medication or who did not work to relapse more frequently, particularly among the high-EE group.

Psychological well-being in families with a member suffering from schizophrenia. An investigation into long-standing problems

Levels of stress in carers of long-term schizophrenia sufferers attending a depot clinic were assessed. Nine out of 25 carers (36%) were identified as possible or definite cases on either the GHQ or the HAD. However, a substantial proportion of carers managed to cope with the difficulties without suffering psychologically.

Prediction of employability in schizophrenic patients

This study, the third of a series of reports on employability and schizophrenia, investigated the effects of both interview and non-interview variables on employability. Data on 46 chronic schizophrenic inpatients included demographic and illness-related variables, measures of psychopathology and interview-based ratings of employment skill. Latent class analysis using linear structural relations (LISREL) modelling generated the main finding namely, that interview-based measures are the strongest determinants of employability. However, other variables pertaining to illness, prior functioning and negative symptoms, exert an effect on interview performance and hence indirectly influence employability ratings and judgements.

Multivantaged assessment of depression in schizophrenia

While it is recognized that depression frequently can occur together with fundamental symptoms of schizophrenia, estimates of the prevalence of schizophrenia-related depression have been very variable. This variability may be due in part to the difficulty in clearly separating depressive symptoms from negative symptoms. A more valid method of assessing depression might combine evaluations from multiple vantage points. This study, which involved 26 hospitalized schizophrenic patients, tested the proposition that complete assessment of depression requires three separate sources of input: self-rating (subjective mood state), clinician rating (affective state), and observer rating (behavioral manifestations). In the present study, patients were evaluated on self-rating instruments for mood states, clinician-rated scales including the Hamilton Rating Scale for Depression, and observer-rated scales. These vantage points, though overlapping in some respects, were found to provide independent information on the experience of depression in schizophrenia. Clinician-rated and observer-rated assessments tended to correlate significantly, while self-rated subjective reports were discordant, thus complementing the assessments from the other two vantage points.

Training community psychiatric nurses for psychosocial intervention. Report of a pilot study

Community psychiatric nurses were trained to deliver psychosocial intervention to clients with a diagnosis of schizophrenia living at home with relatives. The training package consisted of family assessment, health education, and family stress management strategies. In a 'quasi-experimental' design, a sample of families (n = 54) were recruited to either a control or experimental condition and followed up for 12 months. A number of favourable outcomes were observed in the experimental group, including improvements in the client's target symptoms, personal functioning, and social adjustment. Relatives' satisfaction with services increased and reports of their own minor psychiatric morbidity improved.

The Northwick Park 'Functional' Psychosis Study: diagnosis and outcome

Three hundred and twenty-six consecutively admitted patients with functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2.5 years. They were examined in social, clinical and psychological terms and the CATEGO programme and DSM-III criteria were applied to data concerning the index episode to derive diagnostic classifications. The deterioration in occupational functioning and the hospital careers of patients with diagnostic classifications of schizophrenia were worse than those in the other groups and positive and negative features were also more severe in patients with a classification of schizophrenia. By contrast, no differences in psychological test performance were found between the groups based upon diagnostic classification. Impaired psychological test performance was found and it was strongly related to concurrent mental state abnormalities, particularly negative symptoms. It is concluded that the diagnostic classifications used were of limited value in predicting outcome in functional psychosis.

Elevated IgG anti-histone antibodies in a subgroup of medicated schizophrenic patients

A total of 57 schizophrenic patients (of which 17 were first-episode, neuroleptic naive) and 76 healthy controls were screened for anti-histone IgG antibodies using an enzyme immunoassay (ELISA). All patients had significantly higher anti-histone antibody titers than controls (t = 3.1, p less than 0.003). Previously medicated patients had significantly higher titers than neuroleptic-naive first episode patients (t = 2.87, p less than 0.006). This study suggests that neuroleptic medications are associated with anti-histone antibodies.

Outcome of schizophrenia in the Afro-Caribbean community

It has been suggested that atypical psychoses of good prognosis might account for the high rates of schizophrenia in the Afro-Caribbean community in Britain. In this study 39 Afro-Caribbean admitted with RDC schizophrenia were followed up in the community, as were matched white subjects. Psychological and social impairments were similarly severe in both groups, showing that schizophrenia among Afro-Caribbeans in Britain is not marked by a favourable outlook. This finding has major implications both for our understanding of the aetiology of schizophrenia, and for the provision of psychiatric services.

Patterns of cerebral blood flow in schizophrenia

Positron emission tomography was used to study the relationship between rCBF and symptom profiles in 30 schizophrenic patients. Factor analysis confirmed that the symptoms segregated into three syndromes--psychomotor poverty, disorganisation, and reality distortion--described previously. Analysis of the correlations between syndrome scores and rCBF revealed that each syndrome was associated with a specific pattern of perfusion in paralimbic and association cortex, and in related subcortical nuclei. The study confirmed predictions that psychomotor poverty and disorganisation are associated with altered perfusion at different loci in the pre-frontal cortex, and reality distortion with altered perfusion in the medial temporal lobe. The perfusion patterns suggest that the abnormalities of brain function underlying each of the three syndromes are not confined to single loci, but involve distributed neuronal networks.

The Nithsdale schizophrenia surveys. An overview

The Nithsdale surveys over a ten year period have examined a community of schizophrenic patients. Although almost three-quarters of patients were living outside hospital, social and psychiatric disability was considerable, with flattening of affect and social withdrawal most prominent. The majority probably cause little disturbance to most people in the community. Only 13% of the total Nithsdale schizophrenic population were living in a high contact/high Expressed Emotion family, the family structure believed to be most conducive to schizophrenic relapse. An attempt at family intervention found it difficult to engage relatives in treatment; however, where such intervention did take place, there was a fall in the total number of relapses. Reassessment found that the level of EE was stable in most relatives over a five year period. Patients who lived in a high or fluctuating EE home, and who relapsed, did so more often than those who lived in a low EE home. Assessment of the prevalence of motor disorders secondary to antipsychotic medication found a point prevalence of parkinsonism of 27%, of tardive dyskinesia (TD) 29%, and of akathisia or pseudoakathisia 23%. Only 44% had no movement disorder. Eight percent had persistent TD. Parkinsonism was associated with a history of obstetric complications and TD with left-handedness. An obstetric history obtained from mothers of schizophrenic patients found there was no difference in the proportion of schizophrenic patients and their sibs who had at least one definite obstetric complication.

The association among negative symptoms, movement disorders, and frontal lobe psychological deficits in schizophrenic patients

Neuropsychological tests of frontal lobe function were undertaken in 46 chronic schizophrenic patients who were also rated for movement disorders and negative symptoms. "High" and "low" SANS groups were formed by segregating around the median value. The "high" SANS group was found to differ significantly in terms of the severity of tardive dyskinesia (TD) and drug-induced parkinsonism, and frontal psychological tests. A possible mechanism is discussed within the context of known neostriatal psychological function.

Douglas House. Seven years' experience of a community hostel ward

Of 24 residents of a ten-bed, community-based hostel ward suffering chronic psychiatric illness, nine have been resettled in the community, with four more expected to follow them. Five residents have made Douglas House their home but another six have manifested behavioural disturbance necessitating return to hospital wards. We found community discharge to be associated with illnesses having good prognostic features, while organic illness militated against such placement. Indicators of a prior history of behavioural disturbance seem to predict difficulties in managing a patient in this environment.

Negative symptoms in chronic schizophrenia. Relationship to duration of illness

The frequency and distribution of negative symptoms in a sample of 40 patients admitted to hospital with RDC-definite schizophrenia were examined. There was a highly significant positive correlation between negative symptom scores obtained using three different rating scales, but the presence of negative symptoms was not significantly related to duration of illness or number of episodes of illness. These findings do not support a model of negative symptoms being the consequence of schizophrenic relapse, but are in favour of their being an integral component of the schizophrenic syndrome, as salient in the first as in later episodes.

Psychometric evaluation of a standardized and expanded Brief Psychiatric Rating Scale

The interrater reliability, factorial and discriminant validity of a standardized and expanded Brief Psychiatric Rating Scale (BPRS-E) were investigated in a heterogeneous short-stay group of psychiatric inpatients in the Netherlands (n = 162). Repeated separate interviews by single clinicians (psychiatrists, residents or clinical psychologists), best reflecting the way the BPRS is usually employed in clinical practice and psychopharmacological research, were used to determine interrater reliability (n = 79). Although the 5 subscales of the original 18-item BPRS (BPRS-18) were successfully cross-validated in this Dutch sample, 4 of these subscales (except for thought disturbance) were found to lack interrater reliability. The 10-item schizophrenia scale derived from the BPRS-18 by a Scandinavian group met the standard of acceptable interrater reliability; BPRS-18 and BPRS-E global scales approximated this standard. For the thought disturbance subscale, the schizophrenia scale and for BPRS-18 and BPRS-E global scales, findings supported discriminatory power.

Alcohol abuse in chronic schizophrenics: implications for management in the community

This study was designed to investigate the effects of regular alcohol consumption on chronic schizophrenic patients maintained on fluphenazine decanoate in the community. A group of patients who consumed more than 20 units of alcohol per week was compared with those who did not drink or did so only occasionally. It was found that patients in the alcohol group had a higher frequency of previous relapses, a greater severity of positive symptoms and a lower incidence of extrapyramidal side effects except tardive dyskinesia for which there was no difference. Serum fluphenazine levels were lower in this group (NS). It was concluded that patients who regularly consume alcohol tend to be clinically unstable, perhaps because of poor therapeutic control.

Expressed emotion and early onset schizophrenia: a one year follow-up

Key relatives of 33 first or early admission psychotic patients (mainly schizophrenics) were interviewed to determine household levels of expressed emotion (EE). The patients were followed up for 12 months from index admission, during which time 13 (39%) experienced psychotic relapse. There was no association between relapse rate and household EE, but correlations between individual components of EE and pre-morbid measures suggest that level of criticism may be related to less acute onset of index episode, greater elapsed time since first signs of illness, and poor adjustment in the realm of work/study. The results are discussed in the context of continuing uncertainties about the precise nature of the relationship between EE and relapse.

Can the neuropsychological case-study approach be applied to schizophrenia?

Neuropsychological studies of schizophrenia typically apply a small number of tests to a large group of patients. This approach has at least two drawbacks. First, the heterogeneity of the condition will lead to group means which may not reflect the behaviour of any individual. Secondly, it is difficult to infer the nature of the underlying cognitive impairments from a small number of tests, since good performance on a particular test depends on many different cognitive processes. In these circumstances it is more appropriate to apply the methods of cognitive neuropsychology where a large number of tests are used on a single case. This approach has proved fruitful in the study of neurological patients. We have intensively studied 5 chronic schizophrenic patients. These patients varied greatly in terms of overall ability. However, all patients, whatever their overall ability, performed badly on tests sensitive to frontal lobe lesions. This result suggests impairment of the supervisory attentional system in these patients. In addition, one patient suffered from a visual agnosia.

Lithium carbonate in chronic schizophrenia--a brief trial of lithium carbonate added to neuroleptics for treatment of resistant schizophrenic patients

The value of lithium carbonate as an adjunctive treatment of resistant schizophrenia was tested in a 4-week clinical trial using a single-blind, randomized, consent design. Treatment and control groups were drawn from a population of detained patients in an English special (maximum security) hospital. The 2 groups were comparable in terms of age, sex, severity of symptoms, length of hospitalization and concurrent neuroleptic dosage. The addition of lithium carbonate to the treatment regimen did not result in symptomatic improvement in patients completing the treatment protocol. The ethical and practical difficulties raised by the trial are discussed.

Pseudoakathisia and negative symptoms in schizophrenic subjects

The characteristics of schizophrenic subjects with pseudoakathisia were compared with those without. Those with pseudoakathisia displayed significantly more negative symptoms. This survived correction for other coexisting movement disorders.

The clinical correlates of neurological soft signs in chronic schizophrenia

Among 16 chronic schizophrenic in-patients, all had at least one neurological soft sign (NSS), and 6 (40%) had definite neurodysfunction. NSS and TD scores were highly intercorrelated, and NSS were significantly correlated with neuroleptic drug exposure. NSS correlated positively with both positive and negative symptoms and cognitive impairment but not with cerebral ventricular size on CT. Patients with neurodysfunction had more positive and negative psychopathology, cognitive impairment and TD than those without. Cerebral ventricular sizes and family histories of schizophrenia were similar in both NSS groups. The presence of NSS may be a simple but important way of identifying a subgroup of schizophrenics with neurodevelopmental predisposing abnormalities, and vulnerability to TD.

Tardive dyskinesia and positive symptoms of schizophrenia

Positive symptoms and movement disorders were rated in 44 schizophrenic inpatients. A significant negative correlation was demonstrated between tardive dyskinesia and positive symptoms. Possible explanatory mechanisms are discussed.

Schizophrenic syndromes and frontal lobe performance

A battery of neuropsychological tests sensitive to frontal lobe impairment was administered to 43 chronic schizophrenic patients to delineate the abnormality of mental processing associated with the syndromes of psychomotor poverty and disorganisation, which had been identified in a previous study of the segregation of schizophrenic symptoms. Psychomotor poverty was found to be associated with slowness of mental activity, including slowness of generating words. The disorganisation syndrome was associated with impairment in tests in which the subject is required to inhibit an established but inappropriate response.

The Scottish survey of old long-stay in-patients

A total of 2605 old long-stay patients, defined as those admitted to hospital before the age of 65 years and in hospital more than six years, were identified in psychiatric hospitals serving 83% of the Scottish population. The bed occupancy was 59 per 100,000 of the general population, with a range among hospitals of 19-123 per 100,000. Of all patients, 64% were schizophrenic and 15% had organic brain disease; most patients were male, single and over 60 years of age; 41% had been in hospital more than 30 years; 61% had either florid psychotic symptoms or symptoms of a deficit state in marked or severe degree, and the rehabilitation potential for 70% was low. An increasing prevalence of deficit symptoms in schizophrenics was associated with increasing length of stay in hospital; the difference was most marked between those admitted before and after 1953.

The Northwick Park 'Functional' Psychosis Study. Phase 2: maintenance treatment

This study blindly compared the value as a prophylaxis against relapse over a period of up to 6 years, of pimozide, lithium, pimozide+lithium and placebo of 30 patients with functional psychotic illness who had achieved satisfactory recovery on the same medications during an acute episode of illness. Pimozide was significantly more effective than placebo pimozide in preventing relapse (p=0.01). No significant effect for lithium was found. There was a significant deterioration in positive symptoms (p < 0.05) as relapse approached, but otherwise features of impending relapse were not detected. It is concluded that prophylactic neuroleptic medication is of value even in patients who have recovered from an acute episode of psychosis without active neuroleptics. Such an acute response does not identify a group of patients who can be predicted to do well without continued medication.

Negative symptoms, defect state and Huber's basic symptoms: a comparison of the concepts

Comparing Crow's schizophrenia model with the defect state and Huber's basic symptoms shows that this model is an oversimplification of the complex reality of schizophrenic outcomes. The concept of negative symptoms is undermined by several factors, such as differing definitions, other confounding cross-sectional variables (e.g., akinesia and depression), short follow-ups and lack of confirmation by factorial analysis. The longitudinal concept of a defect state, which has been used in long-term follow-up studies, includes enduring symptoms currently classified as positive and negative. Huber's conceptualization of basic symptoms describes prodromal and enduring residual symptoms of schizophrenia associated with structural brain abnormalities. The overlap and lack of equivalence of these concepts and the limited empirical evidence does not allow firm conclusions. New longitudinal studies using clinical, psychosocial, and neuropsychological measures are needed to understand the natural history and etiology of the defect state.

Replacing the mental hospital. Community provision for a district's chronically psychiatrically disabled in domestic environments?

Eighteen long-stay patients from an old county asylum moved into hospital hostels. After 12-24 months, there were significant reductions in overall symptoms, as rated by the CPRS and the Krawiecka scale, as well as in deviant but not general behaviour, rated by the REHAB scale. Six later moved to live in supported accommodation. All relatives and patients who expressed an opinion to an independent assessor were satisfied with their present accommodation or wished to move to more independent living.

The relationship of tardive dyskinesia to positive schizophrenia

Investigations aimed at identifying the clinical characteristics that discriminate Tardive dyskinesia (TD) from non-TD patients have yielded disparate findings. A number of studies have suggested that TD may be a feature of negative schizophrenia. In particular, the association of TD with high prevalence of "soft" neurological signs, cognitive deficits, and abnormal brain morphology on CT scan in some patients, have led several investigators to propose that negative schizophrenia may be a risk factor for TD. The neurochemical profile of TD, however, is not consistent with this hypothesis. In the following communication, we present our studies which suggest that TD is specific to and an intergral part of positive schizophrenia. The data suggest that schizophrenic patients with predominant positive symptoms may be at increased risk for the development of TD. In addition, we present evidence linking TD with left cerebral hemispheric dysfunction. By comparison, we provide evidence that negative schizophrenia is related to diencephalic damage, and discuss its relevance to negative schizophrenia and to Parkinsonism. We also provide evidence that negative schizophrenia may be a risk factor for acute drug-induced dystonia. Thus, these findings are consistent with our model that negative schizophrenia is a risk factor for Parkinsonism, whereas positive schizophrenia is related to TD. In analogy with the positive/negative dichotomy of schizophrenia, we propose that TD could be considered a "positive," where Parkinsonism a "negative" movement disorder.

Patient psychopathology and expressed emotion in schizophrenia

The relationship of a full range of psychiatric symptoms to EE was examined in 40 men with BPRS and SANS diagnoses of schizophrenia or schizoaffective disorder. Patients from high-EE families had significantly higher ratings of positive symptoms, anxious depression, and overall psychopathology, but not negative symptoms, than did those from low-EE families. In predicting relapses of schizophrenia, account may need to be taken of an interaction between subtle differences in symptoms and relatives' attitudes.

Chronically ill psychiatric patients in a district general hospital unit. A survey and two-year follow-up in an inner-London health district

A survey was undertaken at the end of 1984 of all patients occupying psychiatric beds for more than six months in an inner-London health district. Excluding those with senile dementia, 30 patients were identified. Two years later, a follow-up survey traced the original cohort and the accumulation of additional patients on the wards. The finding that the rate of discharge from the original group matches the accumulation of new patients into the survey suggests a need for new types of community provision within the district.

The relationship of negative schizophrenia to parkinsonism

The positive-negative distinction of schizophrenia has emerged as a valid means of clarifying its heterogeneity. Despite evidence that the two symptom classes may reflect different dimensions of the disease, there is presently no integrated model for understanding of the pathophysiology of these symptoms and their co-occurrence in schizophrenia. We propose that negative phenomena of schizophrenia may be a variant of Parkinsonism. This view is supported by the overlap with Parkinsonism in terms of clinical features, neurochemistry, pharmacology, as well as neuroradiological and neuropathological aspects. As such, negative symptoms may be a manifestation of disease of the basal ganglia and constitute the core pathology in schizophrenia. Positive symptoms, conversely, may reflect an "accessory" process related to a compensatory increase in striatal and limbic dopamine activity following an injury to the dopaminergic system. In the present communication we present a series of studies that support the association of negative schizophrenia and Parkinsonism. Based on this evidence, we suggest that schizophrenic patients with prominent negative symptoms might be managed like patients with Parkinson's disease, namely, with dopaminergic drugs and MAO-B inhibitors. Finally, the association of negative schizophrenia with Parkinsonism raises the possibility that adrenal medullary tissue transplantation, which may benefit a selected group of Parkinsonian patients, may be a future promising therapy for refractory negative schizophrenia.

Depression, negative and positive symptoms, and the DST in schizophrenia

It has been suggested that the presence of depression is a major determinant of abnormal dexamethasone suppression in patients with schizophrenia. It has been reported that negative symptoms in patients with schizophrenia are associated with increased rates of nonsuppression. In this study of schizophrenic inpatients, the Dexamethasone Suppression Test (DST), depression and negative and positive symptom ratings were carried out in two phases of the acute episode, in the second week after administration to, and in the week prior to discharge from, hospital. There was no association between depression and cortisol nonsuppression or between negative and positive symptoms and cortisol nonsuppression either early or late in the acute episode. It is concluded that the DST has no clinical utility in identifying the non-melancholic depression which occurs commonly in schizophrenia.

Syndromes of chronic schizophrenia

Confirmation is reported of an earlier finding that the symptoms of patients with chronic schizophrenia segregate into three syndromes: psychomotor poverty (poverty of speech, flatness of affect, decreased spontaneous movement); disorganisation (disorders of the form of thought, inappropriate affect); and reality distortion (delusions and hallucinations).

Psychiatric patients' views of their lives before and after moving to a hostel: a qualitative study

This study focuses upon the experiences of a group of 10 long-stay psychiatric patients as they moved from a large institution to a staffed community hostel. The residents were interviewed 2 weeks prior to moving and again 6 weeks after the move. Areas identified in the first set of unstructured interviews were followed up in the second set. Qualitative analysis of the interviews revealed seven recurrent themes that are discussed in relation to other research studies that consider how people experience the effects of institutionalization. The study tests the feasibility of unstructured interviews as a means of collecting accounts of the perceptions and experiences of a client group from which other research methods have failed to elicit detailed information. Unstructured interviews proved successful when undertaken by a researcher who was well known and accepted by the residents. Familiarity with the residents and the context of the interview was also found to be important in analysing interviews qualitatively and the study casts doubt upon the value of primary qualitative analysis of interview transcripts by researchers who have not also participated in the interviews. The methodological implications for future deinstitutionalization studies are discussed.

Enhancement of recovery from psychiatric illness by methylfolate

41 (33%) of 123 patients with acute psychiatric disorders (DSM III diagnosis of major depression or schizophrenia) had borderline or definite folate deficiency (red-cell folate below 200 micrograms/l) and took part in a double-blind, placebo-controlled trial of methylfolate, 15 mg daily, for 6 months in addition to standard psychotropic treatment. Among both depressed and schizophrenic patients methylfolate significantly improved clinical and social recovery. The differences in outcome scores between methylfolate and placebo groups became greater with time. These findings add to the evidence implicating disturbances of methylation in the nervous system in the biology of some forms of mental illness.

The relationship between clinical and biochemical changes following neuroleptic treatment in schizophrenia

Clinical improvement in psychotic symptoms is not immediate when neuroleptic treatment is commenced. Previous studies have demonstrated the development of biochemical tolerance to the effects of neuroleptics on the dopamine system. This study demonstrates a relationship between this biochemical change and the clinical changes occurring in the patients. The results can be explained in terms of dopamine receptor changes in a way that is compatible with the Dopamine Hypothesis for schizophrenia.

Cognitive functioning and symptomatology in chronic schizophrenia

Chronic schizophrenic patients in a long stay hospital were found to have low levels of intelligence (mean IQ of 80), which was attributed to the effects of substantial intellectual deterioration on below average pre-morbid levels of functioning. Patients with the lowest IQ scores had the least severe positive symptoms but symptomatology was not related to age or extent of intellectual decline. Speed of functioning was relatively more impaired than level of intellectual functioning, with cognitive speed being more affected than motor speed. The severity of negative but not positive symptoms was significantly related to the severity of bradyphrenia (cognitive slowing), a result which would be consistent with the notion of a subcortical pathology in patients with Type II schizophrenia.

Remoxipride and haloperidol in the acute phase of schizophrenia: a double-blind comparison

The efficacy and safety of remoxipride in the treatment of schizophrenia were compared with those of haloperidol in a multicentre double-blind 6-week study which was randomized with a parallel group design and was preceded by a washout period. Eighty-nine consecutively admitted men and women meeting the Research Diagnostic Criteria for schizophrenia in an acute phase of the illness were treated with remoxipride 75-300 mg twice daily or haloperidol 5-20 mg twice daily. The efficacy assessments were the Brief Psychiatric Rating Scale, Krawiecka Rating Scale, and Clinical Global Impression. Both antipsychotic drugs produced clinical improvement with no significant differences between the efficacy of the two drugs. There were relatively few side effects. There were significantly fewer extrapyramidal symptoms and instances of blurred vision with remoxipride and less constipation with haloperidol. The results indicate that remoxipride is as effective an antipsychotic as haloperidol. Remoxipride has an advantage over haloperidol in respect to extrapyramidal side effects.

New chronic schizophrenic patients: a comparison of daypatients and inpatients

A group of 24 "new chronic" schizophrenic inpatients was compared with a group of 19 daypatients matched for duration of current care; both had spent between 1 and 6 years in continuous inpatient or daypatient care. The groups were compared on a variety of clinical, demographic, and social variables to identify specific variables that might distinguish the new chronic inpatient group. Despite a few nonsignificant trends in the data, the groups were found not to differ significantly on any variables. Both groups had long psychiatric histories with many previous hospital admissions, presented many negative symptoms of schizophrenia at interview, were quite disabled in terms of self-care and speech skills, had a low incidence of behavioural disturbance and had few contacts outside of the hospital. The majority of both groups expressed a clear preference for community care. The results therefore highlight the urgent need for more comprehensive and detailed assessment of patients in relation to decisions about retention in or discharge from inpatient hospital care and also the need to identify objective predictors of the success of such decisions.

Current conceptualizations of psychiatric illnesses as neurological disorders

This paper reviews a recent body of evidence from computed tomography, imaging methods, and neuropsychological testing, emphasizing schizophrenia. The review indicates important characteristics of this disorder that can be conceptualized as similar to neurological disorders, and that have a probable neuropathologic basis. Although the argument is compelling in many respects, cautionary observations are also discussed, and a need for positioning subgroups based on neurological etiology is advanced. This serves as an introduction to a discussion of neurological diseases as potential models for psychiatric disorders.

Psychometric properties of the Manchester Scale

This article reports a preliminary investigation of the psychometric properties of the Manchester Scale (MS). Fifty-three patients were assessed on the instrument, 33 at time 1 (7-10 days after admission) and 53 at time 2 (during the week prior to discharge). Interrater reliabilities were generally good at time 2. The factor analyses conducted on the 8 MS items at times 1 and 2 suggest that MS contains a heterogeneous group of items: only the MS negative symptoms were related to one another. The MS positive and negative symptoms were strongly correlated with their counterpart items on the Schedules for the Assessment of Positive Symptoms and Negative Symptoms, suggesting that the MS items have good concurrent validity.

Cognitive processing and its relationship to symptoms and social functioning in schizophrenia

This study analyses the relationship between contextual processing ability and symptom and social status in schizophrenia. The results showed that current symptom status is related to occupational status, and contextual processing is related to current symptom status and employment history. Current symptom severity in chronic schizophrenics may indicate an increased frequency and/or duration of symptom episodes in the past, and therefore an increase in the periods in which contextual processing was disturbed, which would therefore account for the observed decrease in work achievements.