A standardized psychiatric assessment scale for rating chronic psychotic patients

Pharmacokinetics and antipsychotic effect of remoxipride in chronic schizophrenic patients

Single dose pharmacokinetics and the antipsychotic effect of 4 weeks treatment with three fixed dose levels of remoxipride (a selective D(2) receptor antagonist) were studied in chronic, stable schizophrenic inpatients. After a placebo washout of 1 month, 15 patients entered the study. Of these, 11 patients received a single 50 mg oral dose of remoxipride for pharmacokinetic evaluations. All 15 patients were randomly assigned to treatment with oral remoxipride either 25 mg t.i.d., 50 mg t.i.d. or 100 mg t.i.d. for 4 weeks. Blood samples for remoxipride and prolactin assays were taken at 0, 0.33, 0.5, 0.66, 1.0, 1.5, 2, 3, 4, 8, 12, 24, 28, 32 and 48 h after drug intake. The pharmacokinetic characteristics were similar to those previously found in normal healthy volunteers: the mean peak plasma concentration of remoxipride after 50 mg was 3.3 μmol/l, the mean time to reach this was 2.1 h; the mean area under the plasma concentration/time curve was 27.8 μmol/1.h.1( -1) and the mean elimination half-life of remoxipride was 5.5 h. A significant increase in prolactin levels was detected 2 h after administration of remoxipride but they had reverted to normal 8 h after drug intake in all but one patient. Antipsychotic effects were estimated using the brief psychiatric rating scale (BPRS) and the Krawiecka rating scale (KRS) at admission, baseline (end of the 4 week placebo washout period) and after 7, 14 and 28 days treatment. Following an increase in mean psychosis ratings for both positive and negative symptoms during the placebo washout period, these decreased during active treatment and at the end of the study were similar to the scores on admission. Thus the possible efficacy of remoxipride in chronic patients with negative symptoms should be further explored in placebo controlled studies. Remoxipride was well tolerated. Sleep disorders occurred in three patients, extrapyramidal symptoms were not aggravated and no clinically significant effects were observed on the cardiovascular system, in clinical chemistry or haematology.

Positive-negative symptom assessment in schizophrenia: psychometric issues and scale comparison

The positive-negative distinction has emerged as a meaningful basis for understanding the heterogeneity of schizophrenia and treatment alternatives, but its delineation requires carefully devised, well validated techniques. This article considers the psychometric requisites for such an instrument and describes 30 criteria associated with operationalization, scale construction, and standardization. Six prominent positive-negative scales are compared on these criteria, and most are found deficient in terms of: a formalized interview procedure; detailed definitions for levels of symptom severity; exclusion of "secondary" negative symptoms; comparative scales to assess positive symptoms, depression, and global severity of illness; broad sampling of negative symptoms; large scale standardization studies; and determination of multiple facets of reliability and validity. The Positive and Negative Syndrome Scale (PANSS) is described as an effort to approach these principles of test standardization, and its clinical and research applications are discussed.

The application of the concept of expressed emotion to the role of the community psychiatric nurse: a research study

The previous article examined the development of the concept of 'expressed emotion', argued that controlled studies had successfully demonstrated the value of psychosocial intervention, but demonstrated that such a therapeutic approach had been mostly limited to the research studies themselves. In the light of the demonstrable efficacy of psychosocial intervention, the psychiatric nursing literature is reviewed in order to establish how far nurses have capitalized on the utility of the 'expressed emotion' concept, to date, in their work with schizophrenic clients and their families. In addition, a brief historical overview of the Community Psychiatric Nurses' (CPNs) role with schizophrenic clients is presented which relates to current ongoing research in this area which is described. In brief, the research project, which is funded by the Department of Health, is evaluating the outcome of teaching CPNs to deliver psychosocial interventions to families caring for a schizophrenic relative at home.

Are employment-interview skills a correlate of subtypes of schizophrenia?

46 inpatients with a DSM-III diagnosis of schizophrenia were assessed in the week prior to discharge from hospital on measures of positive and negative symptoms and on 12 measures of employment interview skills (i.e., eye contact, facial gestures, body posture, verbal content, voice volume, length of speech, motivation, self-confidence, ability to communicate, manifest adjustment, manifest intelligence, over-all interview skill), and a global measure of employability. A cluster analysis based on the total positive and negative symptom scores produced two groups. The group with the lower mean negative symptom score exhibited better employment-interview skills and higher ratings on employability.

The Scottish first episode schizophrenia study. VII. Two-year follow-up. Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 2 years after their first admission to hospital, 37% were well, 47% had been readmitted to hospital at some time over the 2 years, and 38% showed schizophrenic symptoms at follow-up. A poor outcome at 2 years was associated with male sex, poor outcome after the first 5 weeks of the first admission, negative schizophrenic symptoms on first admission, and a diagnosis of definite or probable schizophrenia using the Feighner criteria. Only 23% were in employment. A small double-blind discontinuation study of maintenance antipsychotic medication during the second year found more relapses in those switched to placebo medication. Repeat psychometric assessment at 2 years confirmed modest improvements found at 12 months; that is, there was no evidence of intellectual decline. Relatives showed no more psychosocial distress than that found in a normal community sample; what distress there was correlated with patients' schizophrenic symptoms.

Small intestine permeability in schizophrenia

Gastrointestinal permeability was assessed by means of absorption of 51Cr-labelled EDTA in 24 patients with schizophrenia (12 in relapse and 12 in remission). The results were compared with those for patients with coeliac disease and those for normal controls. Significant differences between the schizophrenic patients and the normal controls were not established. The results for the schizophrenic patients in remission were no different from those for the patients in relapse, and there was no evidence from the study of an effect on gastrointestinal permeability of either anticholinergic or antidepressant medication. It is concluded that schizophrenia is, at least in the majority of cases, unrelated to coeliac disease.

Correlates of positive and negative schizophrenic syndromes in Nigerian patients

The two-syndrome concept of schizophrenia was investigated in a sample of 70 Nigerian schizophrenic patients. The positive and negative syndromes were studied in relation to demographic, historical, neurological and psychometric measures. The negative syndrome was associated with cognitive impairment, behavioural deterioration and left eye dominance, and also with poor pre-morbid educational achievement and longer length of current stay in hospital. The positive syndrome was unrelated to any of the independent variables. The two syndromes were not significantly related, supporting the view that they represent relatively independent dimensions of pathology. This provides further support for the validity of the Type I-Type II subtyping of schizophrenia in populations of patients from different cultural backgrounds, and suggests that the negative syndrome is related to the presence of neurodevelopmental deficits that possibly antedate the schizophrenic illness.

Negative symptoms and social skills performance in schizophrenia

The present study aimed to determine whether the negative symptoms of patients with schizophrenia were better predictors of social competence than a range of other variables pertaining to demographics, illness, hospitalization, and premorbid functioning. Independent raters assessed social skills performance on a video-taped role-play test and 5 min conversation in 53 inpatients with a DSM-III diagnosis of schizophrenia. Patients' social skills were also assessed by ward nurses. Project clinicians assessed depression, medication side effects and positive and negative symptoms. Multiple-regression analyses demonstrated that, generally, negative symptoms were the best predictors of social skills performance.

Focal family therapy outcome study. I: Patient and family functioning

This pilot study compared the efficacy of two models of family therapy plus medication in the treatment of ten schizophrenic patients previously considered poor responders to neuroleptics alone. Focal Family Therapy (FFT), a limited psychodynamic model, was compared with Supportive Management Counselling (SMC), an educative, problem-solving approach. Family treatment was begun during admission to hospital and continued for up to six months post-discharge. Patient and family measures were administered on assessment, termination, and at three, six and 12 month follow-up interviews. Our data suggest that patients in both groups improved significantly following treatment on measures of social functioning and community tenure. The average increase in amount of time out of hospital was a full year, compared to previous rates. Patients receiving FFT demonstrated significantly greater improvement in symptoms, compared to patients in the SMC group. On average, families scored in the normal range on the family functioning measure at assessment and upon termination of treatment.

Collected and neglected: are Oxford hostels for the homeless filling up with disabled psychiatric patients?

OBJECTIVE

To assess the severity of psychiatric symptoms among residents of hostels for homeless people.

DESIGN

Survey of residents in two hostels in Oxford, comprising three weeks of background fieldwork, a demographic questionnaire, and rating behaviour over two weeks with a behavioural rating scale (REHAB) and mental state with the brief psychiatric rating scale.

SETTING

Two hostels for homeless people in Oxford.

SUBJECTS

146 Medium to long term residents, of whom 48 were selected by hostel workers by the following criteria: continuous residence for at least two months, signs of persistent severe mental disability, and difficulty in coping independently in the community. Two subjects died during the study; three (previously long term psychiatric inpatients) declined to be assessed on the psychiatric scale.

MAIN OUTCOME MEASURE

Behavioural disturbance and mental state.

RESULTS

Only a third of the total sample had been born in Oxfordshire. Subjects had been accepted into the hostel either by arrangement with the local psychiatric service (22) or straight off the streets (26); 43 had had a previous (non-drug related) psychiatric admission. Subjects were significantly more likely than other residents to have spent longer (greater than 80 weeks) in a hostel in the past three years (p less than 0.02). With reference to norms for deviant behaviour, the 46 subjects assessed showed considerable deviant behaviour (average weekly scores: 0 (11 subjects), 1 (14), 2-3 (16), and greater than or equal to 4 (5] not significantly different from that expected in moderately to severely handicapped psychiatric inpatients (chi 2 = 1.3, df = 3, p greater than 0.7); 22 had scores equivalent to those in most severely handicapped inpatients. Of the 43 subjects assessed with the psychiatric rating scale, 16 had symptoms of neurosis, 29 of florid psychosis, and 32 of a deficit state. Symptoms of deficit state were positively correlated with ratings of low social activity on the behavioural scale (Spearman's rank correlation coefficient 0.30, p = 0.03).

CONCLUSIONS

Hostels are having to care for long term severely affected psychiatric patients discharged into the community. The suitability of the services offered to such subjects should be assessed.

The significance of stupor in the long-term outcome of chronic schizophrenia

The admission records of 271 long-stay chronic schizophrenic patients, resident in a large psychiatric hospital, were examined in order to identify those who had presented in stupor at the onset of their illness. Twelve patients were found (ten men and two women). When compared, in terms of current mental state and behaviour, with a similar sample of schizophrenics in whom stupor had been absent, significant differences between the two groups were detected, with those presenting in stupor demonstrating a less favourable outcome.

Computed tomography in depression: association between ventricular size and psychopathology

The relationship between psychopathology and brain alterations, measured by computed tomography (CT), was investigated in 44 depressed patients. Comparisons of ventricle-brain ratio (VBR) between "endogenous" vs. "nonendogenous" subgroups, classified by six distinct diagnostic systems, revealed no significant differences. The VBR and the width of the third ventricle correlated significantly with scores on the Brief Psychiatric Rating Scale, the Global Assessment Scale, the Bech-Rafaelsen Melancholia Scale, the Rating for Emotional Blunting, and the Scale for the Assessment of Negative Symptoms, but not with scores on the Hamilton Rating Scale for Depression and the Hamilton Rating Scale for Anxiety. Item analyses of the Bech-Rafaelsen Melancholia Scale revealed that retardation-related items were most significantly correlated with ventricular size. The wider diameter of the third ventricle in psychotic patients was associated with higher scores on retardation in the psychotic subgroup, whereas the greater distances of both Sylvian fissures showed no relationship to psychomotor retardation. No significant correlations were found between CT values and anxiety, suicidal impulses, somatic complaints, and sleep disturbances.

Tardive dystonia. The benefits of time

Tardive dystonia is a rare movement disorder. We outline the development of tardive dystonia in a young schizophrenic, and demonstrate the importance of applying a double-blind, placebo-controlled, cross-over trial of any putative successful treatment.

Clinical characteristics, health beliefs and compliance with maintenance treatment: a comparison between regular and irregular attenders at a depot clinic

This study investigated the relationship between clinical characteristics, health beliefs and compliance with depot neuroleptic maintenance treatment in schizophrenic patients by comparing a group of 40 irregular clinic attenders with another group of regular attenders matched by age and sex. While the 2 groups showed no difference in drug-induced extrapyramidal effects, the former were significantly more often depressed than the latter. Test-retest reliability coefficients of a 4-section health belief questionnaire showed marked variation in individual items. The 2 groups showed no difference in their perception of past effect of illness, likelihood of a relapse if maintenance treatment was stopped and effects of maintenance treatment.

The incidence of negative symptoms in early schizophrenia, mania and other psychoses

Despite increasing interest in negative symptoms in schizophrenia there has been little work on their incidence in early schizophrenia or in other psychoses. This study examined 79 nondepressive psychotics within 2 years of onset of illness, diagnosed by Research Diagnostic Criteria and assessed for negative symptoms using the Scale for the Assessment of Negative Symptoms. Marked negative symptoms were observed in nearly half of patients diagnosed as suffering definite schizophrenia and were rarely found in other psychoses. Negative symptoms were not significantly correlated with positive symptoms, depression or exposure to neuroleptics, but were correlated with developing extrapyramidal side effects.

Is social skills performance a correlate of schizophrenia subtypes?

53 inpatients with a DSM-III diagnosis of schizophrenia were assessed in the week prior to discharge from hospital on measures of social skills performance and on severity of positive and negative symptoms. A cluster analysis based on the total positive and negative symptom scores resulted in three groups. The group with the least negative symptoms exhibited the best social skills performance. The findings add a further dimension to the validity of the subtyping of schizophrenia on the basis of positive and negative symptoms.

Dysphoric and depressive symptoms in chronic schizophrenia

This study suggests that depressive symptoms are less common in severe, chronic, schizophrenic inpatients than would be predicted if these symptoms were manifestations of negative symptoms or drug-induced parkinsonism. The findings further suggest that depressive symptoms in such patients are independent phenomena which conform to a depressive syndrome. This depression does not represent a misidentification of the negative symptoms affective flattening and alogia, as measured by the SANS, or parkinsonism or akathisia. The study findings fail to support the view that long-term depot antipsychotic medication plays an important role in the genesis of depression and dysphoria in chronic schizophrenic patients. Depressive symptoms were found to occur as frequently, and dysphoria more frequently, in schizophrenic patients in the year after drug withdrawal compared with patients continuing on maintenance drug treatment for the same period.

Trial of brief intermittent neuroleptic prophylaxis for selected schizophrenic outpatients: clinical outcome at one year

A study was conducted to investigate a novel approach to the prophylaxis of schizophrenic relapse. The treatment strategy comprised brief intermittent courses of neuroleptic agents begun as soon as non-psychotic symptoms believed to be early signs of relapse appeared. Fifty four stable, remitted outpatients meeting the American Psychiatric Association's DSM-III criteria for schizophrenia were randomised double blind to receive brief intermittent treatment with either active or placebo depot neuroleptic injections. Only three patients given placebo injections and two controls were admitted to hospital during one year of follow up. Eight (30%) of the patients given placebo injections and only 2 (7%) of the controls, however, had a recurrence of schizophrenic symptoms. Patients given placebo injections experienced fewer extrapyramidal side effects and showed a trend towards a reduction in tardive dyskinesia. Dysphoric and neurotic symptoms were identified before eight out of 11 relapses, and these symptoms were more frequent in patients given placebo depot injections. These results suggest a viable but not necessarily better alternative to continuous oral or depot treatment for less ill, chronic, stabilised schizophrenics based on the early treatment of putative prodromal symptoms of relapse.

The Scottish First Episode Schizophrenia Study. VI. Computerised tomography brain scans in patients and controls

This is the initial report of a prospective study by computerised tomography brain scan of first episode schizophrenia. Twenty-seven patients who met Research Diagnostic Criteria for schizophrenia were compared with volunteer controls on ventricular:brain ratio, sulcal:brain volume ratio, and the widths of third ventricle and Sylvian and interhemispheric fissures. The results provide evidence that sulcal enlargement, but not ventricular abnormalities, may be detected at first admission for schizophrenic illness, and are discussed in relation to findings from other studies.

Psychiatric day hospitals--another route to institutionalization?

Nineteen long-stay day patients were referred to a rehabilitation team and their outcome after a year is compared with 19 day patients who were not referred, but were matched for age, sex and diagnosis. Seven rehabilitation team patients had been discharged at 12 months as against 3 of the non-rehabilitation patients, but this was not a significant difference. Discharged patients were less disturbed at the beginning of the study and had fewer negative symptoms throughout. Discharge did not reduce the frequency of social contact. There was a suggestion that morale was sustained better in the rehabilitation patient and in their nurses. We conclude that rehabilitation planning may have beneficially accelerated the discharge of less ill day-patients, but that more resources are needed to prevent 'institutionalization' within the day-hospital.

The spectrum of structural brain changes in schizophrenia: age of onset as a predictor of cognitive and clinical impairments and their cerebral correlates

A range of cerebral structures was assessed in a series of 172 CT scans of groups of psychiatric patients (including 101 in-patients with chronic schizophrenia) and related to assessments of clinical state and psychological function. Ventricular indices were increased in patients with schizophrenia by comparison with patients with other psychiatric disorders: brain area, which is modestly positively correlated with ventricular indices, was significantly (P less than 0.01) reduced in patients with schizophrenia. Among in-patients with chronic schizophrenia, measures of increased ventricular size were significantly associated with impaired social behaviour and with movement disorder. Memory for famous names in the distant past (a test of remote memory) was the only psychological test which showed significant associations with indices of ventricular size; this suggests that ventricular enlargement and its psychological sequelae occur relatively early in the disease process. Dichotomization of the sample of schizophrenic patients around the mean age of onset revealed that a range of clinical and psychological functions are significantly more abnormal in those with an early age of onset than in those in whom the onset was later. Early onset cases also perform less well academically and occupationally before illness onset. Within the early onset group some significant correlations between cognitive function and brain area were seen. The findings suggest that: (i) some at least of the structural changes in schizophrenia arise at a time when the brain is still developing; and (ii) age of onset is an important determinant of social and intellectual impairment and is relevant to the relationship between brain structure and cognitive deficits.

The chronically mentally ill in community facilities. A study of quality of life

The quality of life of chronically mentally ill patients in acute wards in a district general hospital, a hostel ward and group homes was compared. Within the spectrum of care of these patients, the severity of psychopathology corresponded to their placement. Analysis, including adjustments for the influence of psychopathology, showed differences between the three types of facility. Although differences existed between all types of care, residents in group homes and the hostel ward shared more similarities in quality of life than those in the district general hospital. Problems of caring for the chronically mentally ill on acute wards are highlighted.

Topographic subtypes of tardive dyskinesia in schizophrenic patients aged less than 60 years: relationship to demographic, clinical, treatment, and neuropsychological variables

There are conflicting reports about factors that may be associated with the development of involuntary movements in patients exposed to long-term neuroleptic treatment. Recent evidence suggests that some of these inconsistencies may relate to the practice of regarding these disorders as a unitary syndrome. There is also evidence that both the topographic distribution of these involuntary movements and the pathophysiological mechanisms underlying them may differ in the young and in the old. In this study, demographic, clinical, treatment and neuropsychological variables were investigated for association with the presence of orofacial and limb-truncal dyskinesias in 57 schizophrenic patients aged less than 60 years. Stepwise multiple logistic regression analysis showed that orofacial dyskinesia, at different degrees of severity, was negatively associated with positive schizophrenic syndrome and with either age at assessment or age at onset of illness. None of the indices of schizophrenic deficit (cognitive impairment, clinical defect state, behavioural deterioration, or neurological dysfunction) was related to orofacial dyskinesia. Limb-truncal involuntary movements were negatively related to current daily dosage of neuroleptics. The findings indicate that these two types of dyskinesia may involve different underlying mechanisms and that, for young schizophrenic patients, current pathophysiological or neurochemical theories of involuntary movement disorders are inadequate in explaining their origins.

The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse

Schizophrenic patients were recruited into a trial of a prophylactic behavioural intervention with families. Families with at least one high Expressed Emotion (EE) relative were randomly allocated to one of four intervention groups: Behavioural Intervention Enactive; Behavioural Intervention Symbolic; Education Only; Routine Treatment. Patients from low-EE families were randomly allocated to two groups: Education Only or Routine Treatment. Relapse rates over nine months after discharge were significantly lower for patients in the two Behavioural Intervention, compared with Education Only and Routine Treatment groups. There was little difference between the two low-EE groups. Patients returning to high-EE relatives showed significantly higher relapse rates than those returning to low-EE relatives, in groups not receiving active intervention. Changes from high to low EE occurred in the Behavioural Intervention groups, and similar although less extensive changes occurred in the Education Only and Routine Treatment groups. Changes in criticism and marked emotional over-involvement (EOI) occurred generally in high-EE groups but were larger in magnitude in the Enactive and Symbolic groups. Reduction of hostility only occurred in the Behavioural Intervention groups. These results give partial support for the causal role of EE in relapse. There were no significant differences between the groups with respect to contact with the psychiatric services or medication.

Neurological soft signs in Nigerian schizophrenics: a controlled study

The prevalence of neurological soft signs in schizophrenics was compared with that in patients with major affective disorder and in normal subjects. The two patient groups did not differ from one another, but both differed from normal controls in the occurrence of right-left confusion. The paranoid and nonparanoid subtypes of schizophrenia did not differ in the prevalence of neurological soft signs. Schizophrenic patients with or without one sign had similar demographic, clinical and treatment attributes. It is concluded that neurological soft signs are not specific to schizophrenia, but may, in general, reflect the level of obstetric care in a community. However, certain soft signs may be more strongly indicative of neurodysfunction associated with the psychotic state.

Criteria for evaluating improvement in schizophrenia in psychopharmacological research (with special reference to gamma endorphin fragments)

A review of treatment trials with DT gamma E revealed widely discrepant results. Relevant variables were the variety of measures employed for monitoring psychotic symptoms, and the different criteria used to judge the degree of improvement. The authors suggest a uniform outcome criterion for early trials of new treatments, which would generate more consistent and comparable results between studies, and give a stronger indication of the value of the treatment under test. When the data from the various treatment trials of DT gamma E were reanalysed, applying a uniform outcome criterion of improvement of a change of 80% or more on rating-scale score, the results were more consistent than would have been suspected from the original reports.

Seasonal variations in prolactin levels in schizophrenia

As part of an ongoing longitudinal study of drug-free schizophrenic patients, we serially sampled resting early morning prolactin levels in 10 subjects. In a preliminary analysis, these levels were compared to those found in matched normal control subjects over a 4-year period. Both control and schizophrenic subjects showed a marked annual variation in prolactin levels. Six schizophrenic patients sampled in each quarter of the year showed a significant annual rhythm, with prolactin highest in the spring (March-May). In seven schizophrenic patients and nine controls sampled at two seasons in the year, prolactin was significantly higher in spring-summer (March-August) than in fall-winter (September-February), with no difference between patients and control subjects.

The Northwick Park "functional" psychosis study: diagnosis and treatment response

Functional psychosis is conventionally subdivided into schizophrenia and manic depressive psychosis. Response to treatment is assumed to be a validating criterion for these diagnoses. The efficacy of pimozide (a dopamine antagonist neuroleptic), lithium, and a combination of the two was compared with that of placebo in a 4 week trial in 120 functionally psychotic patients each of whom was assessed for psychotic symptoms, manic symptoms, and depressive symptoms. The sample was subdivided into patients with predominantly elevated mood, predominantly depressed mood, and no consistent mood change. Pimozide reduced psychotic symptoms in all groups of patients. The only significant effect of lithium was to reduce elevated mood. Thus dopamine blockade seems relevant to the resolution of psychotic symptoms in all types of "functional" psychosis but the mode of action of lithium in psychotic patients concerns only mood. Application of standardised classifications of functional psychosis to these data did not change this conclusion.

Effects of 4 weeks treatment with chlorpromazine and/or trihexyphenidyl on the pituitary-gonadal axis in male paranoid schizophrenics

Serum prolactin (PRL), luteinizing hormone (LH) and testosterone (T) levels were estimated in a group of 30 male paranoid schizophrenics before and after 4 weeks treatment with chlorpromazine and/or trihexyphenidyl, and in a group of 14 healthy male individuals. After treatment with chlorpromazine (100 mg t.i.d., p.o.), 10 patients presented a significant increase in serum PRL values and a significant decrease in serum T values. A significant increase in serum PRL values was also found in 10 patients who were treated with chlorpromazine (100 mg t.i.d., p.o.) plus trihexyphenidyl (5 mg t.i.d., p.o.). No significant difference in any of the investigated endocrine parameters was detected in 10 patients after 4 weeks administration of trihexyphenidyl (5 mg t.i.d., p.o.). Following chlorpromazine treatment with or without concomitant administration of trihexyphenidyl, 20 patients showed a significant increase in serum PRL levels and a significant decrease in serum LH and T levels.

Longitudinal growth hormone studies in schizophrenia

The growth hormone (GH) response to apomorphine hydrochloride (APO) was examined monthly in 12 schizophrenic patients on drug holiday for up to 22 months and compared with age- and sex-matched controls. There was more variability in the response of patients than controls on the first trial and on several subsequent challenges. Patients' and controls' GH responses to an APO challenge did not distinguish them from each other on the first trial. However, longitudinal data revealed that in a subgroup of five schizophrenic patients and five controls, studied for 12 consecutive trials, the GH response averaged over the 12 trials was significantly lower in the patients than in the controls. Moreover, when schizophrenics' responses on each successive trial were compared, responses decreased over time, but were significantly different from controls only in the later trials. Three of the patients were followed for more than 12 trials, and their GH responsivity increased in the later trials. GH response to APO was significantly correlated with positive symptom scores in three patients but not in four others. There was a trend toward an association between the occurrence of relapse and GH increment induced by APO. A significant association between change in body weight and change in GH response to APO was discovered, suggesting that a changing body weight may contribute to the variability in subjects' response to APO.

The Scottish First Episode Schizophrenia Study V. One-year follow-up. The Scottish Schizophrenia Research Group

Of 49 schizophrenic patients followed up 12 months after their first admission to hospital, only about 45% had experienced no relapse and had no schizophrenic symptoms; a poorer outcome was more often found in Feighner positive than Feighner negative schizophrenic patients. The patients' overall level of unemployment had more than doubled to 51%. In patients whose acute episodes responded to treatment, pimozide taken once weekly as maintenance therapy was as effective as intramuscular flupenthixol decanoate, but tardive dyskinesia appeared in two patients receiving weekly pimozide; the repeat psychometric assessment at 12 months found modest improvements, i.e. no evidence of intellectual decline, in Matrices, Block Design, and Digit Copying tests. Forty per cent of relatives still showed significant psychological distress, which correlated with patients' schizophrenic symptoms, and the relatives' social functioning remained poorer than that of a normal community sample.

The effect of electroconvulsive therapy on CSF amine metabolites in schizophrenic patients

The effects of a series of six ECT treatments were observed on the CSF concentrations of HVA, MHPG, and 5-HIAA in 12 patients suffering from schizophrenia. Four patients were previously neuroleptic drug-free, and eight had received only oral neuroleptic drugs at the same dose for more than 4 weeks. A significant increase in the concentration of HVA was observed after the first ECT treatment but not after the final treatment. No significant changes were observed in the concentrations of MHPG and 5-HIAA. The patients improved clinically, and the results suggest that ECT has important effects on dopaminergic systems.

Serum haloperidol levels and clinical response in chronic, treatment-resistant schizophrenic patients

Eleven chronic treatment-resistant schizophrenic in-patients were treated with haloperidol (HPL) or placebo with a fixed ascending dose schedule for 20 weeks. Seven patients relapsed and were withdrawn and five of these re-entered, single-blind, on known active treatment. Two weekly clinical ratings and weekly serum HPL levels were carried out throughout the study. More patients on placebo dropped out and at an earlier stage than those on active treatment but the difference was not statistically significant. Despite wide individual variations in both serum HPL levels and clinical response, these were positively correlated. HPL appeared to be of more value in the prevention of relapse than in symptom reduction. Overall, the clinical response was poor and a 'therapeutic window' could not be demonstrated either for the group as a whole or in any individual patient. There was no additional therapeutic benefit in exceeding serum HPL levels of 20 ng/ml in any of our patients. Since this serum level was achieved by daily doses of 10-40 mg HPL and the relationship between dose and serum level is linear, the use of serum HPL estimations is not likely to be of value in the routine clinical management of treatment-resistant patients.

The evaluation of a hostel ward. A controlled study using modified cost-benefit analysis

A controlled modified cost-benefit evaluation of a hostel ward caring for new long-stay patients is described and results are presented for the first two years. In some respects the residents of the hostel ward had fewer psychotic impairments than those remaining on the wards of the district general hospital, mainly because the latter seem to continue to acquire such defects, while the former have remained relatively unchanged. The hostel ward residents also develop superior domestic skills, use more facilities in the community, and are more likely to be engaged in constructive activities than controls. These advantages were not purchased at a price, since the cost of providing this form of care for these patients has cost less than care provided by the district general hospital.

Selective decreases in MAO-B activity in post-mortem brains from schizophrenic patients with type II syndrome

The activities of the A and B forms of the enzyme monoamine oxidase (MAO, E.C. 1.4.3.4) have been assessed with the substrates 5-hydroxytryptamine and benzylamine respectively in seven areas of the brains of 39 patients with schizophrenia and 44 control subjects. Whereas previous studies have found the enzyme unchanged in brain in schizophrenia, in this study there was a modest but significant decrease in the activity of MAO-B in frontal and temporal cortices and in amygdala. This decrease could not be accounted for by neuroleptic medication, age, sex or post-mortem variables. In a series of 22 patients who had been assessed in life, the reduction in MAO-B activity was found to be associated specifically with the presence of negative symptoms (flattening of affect and paucity of speech). The findings are therefore consistent with other evidence for structural and neurochemical change in the temporal lobe that have been associated with the type II (defect state) syndrome of schizophrenia. The change in enzyme activity is unlikely to be related to a change in monoamine metabolism but may reflect a disturbance in glial function. The change in MAO-B activity in brain in this study is confined to particular areas of brain and a subgroup of patients; it is thought to be entirely unrelated to earlier reports of reductions of enzyme activity in platelets, which are probably attributable to prolonged neuroleptic medication.

A comparison of scales for assessing rehabilitation patients

Twenty-four chronic schizophrenic patients were assessed by the Morningside Rehabilitation Status Scale, the Krawiecka Scale, and the Social Adjustment Scale by Self-Report. Inter-rater correlations suggest that the MRSS can be used by a rater with little previous knowledge of the patient. Between-scale correlations suggest the three scales assess somewhat different dimensions. A standard approach to rehabilitation assessment is suggested.

Age and duration of illness as predictors of ventricular brain ratio (VBR) size in chronic schizophrenic patients. A stepwise regression analysis study

The CT scans of 18 chronic schizophrenic patients and 17 controls were evaluated for Ventricular Brain Ratio (VBR) size. A trend for the patient group to have larger VBR than controls was present but did not reach statistical significance at the 5% level. Age was found to be an important correlate of VBR within the patient group but not among controls. In a stepwise multiple-regression model age, among other independent variables, can account for 47% of VBR variance in schizophrenic patients. Linear regression analysis did not reveal significant association between VBR and age in control subjects.

Haloperidol decanoate v. fluphenazine decanoate as maintenance therapy in chronic schizophrenic in-patients

In a double-blind study of 38 chronic schizophrenic in-patients, haloperidol decanoate was compared with fluphenazine decanoate as maintenance therapy over 60 weeks. Both drugs were given by injection at 4-week intervals. Haloperidol and fluphenazine were assumed to be equipotent; the mean starting dose of the former was 127 mg and of the latter 106 mg. The number of withdrawals over 60 weeks was similar in both groups but relapses, strictly defined, were significantly more frequent in the haloperidol group. When patients were switched to haloperidol, Parkinsonism diminished more quickly than in the fluphenazine group, but after 60 weeks there was no difference in severity in the two drug groups. The higher relapse rate and the quicker reduction in Parkinsonism in the haloperidol group might be due to a misjudgement in equivalent doses of the two drugs. Plasma haloperidol steady state levels were reached in most patients by 8-12 weeks. Plasma neuroleptic and prolactin levels, week-by-week systemic drug availability and Parkinsonism showed less variation between injections with haloperidol than with fluphenazine.

The effect of sodium valproate on tardive dyskinesia--revisited

As a treatment for tardive dyskinesia, sodium valproate was tested in a double-blind placebo-controlled parallel group trial, with 6-week base-line observation period followed by 6 weeks of treatment. Sodium valproate was not found to be an effective treatment for either tardive dyskinesia or drug-induced Parkinsonism, and did not affect mental state or behaviour.

Chronic schizophrenic disorder. II. Reaction time, social performance and arousal

Reaction time, set index, critical flicker frequency, two-flash threshold, a sustained performance task and psychophysiological parameters from people with chronic schizophrenic disorder (n = 14) and a control group (n = 12) were analysed to assess the association between arousal, attentional dysfunction and social dysfunction in schizophrenia. Shorter reaction time, rated ability to mime and, in the schizophrenic group, scores on Venable's ward activity scale correlated with each other. In the schizophrenic group, prolonged reaction time latency correlated positively with skin conductance level in the right hand and negatively with skin conductance variability in the left hand, the latter being in the opposite direction to that for the control group. The results may provide support for the hypothesis that lateralised cerebral dysfunction is associated with performance deficits in people with chronic schizophrenic symptoms.

Nuclear magnetic resonance brain imaging in chronic schizophrenia

Patients with chronic schizophrenia were examined by nuclear magnetic resonance imaging of the brain. Subgroups of the syndrome with high positive or high negative symptom scores and ventricular dilatation were compared with each other and with normal controls in respect of regional spin lattice relaxation time (T1) changes. Significant differences were not observed between the schizophrenic subgroups and controls but there were significant differences between the subgroups themselves. The presence of tardive dyskinesia was associated with increased T1 of the basal ganglia. The significance of these results is discussed in relation to findings using other techniques.

The relative stability of positive and negative features in chronic schizophrenia

The mental states of 92 inpatients with chronic schizophrenia were assessed on two occasions 4 years apart. The relationship between the two ratings was examined in the 84 patients who were either consistently on or consistently off neuroleptics. Negative features were more stable than positive, but were not irreversible. Every feature examined was shown to resolve in some cases.

Dextro-propranolol and depressive symptoms in a schizophrenic population

1. 36 acute schizophrenic patients were randomly assigned to dextro-propranolol or placebo in a double blind trial lasting four weeks. 2. Detailed assessments were made using the Present State Examination, the Brief Psychiatric Rating Scale and the Manchester Scale before, during and at the end of the trial. 3. The authors report on the change in depressive symptomatology during the period of the trial. 4. One patient in each group became suicidal and was withdrawn at week 2 1/2. 5. With regard to ratings of depression, there was an overall reduction in mean depression scores at the end of the trial in both groups. 6. Emergence of depressive symptoms and increase in the severity of existing symptoms was seen in a small number of patients in both groups, but more so in the placebo group. 7. A depressogenic effect for d-propranolol was not observed in the population studied.

Comparison between the Brief Psychiatric Rating Scale and the Manchester Scale for the rating of schizophrenic symptoms

A reliability study was carried out to compare the short Manchester Scale (MS) to the longer Brief Psychiatric Rating Scale (BPRS), to see if similar items scored the same aspect of pathology and to find the sources of error. The raters were a psychiatrist and a psychologist cum medical student; they had recently arrived in Britain, came from different cultures and had not used the scale previously. Comparisons between the scales were made by interviewing the patients separately and together using either one or both scales. The items on the MS showed a higher interrater reliability as compared to the BPRS, both with independent and simultaneous ratings. Items based on observation only correlated poorly as compared to items based on verbal report. Lower between-scale correlations for delusions and affect were observed even where the same rater used the two scales, suggesting that the scales have different meanings for these items. The MS is a suitable alternative to the BPRS for quantifying schizophrenic symptoms.

Positive and negative subtypes of schizophrenia. A study from India

Ninety-eight schizophrenic patients were studied to examine the concept of positive and negative subtyping. Using a cross-sectional phenomenological approach, the relationship of this subtyping with six definitions of schizophrenia was also investigated. The study provides support for this subtyping. Principal components analysis of the data and correlational structure of positive and negative symptom complexes lend further support to this notion.

Does propranolol have an antipsychotic effect? A placebo-controlled study in acute schizophrenia

Thirty-six acute schizophrenics were randomly assigned to dextro (d)-propranolol or placebo in a double blind trial lasting four weeks. All patients had a fixed dose of haloperidol during the first week, which resulted in an initial improvement in both groups. Thereafter, a deterioration towards base-line was seen. Six patients on placebo, but none on propranolol were treatment failures at the end of three weeks (P less than 0.001). Comparison of change in scores from week 2 to 4 showed significantly greater deterioration in the placebo group; d-propranolol thus had a better effect than placebo in sustaining the initial improvement with haloperidol. The overall magnitude of clinical change from pre-treatment scores is small, the majority of the patients showing little or no overall improvement. It is concluded that d-propranolol has a detectable therapeutic effect, which by inference must have a novel pharmacological basis, but this is not as potent as standard neuroleptics.