A standardized psychiatric assessment scale for rating chronic psychotic patients

Deficits of chronic schizophrenia in relation to long-term hospitalization

Eighty chronic schizophrenic and 16 manic-depressive psychotic patients conforming to Research Diagnostic Criteria were examined in terms of their mental state, cognitive functioning, current behaviour, and neurological status. They comprised out-patients, day-care patients, and long-stay in-patients belonging to two mental hospitals with different social conditions. Assessed deficits were not significantly related to record variables such as age, duration of illness, duration of hospitalisation, or treatment received. Analysis of the different groups of patients reveals that long-term hospital care has had little effect on the deficits of chronic schizophrenia, and suggests that these are integral features of the disease process.

A magnetic resonance study of early schizophrenia

Patients with untreated first schizophrenic episodes and others who had made varying degrees of recovery from such episodes were blindly compared with normal volunteers in terms of the periventricular appearances on spin echo magnetic resonance scans. Significant differences were not found.

A crossover study of clocapramine and haloperidol in chronic schizophrenia

Therapeutic efficacy and target symptoms with clocapramine were compared with those with haloperidol by the crossover method, in a total of 26 chronic schizophrenic patients, by administration of one of the drugs for the first 14 weeks and the other for the next 14 weeks. The final global improvement rating showed no significant difference between the two groups, but clocapramine administered as first drug appeared to have a more pronounced effect than haloperidol. According to the improvement rate in psychotic symptoms, clocapramine tended to be superior to haloperidol for motor retardation, scanty speech and disturbance of thought. In addition the frequency of side-effects was lower with clocapramine than with haloperidol. Neither the side-effects nor abnormal laboratory test results were severe enough to terminate the trial. Clocapramine is considered to be equivalent or superior to haloperidol in terms of anti-psychotic effect in chronic schizophrenia, and is relatively safer than haloperidol.

A Negative Symptom Rating Scale

Renewed interest in the role of negative symptoms in "defect state" schizophrenia calls for the design of a standardized, easy to use, reliable, and valid instrument to assess these aspects of psychopathology. In order to measure negative symptoms, we developed the Negative Symptom Rating Scale (NSRS). We report on the design, interrater reliability, and construct-validation of NSRS against the most frequently used negative symptom scales or subscales. In summary, the NSRS is a short, sensitive, highly specific, reliable, and apparently valid instrument for measuring negative symptoms in schizophrenia.

A psychoendocrine study in male paranoid schizophrenics with delusional ideas of homosexual content

The serum prolactin (PRL), luteinizing hormone (LH), testosterone (T) and estradiol (E) levels were investigated in a group of male paranoid schizophrenics with delusional ideas of homosexual content, in a group of male paranoid schizophrenics without delusional ideas of homosexual content, and in a group of healthy, male heterosexual subjects. Only male paranoid schizophrenics with delusional ideas of homosexual content had significantly lower serum PRL values and significantly higher serum E levels than those of the age-matched group of normal, male heterosexual controls; also, these patients tended to have higher (though not to a statistically significant degree) serum LH and T levels than those of normal controls. Findings of this study are discussed within the framework of the possible involvement of endocrine factors in the occurrence of delusional ideas of homosexual content in male patients with paranoid schizophrenia.

Positive symptoms and the organization within and between ideas in schizophrenic speech

The study examined the performance of positive symptom schizophrenics vis à vis that of demographically well-matched negative symptom schizophrenics and normals in organizing words into ideas and ideas into integrated spoken discourse. This involved applying a series of analyses to speech produced when describing pictures in an unconstrained way. The results showed that, for the most part, positive symptom schizophrenics organized their speech, both within and between ideas, as well as negative symptom schizophrenics and normals. The results did, however, show an increased tendency by the positive speech disordered schizophrenics to omit referents for noun phrases requiring referents. This constitutes a specific failure to connect ideas and does, at least in part, explain what makes positive speech disorder (incoherence of speech) unintelligible. However, taken altogether, the results do not support the extant view that positive symptom schizophrenics suffer from a general loss of control in producing speech.

Lateral ventricular size in schizophrenia: relationship to the disease process and its clinical manifestations

Using computed tomography, lateral ventricular size was studied in a sample of 112 institutionalized chronic schizophrenic patients (selected from 510 cases to investigate the correlates of the defect state and intellectual decline and the effects of insulin, electroconvulsive and neuroleptic treatment), and compared with matched groups of non-institutionalized schizophrenics, patients with first schizophrenic episodes, institutionalized and non-institutionalized patients with primary affective disorder, and neurotic out-patients. Age was significantly correlated (P less than 0.0002) with lateral ventricular size, but the institutionalized schizophrenic patients had significantly larger (P less than 0.025) lateral ventricles than the neurotics when age was taken into account. Ventricular enlargement was unrelated to past physical treatment (neuroleptics, insulin coma and electroconvulsive therapy). Within the group of institutionalized schizophrenic patients few correlates of ventricular enlargement were identified; thus in this population increased ventricular size was not clearly associated with the features of the defect state (negative symptoms and intellectual impairment). However, there was a curvilinear (inverted-U) relationship between intellectual function and ventricular size. Increased ventricular size was significantly related to absence of hallucinations, impairment of social behaviour, inactivity and the presence of abnormal involuntary movements. The findings confirm that structural brain changes do occur in chronic schizophrenia, but illustrate some of the difficulties in elucidating the clinical significance of ventricular enlargement. Lateral ventricular size is strongly age-related and the distribution in chronic schizophrenia is skewed and not bimodal; the relationship to particular features of the disease is complex and likely to emerge only in studies with a large sample size.

Institutionalisation and the outcome of functional psychoses

The outcome in patients receiving long-term in-patient care for manic-depressive psychosis was compared with that in long-stay schizophrenic in-patients and discharged schizophrenic patients. The manic-depressive and schizophrenic in-patients differed in terms of positive and negative features and in the pattern of behaviour, but were equally cognitively impaired. The pattern of behaviour in both schizophrenic groups was the same. The results offer some support for the use of outcome as a validating criterion for the diagnosis of schizophrenia.

Schizophrenic patients discharged from hospital--a follow-up study

A cohort of 120 patients, comprising all those who met the St Louis criteria for a diagnosis of schizophrenia, discharged from a mental hospital over a five-year period, were followed-up in the community after an interval of five to nine years; 105 were traced and 94 were alive. Of those, 66 were living in UK, out of hospital, and willing to be seen. Their mental states, and social functioning and circumstances were assessed by interview with the patients and those with whom they lived; 18% had recovered to the extent that they had no significant symptoms and appeared to function satisfactorily. More than 50% had definite psychotic features. No patients and few relatives sought a return to hospital care, but severe emotional, social, and financial difficulties were commonplace; 27% of the sample had no contact with medical or social services, a further 14% saw only community nurses, and 24% only their general practitioners. The findings emphasise the limitations of community services in dealing with the chronicity and severity of the impairments resulting from schizophrenic illness.

The measurement of psychiatric rehabilitation status. A review of the needs and a new scale

The recognition of rehabilitation as a special interest in psychiatry, and its practice by professional teams, raises the need for some uniformity in examining patient outcome. The features required in a scale designed for this purpose are considered and the Morningside Rehabilitation Status Scales, which have been prepared specifically for psychiatric rehabilitation, have their development and use described. They measure the dimensions of dependency, inactivity in occupation and leisure, social integration/isolation, and current symptoms and deviant behaviour. The measures can be expressed as a profile of the dimensions, with the total a measure of overall level of functioning; reliability has been established, and validity assessed. The scales are not difficult to apply when the patients are known to the staff using them. They should be useful to rehabilitation teams for defining the current status of patients, measuring changes produced by rehabilitation programmes, deciding areas where treatment or service deficits may exist which the team should be attempting to remedy, as well as for teaching purposes.

The effect of context during word perception in schizophrenic patients

Hospitalized chronic and acute schizophrenics were compared with age- and social-status-matched controls on word perception tests to measure the effect of context on recognition thresholds. In Experiment 1 the method of J. Morton (1964, British Journal of Psychology, 55, 165-180) was adopted to see how related and unrelated contexts influenced word recognition thresholds when both context and stimulus word were presented visually. Experiment 2 was an auditory analog of Experiment 1 and in addition the chronic schizophrenics were selected on the basis of a presence or absence of auditory hallucinations. The influence of context on perceptual thresholds was quite normal in all schizophrenics. However, analysis of the incorrect responses elicited showed that some schizophrenic subjects do produce bizarre or irrelevant responses or perseveration to a greater extent than their controls. These results are explained in terms of automatic and strategic modes of information processing. The automatic processes responsible for the adjustment of perceptual thresholds operate normally in schizophrenics but response production which demands strategic selection and editing of responses is prone to malfunction which results in the observed deviations in the normal use of language.

'Psychosocial' interventions with families and their effects on the course of schizophrenia: a review

Recent interest in the way social factors influence the course of schizophrenia has led to attempts to monitor and manipulate these factors. The work on the Expressed Emotion of the relative has been especially influential in this area. A number of studies have now been conducted in which a psychosocial intervention has been employed in an attempt to prevent relapse after discharge from hospital. These studies are reviewed with an emphasis on their methodological adequacy and on the nature of the intervention used. Recent studies have demonstrated a positive result for psychosocial interventions used in combination with neuroleptic medication. However, analysis of these studies does not allow us to conclude that we can identify the 'active ingredients' in these psychosocial treatment regimes. Although there is cause for optimism, further investigation is required.

Positive and negative symptoms and the thematic organisation of schizophrenic speech

This study questions the prevailing view that schizophrenic delusions, hallucinations and incoherence of speech (positive symptoms) reflect loss of cognitive control and that flattening of affect and poverty of speech (negative symptoms) reflect restriction of cognitive processing. The prevailing view was examined by analysing the thematic organisation of speech produced by 18 patients describing pictures. Results showed that (a) positive and negative symptom schizophrenics did not differ in the control and restriction of thematic speech organisation; (b) speech disordered schizophrenics, positive as well as negative, showed cognitive restriction, by producing fewer inferential ideas than non-speech disordered schizophrenics. The wider implications of these results are discussed, particularly the implications of (b) for the notion of concreteness in schizophrenia.

Lateral ventricular enlargement associated with persistent unemployment and negative symptoms in both schizophrenia and bipolar disorder

Forty-six patients with schizophrenia or bipolar disorder and 46 individually matched normal volunteers underwent computed tomographic (CT) scans of the head. The ventricular-to-brain ratio was strongly associated with persistent unemployment and negative symptoms in both patient groups. Previous findings of relative lateral ventricular enlargement in a proportion of schizophrenic and bipolar patients were also replicated. Implications of the relationship between CT changes and chronic unemployment among the patients are discussed.

Hormonal effects of apomorphine in schizophrenia

The hormonal effects of apomorphine, a direct-acting dopamine receptor agonist, in schizophrenic patients are of interest in view of the therapeutic efficacy of dopamine receptor antagonists. In this study, apomorphine (0.75 mg s.c.) and placebo were administered to unmedicated acute and chronic schizophrenics and controls. Apomorphine-induced prolactin suppression did not discriminate between the groups. However, an inverse relationship between basal prolactin levels and the severity of positive symptoms was detected in the patients with acute schizophrenia, consistent with a role for dopamine in the genesis of these symptoms. Growth hormone increments after apomorphine administration were blunted in the chronic schizophrenic patients, particularly those with 'negative' symptoms. It is argued that this blunting is not due to previous neuroleptic therapy and may represent evidence of structural change in the hypothalamus in this group of patients.

Clinical effects of apomorphine in schizophrenia

There have been reports that low doses of the dopamine-agonist apomorphine, which may inhibit dopamine neurotransmission, are of therapeutic benefit in schizophrenia. We conducted a placebo-controlled study of acute and chronic schizophrenics in which videotaped interviews were blindly rated. No specific therapeutic effect was demonstrated for apomorphine other than a reduction in anxiety in acute schizophrenics. Furthermore, there was no difference in the frequency of side-effects of apomorphine between schizophrenic patients and controls, and no specific effect of apomorphine on blink-rates. These findings emphasize the importance of placebo-controlled studies in schizophrenia research.

Reliability of clinical assessment of blunted affect

The affect of 20 chronic schizophrenic in-patients was assessed by two psychiatrists using two rating scales. The interview recordings were reviewed three times--firstly with the auditory information only (the "audio review"), secondly with the visual information only (the "visual review") and thirdly with both (the "audio-visual review"). The "blunted affect score" correlated strongly with the total score of the verbal items of scales, but did not when a single mode of information was given. Since the absolute values of the "blunted affect score" were lower in the "visual review" than in the live interview and in the "audio-visual review", it was speculated that speech tended to bias the assessment of affect.

Peptides, the limbic lobe and schizophrenia

The human brain contains several peptides with probable synaptic actions, some of which form complex neuronal networks in the limbic lobe (amygdala, hippocampus and temporal cortex). A limbic lobe abnormality has been postulated in schizophrenia on the basis of similarities between schizophrenic symptoms and symptoms in cases of known limbic pathology. Cholecystokinin (CCK), somatostatin (SRIF), neurotensin (NT), vasoactive intestinal polypeptide (VIP) and substance P (SP)-like immunoreactivities were measured by radioimmunoassay in 10 brain areas of 14 schizophrenics and 12 controls. In the schizophrenic group symptoms had been rated in life and the group was divided into Type I (n = 7) and Type II (n = 7) subgroups on the basis of the absence or presence of morbid negative symptoms. In control brains each peptide showed a characteristic distribution with high levels in cortex (CCK), limbic lobe (SOM, NT, VIP) or striatal areas (SP) and low levels of each of the peptides in thalamus. Significant (P less than 0.05) differences between groups were: reductions of CCK and SOM in hippocampus and CCK in amygdala in Type II schizophrenics, and CCK in the temporal cortex of the total schizophrenic group; and elevations of VIP in amygdala in Type I schizophrenics and of SP in the hippocampus in the total schizophrenic group. The findings could not be explained by variables such as age, delay between death and necropsy or to neuroleptic medication. These clinical-state related alterations in the peptide content of the limbic system in schizophrenia may illuminate the pathophysiological basis of the disease, particularly the distinction between Type I and II syndromes.

Do positive symptom and negative symptom subtypes of schizophrenia show qualitative differences in language production?

The present study examined a prominent symptom subtype conception of the psychopathology of schizophrenia. It analysed the presumed dichotomy between hallucinations, delusions and formal thought disorder as positive symptoms and flattening of affect and poverty of speech as negative symptoms, and tested predictions concerning the nature of the mediating processes of positive and negative symptoms. Four different analyses were applied to the transcripts of speech produced by 9 normals, 10 chronic schizophrenics with only positive symptoms of whom 7 had incoherence of speech, and 9 chronic schizophrenics with only negative symptoms of whom 4 had poverty of speech. The conception of the nature of the mediating processes of positive and negative symptoms was not supported by the results. Further, a clear dichotomy between positive and negative symptom groups was not shown to exist, because positive speech disorder and negative speech disorder did not follow the presupposed dichotomy. Thus, contrary to existing conceptions of speech disorder in schizophrenia, both positive and negative speech disorder are marked by poverty of thought, as measured by the production of fewer and shorter ideas and lower speech variability.

Stereotyped responding by schizophrenic patients on a two-choice guessing task

On each of a sequence of trials subjects had to guess whether a cross would appear on the left or the right side of a computer screen. The sequence of cross positions was random. Normal controls, manic-depressive patients and patients with senile dementia produced relatively random sequences of responses, as did acute schizophrenic patients with positive symptoms. Acute schizophrenic patients with negative symptoms and chronic patients produced more stereotyped sequences with many response alternations (LRLR). Chronic schizophrenic patients with negative symptoms and intellectual deterioration (defect state) produced very stereotyped sequences with many preservations (LLLL). This severe restriction of response sequences is similar to that shown by animals after treatment with amphetamine. It is suggested that it is due to an impairment of a higher order control process which normally inhibits the repetition of sequences of behaviour when these have proved inappropriate.

Adverse effects of anticholinergic medication on positive schizophrenic symptoms

In a series of 36 patients with acute schizophrenia flupenthixol dosage was blindly adjusted to give a fixed level of sedation. Patients were than randomly allocated to procyclidine or placebo. The patients receiving procyclidine experienced more positive schizophrenic symptoms and less severe extrapyramidal features by comparison with placebo patients. Blood levels of prolactin and flupenthixol estimated by radioimmunoassay were not significantly changed by the addition of procyclidine. Flupenthixol dosage and levels and prolactin levels were significantly related. There was no significant association between clinical and laboratory measures, with the exception that a curvilinear (inverted U) relationship was demonstrated between flupenthixol levels and antipsychotic and extrapyramidal effects. This relationship may be due to the fact that, in a study of this design, patients resistant to the effects of neuroleptic medication are likely to be given the highest doses. The findings support earlier claims that anticholinergic medication has adverse effects on schizophrenic symptoms.

Reduced cholecystokinin-like and somatostatin-like immunoreactivity in limbic lobe is associated with negative symptoms in schizophrenia

Cholecystokinin-like immunoreactivity (CCK) and somatostatin-like immunoreactivity (SRIF) were determined in fourteen brains from patients dying with a diagnosis of schizophrenia and in twelve brains from control cases. The schizophrenics had been rated during life and were divided into two groups on the basis of the presence or absence of negative symptoms (affective flattening and poverty of speech). CCK was reduced in temporal cortex of the schizophrenics and in hippocampus and amygdala of those patients with negative symptoms. SRIF was reduced in the hippocampus in samples from the latter group. The selectivity of these changes to limbic lobe may reflect the presence of a degenerative process in that area. The association of changes in hippocampus and amygdala with negative symptoms of schizophrenia suggests a separate mechanism underlying these symptoms.

Growth hormone responses to apomorphine HCl in schizophrenic patients on drug holidays and at relapse

In nine schizophrenic patients on drug holiday, growth hormone (GH) response to apomorphine HCl 0.75 mg (APO) was compared with normal control data. Patients were tested at two month intervals for up to 14 months. Seven patients relapsed, and of these, five had exaggerated GH responses to APO at that time. Of these five, three had exaggerated GH responses to APO prior to clinical deterioration. Further work is required to determine whether this test can be a useful predictor of relapse.

Residential care and social behaviour: a study of rehabilitation needs

Although most chronically impaired psychiatric patients now reside in community-based residential homes, a substantial number show little progress in their social rehabilitation. To establish the rehabilitative needs of this population, the current study sought to examine the social behaviour of residents of a large residential care facility. After an analysis of the social behaviour of all residents, two groups were selected for detailed study on the basis of their contrasting patterns of social interaction. These two groups were found to differ significantly with respect to their interpersonal activity, social contact, conversation skill, employment, and participation in community rehabilitation programmes. Psychiatric status was substantially different in each group. The implications of these findings for rehabilitation strategies in the management of severe mental illness are discussed.

The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences

In a prospective follow-up the outcome of 60 chronic schizophrenic patients who discontinued neuroleptic therapy after remaining stable 12-48 months was compared with controls continuing medication. Not only did the drug-discontinued patients have more relapses (P less than 0.001), but the form of relapse was both more severe and acute, resulting in differences of self-injury (P less than 0.05), anti-social behaviour (P less than 0.01), inpatient admissions (P less than 0.001), and the use of compulsory powers (P less than 0.01). In patients who relapsed, both social and work function was affected adversely for some months. Patients who remained relapse-free without drugs (20%) had a level of work and social function similar to medicated patients. At the end of 18 months the patients who discontinued depot maintenance therapy were found to have been prescribed one-third more neuroleptic drugs than controls, with a possible increase in the risk of long-term tardive dyskinesia.

The effect of propranolol on CSF amine metabolites in psychiatric patients

In view of the central side effects of beta-adrenoceptor blocking agents and their alleged antipsychotic action in the absence of DA receptor blockade, it is important to establish which neurotransmitters are likely to be involved. Previous animal and patient studies have, however, produced conflicting data on this point. The changes in CSF HVA, 5HIAA and MHPG during treatment with propranolol (960 mg/day) in chronic schizophrenic patients were monitored on four occasions over 30 days. Clinical changes were monitored by the Wing and Krawiecka Scales and motor activity was assessed by pedometer. CSF HVA levels were significantly increased by propranolol and the rise continued throughout the 30 day period. There were no significant changes in the other metabolites. There was no evidence of any therapeutic benefit from propranolol treatment in these patients. These findings may explain the central side-effects and occasional reports of schizophreniform psychosis after propranolol, since an increase in DA turnover occurs without DA receptor blockade.

Reduced nocturnal melatonin secretion in chronic schizophrenia: relationship to body weight

Melatonin was estimated by RIA in samples taken at 24.00 h and 08.00 h from twenty-one male chronic schizophrenics and twelve age--sex matched controls and subsequently in more frequent nocturnal samples from nine of the chronic schizophrenics. The 24.00 h melatonin level and the 24.00/08.00 h melatonin ratio were significantly reduced in the chronic schizophrenic patients. Similar results, with no evidence of subsidiary peaks of melatonin secretion, were obtained in those patients who were retested. No relationships between melatonin secretion and age or anterior pituitary hormone secretion were demonstrated, but an effect of body weight was noted which accounted, in part, for the difference between schizophrenics and controls. These results suggest that the low levels of melatonin noted in studies on depressed patients may not be specific and that body weight must be controlled in subsequent studies of melatonin secretion in patients with psychiatric disease.

The Nithsdale schizophrenia survey: I. Psychiatric and social handicaps

A review of all known schizophrenics from a discrete geographical area, Nithsdale in Dumfries and Galloway REgion, found a point prevalence of 2.38 per 1000 of the total population; this figure fell to 1.73 when only Feighner positive schizophrenics were considered. Only 3 per cent of the population interviewed had no abnormality in mental state or behaviour; negative schizophrenic symptoms were prominent, positive symptoms uncommon. Approximately one quarter were in-patients, who were an atypical group, showing much more obvious social and psychiatric disability. In- and day patient care and state benefits for schizophrenics cost each member of the Nithsdale community approximately 12 pounds a year.

Gonadotropin secretion abnormalities in chronic schizophrenia

LH, FSH, PRL and testosterone were estimated by radioimmunoassay in serial venous samples from 20 male chronic schizophrenic patients, 17 age-matched controls, 3 patients in remission from acute schizophrenia, and in single samples from age-sex matched populations. LH and FSH, but not testosterone or PRL, were significantly reduced in patients with chronic schizophrenia. There was an associated reduction in the frequency, but not amplitude, of LH secretory episodes in patients with chronic schizophrenia. No abnormalities of LH secretion were detected in those patients in remission from acute schizophrenia. Fourteen of the chronic schizophrenic patients were retested at a later date with similar results, except in the case of the few patients who had been started on neuroleptic medication. Some relationships were established between hormonal secretion and the clinical features of these patients. The possible significance of these findings is discussed in the context of the complex control of gonadotropin secretion from the anterior pituitary and the natural history and nature of chronic schizophrenia.

Once weekly pimozide versus fluphenazine decanoate as maintenance therapy in chronic schizophrenia

In a double blind trial, 28 male chronic schizophrenic in-patients received either pimozide, given once weekly, or fluphenazine decanoate, given mostly once fortnightly. There was no difference in relapse rates over nine months. However, three-quarters of the patients on pimozide who completed the trial developed at least mild tardive dyskinesia. All patients on pimozide lost weight, the average loss being 5.4 kg (12 lbs). Plasma pimozide levels suggested satisfactory drug compliance. Plasma prolactin levels confirmed that in the pimozide group there was fluctuating dopamine receptor antagonism, while in the fluphenazine group average plasma prolactin levels throughout most of the interval between injections were at the upper limit of normal.

Institutionalization and the defects of schizophrenia

Patients conforming to the Feighner criteria for schizophrenia who had been discharged from hospital were traced after 5-9 years. They were assessed in terms of mental state and cognitive, behavioural and neurological functioning; the results of these assessments were related to information obtained from casenotes. The findings of this study of 120 discharged patients were compared with those of an earlier study of 510 in-patients with schizophrenia. When factors of age and duration of illness were taken into account, there was no difference between the two groups in terms of positive or negative schizophrenic features or behavioural performance, although the in-patients performed less well on cognitive tests. This study indicates that the deficits of chronic schizophrenia are an integral feature of the disease process, and that any effects of institutionalisation are relatively small.

Platelet monoamine oxidase activity in acute schizophrenia: relationship to symptomatology and neuroleptic medication

Platelet MAO activity was assessed in 35 schizophrenics during a trial of the isomers of flupenthixol. Enzyme activity was unrelated to severity of symptoms, the presence of delusions, hallucinations or thought disorder or to negative symptoms. In a few patients MAO activity fluctuated widely with time, but in the group of patients on medication there was a slow decrease in enzyme activity which was significant after 28 days of treatment. Enzyme activity after 14 days' drug treatment was still correlated with activity before treatment, but after 28 days this significant correlation disappeared. Slow effects of neuroleptic drugs on platelet MAO activity may explain previous findings of reduced activity of the enzyme in schizophrenia.

Neurological changes in a population of patients with chronic schizophrenia and their relationship to physical treatment

Although chronic schizophrenia is a disorder for which very large numbers of patients receive long-term inpatient care there have been few systematic studies of the disabilities of this condition. The present study was designed to define the nature of these disabilities, to determine their frequency in a large population of inpatients with chronic schizophrenia and to determine the extent to which they are a feature of the illness itself and that to which they results from other factors such as physical treatment. The abnormalities of this population were therefore assessed in terms of cognitive functioning, neurological signs, features, of the mental state and behavioral performance. These abnormalities were related to the earlier features of the illness to personal and historical factors and to physical treatments received. In this presentation the main emphasis is upon the neurological findings.

(Des-Tyr)-gamma-endorphin in the treatment of schizophrenia

Inj. (Des-Tyr1)-γ-endorphin was used in a pilot study over a period of 12 days for the treatment of 11 schizophrenics and the assessments were carried out using standardized rating scales. Only 2 patients showed an improvement. Euphoria and excitement were observed in 3 patients. The findings are discussed in contrast to the earlier reports of a dramatic improvement with the compound.

Intermittent pimozide versus fluphenazine decanoate as maintenance therapy in chronic schizophrenia

In a double-blind trial, 34 male chronic schizophrenic day-patients or in-patients in a hostel ward continued on fluphenazine decanoate given mostly once fortnightly or were switched to pimozide, given on four days each week. Over nine months relapse rates were similar for both groups, and while fewer patients on pimozide were prescribed antiparkinsonian drugs one quarter developed buccolingual masticatory dyskinesia. Plasma pimozide levels suggested satisfactory drug compliance. Average plasma prolactin levels were within the normal rage for untreated men in one quarter of non-relapsing patients on pimozide and three quarters on fluphenazine.

The disabilities of chronic schizophrenia--their nature and the factors contributing to their development

Five hundred and ten patients receiving long-term in-patient care for schizophrenia were examined in terms of their current mental state, cognitive functioning, neurological status and behavioural performance. The abnormalities of these areas of their present state were related to historical factors, personal details, the features of the illness at its worst and physical treatment received. Significant associations between the present state and historical factors are few and mainly concerned time and the features of the illness at its worst. Current abnormalities were not related to past physical treatment, but highly significant correlations were found between the impairments of the four areas of the present state. It is concluded that these impairments are likely to be an integral part of the disease.

3-Methoxy-4-hydroxyphenylglycol excretion in acutely schizophrenic patients during a controlled clinical trial of the isomers of flupenthixol

Urinary MHPG excretion in patients with acute schizophrenia was studied before and during a trial of the isomers of flupenthixol and placebo. Pretrial MHPG excretion was not related to severity of illness before the trial or to other pretrial clinical variables. In male subjects higher pretrial MHPG excretion was associated with a better outcome 1 year post-trial. However in females no relationship between MHPG excretion and outcome was established. During the trial there was a reduction in MHPG excretion in patients treated with beta-flupenthixol but no decrease in the group treated with alpha-flupenthixol or chlorpromazine. In patients on placebo there was a reduction in MHPG excretion in those who did well clinically, but not in those who did poorly. Thus low MHPG excretion may be a predictor of poor outcome in schizophrenia, but MHPG excretion also changes both as a function of clinical state and of neuroleptic drug administration.

Skin conductance responsivity during acute episodes of schizophrenia as a predictor of symptomatic improvement

Skin conductance responses to a series of tones were measured in 41 patients during an acute episode of schizophrenia before they received treatment and after 4 weeks of treatment with either alpha-flupenthixol, beta-flupenthixol or placebo. Patients who did not habituate to the tones prior to treatment tended to show no symptomatic improvement during the course of treatment. Patients who habituated and also showed an acute onset of their current symptoms ('Feighner negative' patients) showed a marked improvement even without active medication. Skin conductance responsivity did not change with improvement in symptoms alone, but decreased in patients on active medication (alpha-flupenthixol). Non-habituation of skin conductance and insidious onset (i.e. fulfilment of the Feighner criteria) were found to be independent predictors of poor outcome. Taken together, these criteria may define a group of patients with particularly poor prognosis.

The outcome of severe acute schizophrenic illnesses after one year

Forty-five patients with acute schizophrenic illnesses (defined by PSE criteria) were assessed in clinical, cognitive and social terms before being entered in a four week study of the isomers of flupenthixol and placebo. At the end of one year they were re-assessed in the same terms. The clinical and psychological features of the acute illness and the drug treatment given did not predict outcome. Poor outcome in social terms was significantly related to severe social isolation in the initial assessment and to the presence of nuclear symptoms and negative schizophrenic features at follow-up.

Neuroendocrine changes in acute schizophrenia as a function of clinical state and neuroleptic medication

Changes in levels of prolactin, growth hormone, luteinizing hormone, and follicle stimulating hormone in serum, and testosterone in plasma, have been studied in 38 patients with acute schizophrenic illnesses in a 4-week double-blind comparison of the 2 isomers of flupenthixol and placebo. Only prolactin showed changes which could be related either to changes in clinical state or to the effects of medication. Prolactin levels increased during treatment with the therapeutically active alpha-isomer of flupenthixol but were unchanged with the inactive beta-isomer and placebo. Although there was a significant relationship between prolactin level and antipsychotic effect in patients on alpha-flupenthixol, in the individual case prolactin level was not a strong predictor of therapeutic response; and in patients on inactive medication changes in prolactin level could not be related to sympton change. There was a time lag of at least 2 weeks between the increase in prolactin secretion in patients on alpha-flupenthixol and the therapeutic effect attributable to medication. This delay suggests that if the antipsychotic effect is dependent upon dopamine receptor blockade it is not a direct consequence of this action. Perhaps dopamine receptor blockade permits other, and slower, changes to take place and it is these changes, rather than dopamine receptor blockade itself, which are reflected in clinical improvement.

N-acetyl-p-amino-phenol (paracetamol, acetaminophen) in the treatment of acute schizophrenia

The hypothesis that schizophrenia is caused by the release of prostaglandin E into the hypothalamus and may sometimes be accompanied by an elevation of temperature was examined by a clinical trial of the prostaglandin E suppressant N-acetyl-p-amino-phenol (paracetamol, acetaminophen). Ten acute schizophrenic patients were included in a double-blind, crossover trial of paracetamol and a placebo, in which each treatment was given for a week. Regular 4-hourly temperatures were recorded in all these cases and in 5 non-schizophrenic patients for comparison. The findings provided no evidence that paracetamol mitigated the symptoms of schizophrenia. The temperatures of the schizophrenics were not elevated more than those of the controls, but the number of cases used was probably too small for this finding to be conclusive.

Mechanism of the antipsychotic effect in the treatment of acute schizophrenia

In a double-blind trial in which 45 patients with acute schizophrenia took part the alpha-isomer of flupenthixol (which blocks the dopamine receptor) was found to be significantly more effective than both beta-flupenthixol (which does not) and placebo. The drug effect was confined to the "positive" symptoms--delusions, hallucinations, and though disorder--and appeared only in the 3rd and 4th weeks of the trial. It was as great in patients with evidence of deterioration (Feighner-positive patients) as in patients without deterioration and was less in patients who had affective disturbance in addition to schizophrenia symptoms. The findings are consistent with the hypothesis that dopamine-receptor blockade is the only requirement for antipsychotic activity and suggest that the antipsychotic effect occurs in patients with typically schizophrenic illnesses but may be limited to positive symptoms.