Langfeldt's schizophreniform psychoses fifty years later

Historical and conceptual features of acute polymorphic psychosis: a myth of European psychiatry from bouffée délirante to ICD-11 acute and transient psychotic disorder

This paper deals with the history and epistemology of acute polymorphic psychosis. We undertook a comparative study of short-lived psychotic disorders used in different European countries since the late nineteenth century. The theory of degeneration offered a speculative basis to conceptualization of conditions such as bouffée délirante, cycloid psychosis and reactive psychosis, but it seems likely that different factors contributed to the profusion of clinical concepts with adverse effects on both nomenclature and classification. The resulting picture suggests that earlier nosological concepts tend to converge on common descriptive features and challenge the diagnostic categories for short-lived psychotic disorders listed in modern symptom-based psychiatric classifications.

Clozapine dose for schizophrenia

BACKGROUND

Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects.

OBJECTIVES

To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (August 2011 and 8 December 2016).

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria.

DATA COLLECTION AND ANALYSIS

We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low doseWe found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI -4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD -0.10, 95% CI -0.95 to 0.75, low-quality evidence). Very low dose compared to standard doseWe found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31, MD 6.67, 95% CI -2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI -0.76 to 0.96, low-quality evidence) Low dose compared to standard doseWe found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95% CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI -0.84 to 1.24, low-quality evidence).We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low doseThere was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard doseWeight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD -2.70, 95% CI -5.38 to -0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD -1.60, 95% CI -2.90 to -0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard doseThere was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD -3.99, 95% CI -5.75 to -2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose.

AUTHORS' CONCLUSIONS

We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate.

Is schizophrenia disappearing? The rise and fall of the diagnosis of functional psychoses: an essay

BACKGROUND

The categories of functional psychoses build on views of influential professionals. There have long been four main categories - affective, schizophrenic, schizoaffective/cycloid/reactive/polymorphic, and delusional/paranoid psychoses. The last three are included in "psychotic disorders". However, this dichotomy and the distinctions between categories may have been over-estimated and contributed to lack of progress.

TEN TOPICS RELEVANT FOR THE DIAGNOSIS OF FUNCTIONAL PSYCHOSES

1. The categories of functional psychoses have varied with time, place and professionals' views, with moving boundaries, especially between schizophrenia and affective psychoses. 2. Catatonia is most often related to affective and organic psychoses, and paranoia is related to grandiosity and guilt, calling in question catatonic and paranoid schizophrenia. Arguments exist for schizophrenia being a "misdiagnosis". 3. In some countries schizophrenia has been renamed, with positive consequences. 4. The doctrine of "unitary psychosis", which included abnormal affect, was left in the second half of the 1800s. 5. This was followed by a dichotomy between schizophrenia and affective psychoses and broadening of the schizophrenia concept, whereas affective symptoms were strongly downgraded. 6. Many homogeneous psychoses with mixtures of schizophrenic and affective symptoms were described and related to "psychotic disorders", although they might as well be affective disorders. 7. Critique of the extensive schizophrenia concept led to, in DSM-III and ICD-10, affective symptoms being exclusion criteria for schizophrenia and acceptance of mood-incongruent psychotic symptoms in affective psychoses. 8. However, affective symptoms are often difficult to acknowledge, diagnosis is often done on the basis of tradition and previous education, and patients' affect characterized accordingly. 9. DSM-5 is up-dated with separate chapters for catatonia and psychotic symptoms, and removal of the subtypes of schizophrenia. However, time may be running out for categorical psychosis diagnoses, which may be replaced by continuum, spectrum, dimensional and research domain criteria, in line with new biological data 10. This is supported by treatment responses across categories.

CONCLUSION

The time-consuming works on diagnosis of psychoses may have hampered progress. Chronic mood disorders may appear as schizophrenic or paranoid psychosis, end-stages like heart failure in heart diseases. This underscores the importance of early and optimal treatment of mood disorders.

Distinguishing between first-admission schizophreniform disorder and schizophrenia

BACKGROUND

The validity of schizophreniform disorder remains controversial. Past research suggests that cases of schizophreniform disorder may be: (1). atypical cases of affective disorders, (2). cases of schizophrenia in early course, or (3). a heterogeneous group of disorders including a subgroup with benign course and outcome which maintains this diagnosis in the long term.

METHOD

We tested the validity of the schizophreniform disorder diagnosis by comparing the socio-demographic and baseline clinical characteristics, 24-month course and outcome, and 6- and 24-month research diagnoses of 34 cases initially diagnosed with schizophreniform disorder, and 128 cases with schizophrenia, drawn from a cohort of 628 first-admission patients in the Suffolk County Mental Health Project.

RESULTS

Compared to patients with schizophrenia, those with schizophreniform disorder were more likely to remit fully by 6 months and retain this status by 24 months. Only about half of the patients with schizophreniform disorder were re-diagnosed with schizophrenia or schizoaffective disorder at 24-month follow-up, 13% were re-diagnosed with affective disorders and 19% retained the diagnosis of schizophreniform disorder. In contrast, 92% of cases with a baseline diagnosis of schizophrenia retained this diagnosis at 24-month follow-up. The findings were similar in comparisons with schizophrenia patients having onset of symptoms within 6 months of hospitalization.

CONCLUSIONS

Schizophreniform disorder is a heterogeneous category, which includes a small group with benign psychotic disorders who maintain this diagnosis over at least 24 months. Better delineation of this subgroup has important treatment implications.

Electroencephalographic findings in patients with DSM-IV mood disorder, schizophrenia, and other psychotic disorders

BACKGROUND

Although numerous electroencephalographic (EEG) studies have been performed in psychiatric populations, and some have identified specific abnormalities within groups of functional psychoses, differences in EEG findings among subgroups of functional mental illness need to be evaluated with careful consideration of the nosologic systems employed in each study. In the present study, we examined whether there might be EEG differences among subgroups of functional psychoses defined by DSM-IV.

METHODS

A total of 143 patients, whose discharge diagnoses met the DSM-IV criteria for mood disorder, schizophrenia, and other psychotic disorders, were studied. EEG findings were compared among seven diagnostic categories: mood disorder without, with mood-congruent, and with mood-incongruent psychotic features; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder; and schizophrenia.

RESULTS

The frequency of epileptiform variants, including the phantom spike and wave, positive spikes, and small sharp spikes, was significantly higher among patients with mood-incongruent psychotic mood disorder (33%), schizoaffective disorder (33%), and schizophreniform disorder (30%), as compared with patients with nonpsychotic mood disorder (3.2%) and schizophrenia (0%).

CONCLUSIONS

Our results imply that patients with "atypical" psychoses that are located between typical mood disorder and schizophrenia have similar biological vulnerability, represented by epileptiform EEG variants.

Five-year course of schizophreniform disorder

Roughly one-quarter of persons experiencing a first episode of psychosis and receiving a diagnosis of schizophreniform disorder recovered within 6 months of the onset of illness. Five years later, these 'true schizophreniform disorder' subjects were functioning better than others who experienced a first episode of schizophrenia or affective disorder. Although 40% of people with schizophrenia or affective disorder were rehospitalized at least once during the 5-year follow-up, none from the true schizophreniform disorder group reentered the hospital. Compared with people with schizophrenia, true schizophreniform disorder subjects had more positive symptoms, fewer negative symptoms, and more manic symptoms. Thus, a schizophrenia-like acute remitting psychosis has sufficiently unique clinical features to merit separate diagnostic classification.

Convergence of American and Scandinavian diagnoses of functional psychoses

One hundred ninety-nine case summaries of a consecutive sample of functional psychoses, which had been classified by Odegård, were diagnosed independently using DSM-III-R criteria by four experienced psychiatrists. Odegård's classification and DSM-III-R showed high concordance for schizophrenia and affective psychoses. Odegård's concept of reactive psychoses had high concordance with atypical psychoses in DSM-III-R. These findings imply that the results of genetic and follow-up studies from Scandinavia might be relevant for these diagnostic categories in DSM-III-R.

A follow-up and family study of DSM-III-R schizophreniform disorder with good prognostic features

A follow-up and family study was carried out of 16 first episode, DSM-III-R schizophreniform disorder patients with good prognostic features. Mean length of follow-up was 52.3 months. It was found that 62.5% had affective episodes, 31.2% had schizophreniform episodes. No case of schizophrenia was observed. Outcome was good. Morbid risk for affective disorder among first degree relatives was 25%, morbid risk for schizophrenia was 0%. These findings suggest a link between DSM-III-R schizophreniform disorder with good prognostic features and affective disorder, and no relationship with schizophrenia.

The concept of cycloid psychosis: sensitivity and specificity of syndromes derived by multivariate clustering techniques

A total of 154 patients admitted for the first time to hospital for a psychotic or affective disorder in 1925 were rediagnosed in accordance with DSM-III and Leonhard's diagnostic system. Symptoms were rated in accordance with a rating protocol containing 33 items based on Leonhard's descriptions of cycloid psychoses. The patients were followed up through parish registers and hospital records. Of 42 cases considered to be cycloid psychosis at index admission, 34 were prognostically verified. The symptom ratings of the 154 patients were analysed by K-means cluster analysis to test whether the patients with cycloid psychoses would separate from the rest of the material. With a 2-cluster solution, 30 of 34 cases (88%) were contained in the same cluster. The sensitivity of the ratings was therefore judged to be acceptable. Specificity was low, however, since 19 cases in the cluster were differently diagnosed. A subcohort of 64 patients, satisfying at least 5 items of the rating protocol, was then analysed by Q-factor analysis to test whether nuclear cases of cycloid psychosis differ from symptomatically related syndromes. No such differences could be statistically verified; no symptom profile specifically indicating cycloid psychosis could be found. Prominent confusion symptoms appear, however, to be prognostically favourable, whereas motility symptoms without confusion seem to indicate an unfavourable course.