Recognition and management of clozapine adverse effects: A systematic review and qualitative synthesis

OBJECTIVE

Clozapine is substantially underutilized in most countries and clinician factors including lack of knowledge and concerns about adverse drug effects (ADEs) contribute strongly to treatment reluctance. The aim of this systematic review was to provide clinicians with a comprehensive information source regarding clozapine ADEs.

METHODS

PubMed and Embase databases were searched for English language reviews concerned with clozapine ADEs; publications identified by the automated search were manually searched for additional relevant citations. Following exclusion of redundant and irrelevant reports, pertinent information was summarized in evidence tables corresponding to each of six major ADE domains; two authors reviewed all citations for each ADE domain and summarized their content by consensus in the corresponding evidence table. This study was conducted in accordance with PRISMA principles.

RESULTS

Primary and secondary searches identified a total of 305 unique reports, of which 152 were included in the qualitative synthesis. Most clozapine ADEs emerge within 3 months, and almost all appear within 6 months, after initiation. Notable exceptions are weight gain, diabetic ketoacidosis (DKA), severe clozapine-induced gastrointestinal hypomotility (CIGH), clozapine-induced cardiomyopathy (CICM), seizures, and clozapine-induced neutropenia (CIN). Most clozapine ADEs subside gradually or respond to dose reduction; those that prompt discontinuation generally do not preclude rechallenge. Rechallenge is generally inadvisable for clozapine-induced myocarditis (CIM), CICM, and clozapine-induced agranulocytosis (CIA). Clozapine plasma levels >600-1000 μg/L appear more likely to cause certain ADEs (e.g., seizures) and, although there is no clear toxicity threshold, risk/benefit ratios are generally unfavorable above 1000 μg/L.

CONCLUSION

Clozapine ADEs rarely require discontinuation.

Treatment Bed Utilization Following Placement in a Foster Care Program for Veterans with Serious Mental Illness

Hospital and residential treatment bed utilization rates were measured before and after foster home placement in individuals with serious mental illness. Medical records of all Veterans consecutively enrolled in a Department of Veterans Affairs Community Residential Care (CRC) program during a 6 year period (N = 140) were reviewed retrospectively. Treatment bed days were tabulated by bed type (psychiatric hospital, inpatient detoxification, medical hospital, physical rehabilitation, and psychosocial residential treatment) for each patient during symmetric pre- and post-placement time intervals. Pre- and post-placement bed days were compared using the paired-sample t test in a naturalistic one-group pretest-posttest analytic design. Psychiatric hospital and residential treatment bed days were significantly reduced post-placement (-77.5% and -99.8%, respectively). Most patients (89.0%) had fewer psychiatric hospital bed days post-placement, and all patients with pre-placement residential treatment program bed days had fewer of those days post-placement. Longer CRC placements were associated with greater reductions in bed utilization.

A COMMENTARY ON IMPROVING CLOZAPINE ACCESSIBILITY AND REDUCING TREATMENT COST

Clozapine is vastly underutilized in the United States and many other countries. The most commonly cited reason for this is the requirement for frequent blood monitoring, which continues for the duration of treatment. Despite the notoriety clozapine achieved early in its development, accumulated evidence has demonstrated that close blood monitoring beyond the first year of treatment yields minimal safety benefits. Many health care systems have relaxed clozapine blood monitoring requirements during the COVID-19 pandemic for practical reasons, and this presents an opportunity to implement permanent, long overdue changes in mandated monitoring that reflect what has been learned about the real risk for blood dyscrasias with clozapine.

Frequency and temporal sequence of clinical features in adults with anti-NMDA receptor encephalitis presenting with psychiatric symptoms

BACKGROUND

Anti-NMDA receptor (NMDAr) encephalitis is the most common autoimmune encephalitis in adults. It mimics psychiatric disorders so often that most patients are initially referred to a psychiatrist, and many are misdiagnosed. Without prompt and effective treatment, patients are likely to suffer a protracted course with significant residual disability, or death. This study focuses on the frequency and chronology of salient clinical features in adults with anti-NMDAr encephalitis who are likely to be first evaluated by a psychiatrist because their presentation suggests a primary psychiatric disorder.

METHODS

A systematic search of PubMed and EMBASE databases identified published reports of anti-NMDAr encephalitis associated with prominent behavioral or psychiatric symptoms. After eliminating redundancies, the frequencies and relative timing of clinical features were tabulated. Signs and symptoms were assigned temporal ranks based on the timing of their first appearance relative to the first appearance of other signs and symptoms in each patient; median ranks were used to compare temporal sequencing of both individual features and major symptom domains.

RESULTS

Two hundred thirty unique cases (185 female) met study inclusion criteria. The most common features were seizures (60.4%), disorientation/confusion (42.6%), orofacial dyskinesias (39.1%), and mutism/staring (37.4%). Seizures, fever, and cognitive dysfunction were often the earliest features to emerge, but psychiatric features predominated and sequencing varied greatly between individuals.

CONCLUSIONS

Clinicians should consider anti-NMDAr encephalitis when new psychiatric symptoms are accompanied by a recent viral prodrome, seizures or unexplained fever, or when the quality of the psychiatric symptoms is unusual (e.g. non-verbal auditory hallucinations).

Recognizing psychiatric presentations of anti-NMDA receptor encephalitis in children and adolescents: A synthesis of published reports

AIM

The aim of this study was to improve early recognition of anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDArE) in children and adolescents by identifying characteristic temporal patterns of clinical features in patients likely to be referred for psychiatric evaluation. In this form of autoimmune encephalitis, NMDAr hypofunction is caused by autoantibodies to receptor surface components. Clinical outcomes following prompt immunotherapy are usually good, but delayed treatment often results in a protracted course with significant residual disability or death. Anti-NMDArE frequently mimics psychiatric disorders, so most patients are referred initially to a psychiatrist and treated for days or weeks before being correctly diagnosed.

METHODS

A systematic search of PubMed and EMBASE electronic databases identified all published reports of antibody-confirmed anti-NMDArE associated with psychiatric symptoms in patients <19 years old. Redundant reports were eliminated manually. For each patient, the order in which each feature was first observed was ranked relative to others. Median temporal ranks were used to compare the sequencing of individual features and major symptom domains.

RESULTS

One hundred and sixty seven cases (121 females) met the inclusion criteria. The most common features were dyskinesias (77.8%), seizures (72.5%), mutism or staring (40.7%), insomnia (39.5%), language dysfunction (36.5%), fever (31.1%), disorientation/confusion (28.7%), reduced arousal (28.1%), and memory disturbance (26.9%). The configuration and temporal sequencing of features were highly variable between individuals.

CONCLUSION

Clinicians need to suspect this disorder: if new behavioral symptoms arise in the context of a recent viral prodrome; if they are accompanied by dyskinesias, seizures or insomnia; or if psychiatric symptoms are unusual (e.g., non-verbal auditory hallucinations).

A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency

OBJECTIVE

To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review.

METHOD

EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association.

RESULTS

Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals.

CONCLUSION

NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.

Preparing residents in training to become health-care leaders: a pilot project

OBJECTIVE

The aim of this study is to describe a successful and exportable training module that addresses Next Accreditation System (NAS) behavioral milestones for leadership competencies.

METHODS

A novel leadership training module, which required the creation of original business plans by teams of residents, was incorporated into a psychiatry PGY-2 training curriculum.

RESULTS

In the creation and presentation of their business plans, the residents demonstrated competencies in the NAS functional domains of interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. Residents who responded with feedback after completing the course were very positive about their experience.

CONCLUSIONS

The leadership training module described here allowed residents to acquire and demonstrate many of the competencies specified in leadership-oriented NAS milestones. The module did not require additional funding or a formal rotation or "track," is scalable to accommodate any number of residents and can be modified based on available local teaching resources.

Neuropsychological performance within-person variability is associated with reduced treatment consent capacity

OBJECTIVE

The capacity of older adults to make healthcare decisions is often impaired in dementia and has been linked to performance on specific neuropsychological tasks. Within-person across-test neuropsychological performance variability has been shown to predict future dementia. This study examined the relationship of within-person across-test neuropsychological performance variability to a current construct of treatment decision (consent) capacity.

METHODS

Participants completed a neuropsychological test battery and a standardized capacity assessment. Standard scores were used to compute mean neuropsychological performance and within-person across-test variability. Assessments were performed in the participant's preferred location (e.g., outpatient clinic office, senior center, or home). Participants were recruited from the community with fliers and advertisements and consisted of men (N = 79) and women (N = 80) with (N = 83) or without (N = 76) significant cognitive impairment. Participants completed the MacArthur Competence Assessment Tool-Treatment and 11 neuropsychological tests commonly used in the cognitive assessment of older individuals.

RESULTS

Neuropsychological performance and within-person variability were independently associated with continuous and dichotomous measures of capacity, and within-person neuropsychological variability was significantly associated with within-person decisional ability variability. Prevalence of incapacity was greater than expected in participants with and without significant cognitive impairment when decisional abilities were considered separately.

CONCLUSION

These findings are consistent with an emerging construct of consent capacity in which discrete decisional abilities are differentially associated with cognitive processes and indicate that the sensitivity and accuracy of consent capacity assessments can be improved by evaluating decisional abilities separately.

Cognitive task performance and symptoms contribute to personality abnormalities in first hospitalized schizophrenia

Chronic schizophrenia patients have personality abnormalities and cognitive deficits that are associated with poor clinical, social, and vocational outcomes. Very few studies have examined relationships between personality and cognitive function, and chronic illness effects may have confounded those studies. In this study personality traits in clinically stable first episode schizophrenia patients (21M, 9F) and psychiatrically healthy controls (38M, 24F) were measured with the NEO-FFI, a self-report measure of neuroticism, extraversion, openness, agreeableness, and conscientiousness. All subjects completed the Information, Digit Span, Vocabulary, and Digit Symbol subtests of the Wechsler Adult Intelligence Scale; and Trails A and B. Standard statistical techniques were used to quantify relationships between personality and symptom levels and/or task performance, and relative contributions of diagnosis and task performance to personality variance. Patients showed elevated mean neuroticism and openness, and reduced mean extraversion, agreeableness and conscientiousness. Task performance and negative symptoms contributed significantly and uniquely to most personality dimensions in patients. Task performance accounted for significant amounts of personality variance even after accounting for diagnosis, and it also contributed to personality variance in controls. These results suggest that cognitive deficits and negative symptoms contribute to consistently observed personality abnormalities in this disorder, and that the contribution of neuropsychological performance to personality variance may be independent of diagnostic classification. Personality abnormalities in schizophrenia may stem from the neurocognitive deficits associated with this disorder, and add to their adverse effects on social and vocational functioning.

WITHDRAWN:A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome

Ahead of Print article withdrawn by publisher.

An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method

OBJECTIVE

The lack of generally accepted diagnostic criteria for neuroleptic malignant syndrome (NMS) impedes research and clinical management of patients receiving antipsychotic medications. The purpose of this study was to develop NMS diagnostic criteria reflecting a broad consensus among clinical knowledge experts, represented by an international multispecialty physician panel.

PARTICIPANTS

Eleven psychiatrists, 2 neurologists, 2 anesthesiologists, and 2 emergency medicine specialists participated in a formal Delphi consensus procedure.

EVIDENCE

A core bibliography consisting of 12 prominent, current reviews of the NMS literature was identified by an objective, comprehensive electronic search strategy. Each panel member was given a copy of these references and asked to examine them before commencing the survey process.

CONSENSUS PROCESS

After reviewing the core bibliography, panel members were asked to list any clinical signs or symptoms or diagnostic studies that they believed, on the basis of their knowledge and clinical experience, were useful in making a diagnosis of NMS. In subsequent survey rounds, panel members assigned priority points to these items, and items that failed to receive a minimum priority score were eliminated from the next round. Information about individual panel member responses was fed back to the group anonymously in the form of the group median or mean and the number of members who had ranked or scored each survey item. The a priori consensus endpoint was defined operationally as a change of 10% or less in the mean priority score for any individual item, and an average absolute value change of 5% or less across all items, between consecutive rounds. The survey was conducted from January 2009 through September 2009.

RESULTS

Consensus was reached on the fifth round regarding the following criteria: recent dopamine antagonist exposure, or dopamine agonist withdrawal; hyperthermia; rigidity; mental status alteration; creatine kinase elevation; sympathetic nervous system lability; tachycardia plus tachypnea; and a negative work-up for other causes. The panel also reached a consensus on the relative importance of these criteria and on the following critical values for quantitative criteria: hyperthermia, > 100.4°F or > 38.0°C on at least 2 occasions; creatine kinase elevation, at least 4 times the upper limit of normal; blood pressure elevation, ≥ 25% above baseline; blood pressure fluctuation, ≥ 20 mm Hg (diastolic) or ≥ 25 mm Hg (systolic) change within 24 hours; tachycardia, ≥ 25% above baseline; and tachypnea, ≥ 50% above baseline.

CONCLUSIONS

These diagnostic criteria significantly advance the field because they represent the consensus of an international multispecialty expert panel, include critical values, provide guidance regarding the relative importance of individual elements, and are less influenced by particular theoretical biases than most previously published criteria. They require validation before being applied in clinical settings.

Reasoning in the capacity to make medical decisions: the consideration of values

PURPOSE

To examine the contribution of "values-based reasoning" in evaluating older adults' capacity to make medical decisions.

DESIGN AND METHODS

Older men with schizophrenia (n=20) or dementia (n=20), and a primary care comparison group (n=19), completed cognitive and psychiatric screening and an interview to determine their capacity to make medical decisions, which included a component on values. All of the participants were receiving treatment at Veterans Administration (VA) outpatient clinics.

RESULTS

Participants varied widely in the activities and relationships they most valued, the extent to which religious beliefs would influence healthcare decisions, and in ratings of the importance of preserving quality versus length of life. Most participants preferred shared decision making with doctor, family, or both. Individuals with schizophrenia or dementia performed worse than a primary care comparison group in reasoning measured by the ability to list risks and benefits and compare choices. Individuals with dementia performed comparably to the primary care group in reasoning measured by the ability to justify choices in terms of valued abilities or activities, whereas individuals with schizophrenia performed relatively worse compared to the other two groups. Compared to primary care patients, participants with schizophrenia and with dementia were impaired on the ability to explain treatment choices in terms of valued relationships.

CONCLUSION

Medical decision making may be influenced by strongly held values and beliefs, emotions, and long life experience. To date, these issues have not been explicitly included in structured evaluations of medical decision-making capacity. This study demonstrated that it is possible to inquire of and elicit a range of healthcare related values and preferences from older adults with dementia or schizophrenia, and individuals with mild to moderate dementia may be able to discuss healthcare options in relation to their values. However, how best to incorporate a values assessment into a structured capacity evaluation deserves further research attention.

Neuropsychological disturbance in schizophrenia: a diffusion tensor imaging study

Patients with schizophrenia and healthy control subjects underwent both neuropsychological evaluation and magnetic resonance diffusion tensor imaging, during which the cingulum bundle (CB) and the uncinate fasciculus (UF) were defined with fiber tractography and their integrity was quantified. On the basis of prior findings, it was hypothesized that neuropsychological disturbance in schizophrenia may be characterized, in part, by 2 dissociable functional neuroanatomical relationships: (a) executive functioning-CB integrity and (b) episodic memory-UF integrity. In support of the hypothesis, hierarchical regression results indicated that reduced white matter of the CB and the UF differentially and specifically predicted deficits in executive functioning and memory, respectively. Neuropsychological correlates of the CB also extended to lower generalized intelligence, as well as to reduced visual memory that may be related to failures of contextual monitoring of to-be-remembered scenes. Reduced white matter of the CB and the UF may each make distinct contributions to neuropsychological disturbance in schizophrenia.

Episodic memory and neuroimaging of hippocampus and fornix in chronic schizophrenia

A group of 44 patients with schizophrenia and 43 age-matched controls completed psychometrically-matched tasks of recall and recognition. The patients showed similarly depressed scores across both recall and recognition matched tasks, independent of their reduced IQ and executive functioning scores. In addition, reduced memory scores correlated in the expected direction with magnetic resonance imaging (MRI) of the hippocampus and diffusion tension imaging (DTI) of the fornix for subsets of both patients and controls that had available these structural imaging measures. Reduced executive functioning also correlated with lower fornix integrity for the patient subset. However, increased hippocampal volume correlated, in the negative direction, with lower scores for executive functioning and IQ in the control subset. Implications of these results are discussed.

Assessment of Capacity to Consent to Treatment: Challenges, the "ACCT" Approach, Future Directions

OBJECTIVE: To review approaches to assessing consent capacity in patients with neurocognitive or neuropsychiatric illness; to summarize the rationale behind our structured interview for consent capacity; and to outline questions for future research. METHOD: After reviewing legal and clinical literature, and empirically comparing three leading consent capacity instruments, we developed the Assessment of Capacity to Consent to Treatment (ACCT) interview and administered it to adults with dementia (n=20), schizophrenia (n=20), and controls (n=19). Capacity ratings by primary care clinicians and experts blind to the patients' status were obtained for a subsample. RESULTS: Interscorer reliability was r=.90; internal consistency reliability was .α=96. ACCT scores agreed 82% of the time (kappa = .44; p<.01) with primary care clinician ratings of capacity and 75% of the time (kappa = .50; p<.05) with expert ratings of capacity. Patients with dementia and schizophrenia could express treatment choices but performed worse than controls on measures of understanding, appreciation as problems with foresight, rational reasoning, and values-based reasoning. Only patients with schizophrenia performed worse on a measure of appreciation as problems with distrust. CONCLUSION: The method of assessing consent capacity described here has adequate reliability and validity, and may provide a useful starting point for clinicians and researchers. Many questions remain about the nature of consent capacity, its component constructs, and the meaning of instrument versus clinician ratings of capacity. Future adaptations, particularly in the assessment of appreciation and reasoning, and additional studies in more diverse samples, are needed.

Dissociable contributions of MRI volume reductions of superior temporal and fusiform gyri to symptoms and neuropsychology in schizophrenia

We sought to identify the functional correlates of reduced magnetic resonance imaging (MRI) volumes of the superior temporal gyrus (STG) and the fusiform gyrus (FG) in patients with chronic schizophrenia. MRI volumes, positive/negative symptoms, and neuropsychological tests of facial memory and executive functioning were examined within the same subjects. The results indicated two distinct, dissociable brain structure-function relationships: (1) reduced left STG volume-positive symptoms-executive deficits; (2) reduced left FG-negative symptoms-facial memory deficits. STG and FG volume reductions may each make distinct contributions to symptoms and cognitive deficits of schizophrenia.

Meta-analytic evidence of systematic bias in estimates of neuroleptic malignant syndrome incidence

OBJECTIVE

The aim of this study was to examine published reports for sources of excessive variance in neuroleptic malignant syndrome (NMS) incidence estimates.

DATA SOURCES

An unrestricted computerized MEDLINE search was conducted with a comprehensive search logic and supplemented by secondary references and a manual search of an extensive personal library.

STUDY SELECTION

Studies were analyzed if they presented original data and provided at least 2 of the following: number of NMS cases, number of patients at risk, or ratio of cases to patients at risk. Twenty-six of the 28 candidate studies met these minimal criteria.

DATA EXTRACTION

Variables included incidence, year of study publication, mean year of NMS occurrence, patient population at risk, study design, diagnostic criteria, and country of origin.

DATA SYNTHESIS

Standard error, which reflects study size, accounted for 90.8% of the variance (beta = .953, P < .001) in this international series of 26 NMS incidence estimates. Incidence was significantly lower in 7 studies the time end points of which were set in advance of case identification (chi(2) = 71.08, P < .001). No other variable was significantly related to incidence.

CONCLUSIONS

Neuroleptic malignant syndrome incidence estimates to date are non-trivially biased such that larger study size (patients at risk) is strongly related to lower observed incidence. Future studies can minimize the contribution of this and other sources of experimental error by incorporating several very feasible recommendations.

Agreement between instruments for rating treatment decisional capacity

OBJECTIVE

The objective of this study was to measure agreement between three treatment decisional capacity assessment instruments in mild to moderate dementia.

METHOD

Subjects (N=79) were recruited from the community. Rating agreement was evaluated with kappa statistics.

RESULTS

Three-way agreement was fair for overall capacity (kappa=0.451), very good for understanding (0.618), very poor for choice (0.158), and no better than chance for reasoning and appreciation. Pairwise agreement showed a similar pattern.

CONCLUSIONS

With the exception of understanding, current treatment decisional capacity assessment instruments do not consistently agree with one another in assessing treatment decision abilities.

Empirical advances in the assessment of the capacity to consent to medical treatment: Clinical implications and research needs

The clinical evaluation of capacity to consent to treatment occurs in the medical setting and is based on legal foundations of informed consent and capacity. Clinical judgment is still the "gold standard" for capacity determination, although it can be unreliable. In the past 10 years the empirical basis for these assessments has been advanced considerably by the introduction of a number of instruments designed to assess capacity to consent to treatment. In this paper, we review studies, mostly with older adult populations, that consider the cognitive and non-cognitive correlates of consent capacity, rates of impaired capacity in various patient groups, the relation of instrument-based to clinician-based capacity assessment, and the inter-rater and test-retest reliability of consent capacity assessment. We also overview key research focusing on factors influencing, and procedural and processing variables involved in, medical decision-making. We conclude that these studies have yielded quite varied results, and promote no consensus regarding the reliability and validity of instrument-based consent capacity assessment. Overall, the results of these studies provide some guidance for clinicians, but, at present, practitioners should view these instruments as supplemental resources rather than benchmarks for assessment. However, this first generation of instruments provides a good foundation for future research, which should continue to systematically study aspects of reliability and validity, most especially construct validity, in well-defined patient populations.

Cognitive performance predicts treatment decisional abilities in mild to moderate dementia

OBJECTIVE

To examine the contribution of neuropsychological test performance to treatment decision-making capacity in community volunteers with mild to moderate dementia.

METHODS

The authors recruited volunteers (44 men, 44 women) with mild to moderate dementia from the community. Subjects completed a battery of 11 neuropsychological tests that assessed auditory and visual attention, logical memory, language, and executive function. To measure decision making capacity, the authors administered the Capacity to Consent to Treatment Interview, the Hopemont Capacity Assessment Interview, and the MacCarthur Competence Assessment Tool--Treatment. Each of these instruments individually scores four decisional abilities serving capacity: understanding, appreciation, reasoning, and expression of choice. The authors used principal components analysis to generate component scores for each ability across instruments, and to extract principal components for neuropsychological performance.

RESULTS

Multiple linear regression analyses demonstrated that neuropsychological performance significantly predicted all four abilities. Specifically, it predicted 77.8% of the common variance for understanding, 39.4% for reasoning, 24.6% for appreciation, and 10.2% for expression of choice. Except for reasoning and appreciation, neuropsychological predictor (beta) profiles were unique for each ability.

CONCLUSIONS

Neuropsychological performance substantially and differentially predicted capacity for treatment decisions in individuals with mild to moderate dementia. Relationships between elemental cognitive function and decisional capacity may differ in individuals whose decisional capacity is impaired by other disorders, such as mental illness.

Neuropsychological predictors of decision-making capacity over 9 months in mild-to-moderate dementia

BACKGROUND

Older adults with dementia may have diminished capacity to make medical treatment decisions.

OBJECTIVE

To examine rates and neuropsychological predictors of treatment decision making, or consent capacity, among older adults with dementia over 9 months.

DESIGN

Consent capacity was assessed initially and 9 months later in subjects with and without dementia using a longitudinal repeated measures design.

PARTICIPANTS

Fifty-three older adults with dementia and 53 similarly aged adults without dementia.

MEASUREMENTS

A standardized measure MacArthur Competence Assessment Tool-Treatment of 4 legal standards for capacity (Understanding, Appreciation, Reasoning, and Expressing a Choice) and a neuropsychological battery.

RESULTS

In the dementia group, 9.4% had impaired capacity initially, and 26.4% had impaired capacity at 9 months. Mean scores in the dementia group were impaired relative to controls initially and at 9 months for Understanding (initial t=2.49, P=.01; 9-month t=3.22, P<.01) and Reasoning (initial t=2.18, P=.03; 9-month t=4.77, P<.01). Declining capacity over 9 months was attributable to a further reduction in Reasoning (group x time F=9.44, P=.003). Discriminant function analysis revealed that initial scores on naming, delayed Logical Memory, and Trails B were associated with impaired capacity at 9 months.

CONCLUSIONS

Some patients with mild-to-moderate dementia develop a clinically relevant impairment of consent capacity within a year. Consent capacity in adults with mild-to-moderate dementia should be reassessed periodically to ensure that it is adequate for each specific informed consent situation. Interventions that maximize Understanding and Reasoning by supporting naming, memory, and flexibility may help to optimize capacity in this patient group.

The five-factor model in schizotypal personality disorder

Studies of the five-factor model of personality in schizotypal personality disorder (SPD) have produced inconsistent results, particularly with respect to openness. In the present study, the NEO-FFI was used to measure five-factor personality dimensions in 28 community volunteers with SPD and 24 psychiatrically healthy individuals. Standard multivariate statistical analyses were used to evaluate personality differences as a function of diagnosis and gender. Individuals with SPD had significantly higher levels of neuroticism and significantly lower levels of extraversion, agreeableness and conscientiousness than those without SPD. Female, but not male, SPD subjects had significantly higher openness levels than their healthy counterparts, and this gender-specific group difference persisted when SPD symptom severity was statistically controlled. These findings suggest that gender-associated differences in openness may account for prior inconsistent findings regarding this dimension, and they further underscore the importance of examining gender effects in future studies of SPD.

Personality differences in schizophrenia are related to performance on neuropsychological tasks

Altered cognition and personality appear to emerge in tandem and adversely affect outcome in schizophrenia, yet little research has been done to determine whether these are related or independent domains. In this study, the relationship between the Big Five personality traits--neuroticism, extraversion, openness, agreeableness, conscientiousness--and cognitive and motor performance in outpatients with chronic, clinically stable schizophrenia (N = 30) and age-matched healthy comparison subjects (N = 45) was examined. Subjects completed tests of attention, executive and motor functions, and the NEO-Five Factor Personality Inventory. Patients scored significantly higher on neuroticism and lower on extraversion and agreeableness, but after variance due to neuropsychological performance was statistically removed from NEO scale scores, personality dimensions and profiles no longer differed between groups. Neuropsychological performance and demographic variables, but not diagnosis, uniquely accounted for statistically significant amounts of personality variance, and neuropsychological task performance was correlated with personality dimensions in both patients and comparison subjects. These cross-sectional data provide preliminary evidence that personality dysfunction in schizophrenia may be mediated by disease-related changes in cognitive operations, or the neural processes underlying them. Longitudinal studies utilizing more comprehensive measures of neurocognitive performance are needed to define further the relationship between neuropsychological function and personality in schizophrenia.

Association between reduced extraversion and right posterior fusiform gyrus gray matter reduction in chronic schizophrenia

OBJECTIVE

The authors examined the association between volume of the fusiform gyrus, a region involved in face processing, and the personality trait of extraversion in patients with schizophrenia.

METHOD

Male patients (N=24) and age-matched male comparison subjects (N=26) completed NEO Five-Factor Inventory personality measures of extraversion and underwent high-spatial-resolution magnetic resonance imaging of anterior and posterior fusiform gyrus gray matter.

RESULTS

Low extraversion scores were significantly correlated with gray matter volume reductions in the right posterior fusiform gyrus for patients but not comparison subjects.

CONCLUSIONS

Reduced right posterior fusiform gyrus volume may contribute to disease-related social disturbances, characterized by both low extraversion and reduced sensitivity to human faces.

Auditory P3 indexes personality traits and cognitive function in healthy men and women

The relationship of the auditory P3 event-related potential to major personality dimensions and neuropsychological performance was examined in psychiatrically healthy men and women (28 male, 15 female) recruited from the community. An auditory oddball paradigm was used to collect P3 amplitude and latency data. Personality traits were measured with the NEO Five-Factor Inventory. Several Wechsler Adult Intelligence Scale-Revised (WAIS-R) subtests, the Digit Symbol Test, and the Trail Making Test comprised the neuropsychological tests. A multivariate statistical procedure (Partial Least Squares) was used to quantify the relationships between P3 variables and personality and neuropsychological performance variables. P3 amplitude was negatively related to Neuroticism and positively related to Extraversion, Openness, Agreeableness and Conscientiousness. Better neuropsychological performance was associated with greater P3 amplitude and earlier latency. Thus, greater P3 amplitude was associated with less deviant personality scores and better neuropsychological performance in healthy subjects. Earlier P3 latency was also associated with better neuropsychological performance. The physiological significance of these relationships is not yet clear, but these results suggest that neural assemblies indexed by P3 may subserve both elemental cognition and healthy personality function.

Neuropsychological correlates of diffusion tensor imaging in schizophrenia

Patients with schizophrenia (n = 41) and healthy comparison participants (n = 46) completed neuropsychological measures of intelligence, memory, and executive function. A subset of each group also completed magnetic resonance diffusion tensor imaging (DTI) studies (fractional anisotropy and cross-sectional area) of the uncinate fasciculus (UF) and cingulate bundle (CB). Patients with schizophrenia showed reduced levels of functioning across all neuropsychological measures. In addition, selective neuropsychological-DTI relationships emerged. Among patients but not controls, lower levels of declarative-episodic verbal memory correlated with reduced left UF, whereas executive function errors related to performance monitoring correlated with reduced left CB. The data suggested abnormal DTI patterns linking declarative-episodic verbal memory deficits to the left UF and executive function deficits to the left CB among patients with schizophrenia.

Hopes and Cautions for Instrument-Based Evaluation of Consent Capacity: Results of a Construct Validity Study of Three Instruments

Does instrument based evaluation of consent capacity increase the precision and validity of competency assessment or does ostensible precision provide a false sense of confidence without in fact improving validity? In this paper we critically examine the evidence for construct validity of three instruments for measuring four functional abilities important in consent capacity: understanding, appreciation, reasoning, and expressing a choice. Instrument based assessment of these abilities is compared through investigation of a multi-trait multi-method matrix in 88 older adults with mild to moderate dementia. Results find variable support for validity. There appears to be strong evidence for good hetero-method validity for the measurement of understanding, mixed evidence for validity in the measurement of reasoning, and strong evidence for poor hetero-method validity for the concepts of appreciation and expressing a choice, although the latter is likely due to extreme range restrictions. The development of empirically based tools for use in capacity evaluation should ultimately enhance the reliability and validity of assessment, yet clearly more research is needed to define and measure the constructs of decisional capacity. We would also emphasize that instrument based assessment of capacity is only one part of a comprehensive evaluation of competency which includes consideration of diagnosis, psychiatric and/or cognitive symptomatology, risk involved in the situation, and individual and cultural differences.

Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia

PURPOSE

The purpose of this study was to compare adults with and without dementia on capacities to consent to treatment as assessed by three instruments.

DESIGN AND METHODS

Eighty-eight older adults with mild to moderate dementia were compared with 88 matched controls on four indices of legal competency to consent to medical treatment as assessed with three capacity instruments.

RESULTS

Mean performance of adults with dementia on a legal standard of understanding treatment information was impaired relative to controls on all instruments, and it was also impaired for an appreciation standard on one instrument and a reasoning standard on two instruments. However, in categorical ratings, most adults with dementia were within the normal range on all decisional capacities. Legal standards were operationalized differently across the three instruments for the capacities of appreciation and reasoning.

IMPLICATIONS

Most adults with mild dementia can participate in medical decision making as defined by legal standards, although memory impairments may limit demonstration of understanding of diagnostic and treatment information. In dementia, assessments of reasoning about treatment options should focus on whether a person can describe salient reasons for a specific choice, whereas assessments of appreciation of the meaning of diagnostic and treatment information should focus on whether a person can describe the implications of various choices for future states. More research is needed to establish the reliability and validity of assessment tools and of capacity constructs.

Is neuroleptic malignant syndrome a neurogenic form of malignant hyperthermia?

Neuroleptic malignant syndrome is a rare and potentially lethal disorder associated with the use of antipsychotic medications. Heightened vigilance on the part of clinical providers has reduced morbidity and mortality caused by this disorder over the past decade, but there is still no consensus regarding its diagnosis, pathophysiology, or treatment. Efforts to demonstrate a direct link between neuroleptic malignant syndrome and malignant hyperthermia have been unsuccessful, indicating mutually distinct etiologies despite striking clinical similarities. This paper concisely reviews essential aspects of electromechanical transduction in muscle and nerve cells and current knowledge concerning the pathophysiology of malignant hyperthermia and neuroleptic malignant syndrome. Utilizing this conceptual framework, the author proposes that neuroleptic malignant syndrome may be caused by a spectrum of inherited defects in genes that are responsible for a variety of calcium regulatory proteins within sympathetic neurons or the higher order assemblies that regulate them. In this proposed model, neuroleptic malignant syndrome may be understood as a neurogenic form of malignant hyperthermia.

The P3 auditory event-related brain potential indexes major personality traits

BACKGROUND

The amplitude of the auditory P3 event-related potential is reduced in patients with axes I and II disorders. Data regarding P3 amplitude and normal personality traits in healthy individuals have been inconsistent, however, although more extreme variants of dimensional traits such as neuroticism and extraversion are associated with psychiatric morbidity.

METHODS

Male subjects (n = 18) recruited from the community completed the NEO Five-Factor Inventory, which consists of five scales: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness. P3 potentials were generated using an auditory discrimination paradigm to which a third, novel stimulus was added. Partial least squares analysis, a multivariate statistical procedure, was used to test the relationship, in both stimulus conditions, between P3 amplitude at six electrode sites and the five personality dimensions.

RESULTS

P3 amplitude across conditions and sites was positively related to Extraversion, Openness, Agreeableness, and Conscientiousness and negatively related to Neuroticism.

CONCLUSIONS

Previous studies have shown that both reduced P3 amplitude and a high Neuroticism/low Extraversion-Openness-Agreeableness-Conscientiousness trait pattern are associated with the presence of, and risk for, substantial psychiatric morbidity. Our results suggest that processes indexed by auditory P3 amplitude are related to these broad personality dimensions in healthy individuals.

Personality traits in schizophrenia: comparison with a community sample

The objective of this study was to compare personality trait profiles in patients with schizophrenia and healthy controls. Male outpatients with schizophrenia (N = 24) and a male nonpsychiatric community sample (N = 46) completed the NEO-FFI personality questionnaire. Multivariate analyses were used to compare mean scale scores and scale profiles for each group. The overall personality profile of clinically stable patients with schizophrenia differed significantly from that of a community sample. On individual scales, patients scored significantly higher on neuroticism and significantly lower on conscientiousness. These results confirm and extend those of previous studies that used normative data for comparison and a much longer version of the same personality questionnaire. Prospective studies of populations at risk are needed to determine whether group differences reflect a premorbid diathesis for schizophrenia or a secondary effect of serious mental illness.

Sympathoadrenal hyperactivity and the etiology of neuroleptic malignant syndrome

OBJECTIVE

The author's goal was to develop a pathophysiological model for neuroleptic malignant syndrome with greater explanatory power than the alternative hypotheses of hypothalamic dopamine antagonism (elevated set point) and direct myotoxicity (malignant hyperthermia variant).

METHOD

Published clinical findings on neuroleptic malignant syndrome were integrated with data from human and animal studies of muscle physiology, thermoregulation, and autonomic nervous system function.

RESULTS

The data show that the sympathetic nervous system's latent capacity for autonomous activity is expressed when tonic inhibitory inputs from higher central nervous system centers are disrupted. These tonic inhibitory inputs are relayed to preganglionic sympathetic neurons by way of dopaminergic hypothalamospinal tracts. The sympathetic nervous system mediates hypothalamic coordination of thermoregulatory activity and is a primary regulator of muscle tone and thermogenesis, augmenting both of these when stimulated. In addition, the sympathetic nervous system modulates all of the other end-organs that function abnormally in neuroleptic malignant syndrome.

CONCLUSIONS

There is substantial evidence to support the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most, if not all, features of neuroleptic malignant syndrome. A predisposition to more extreme sympathetic nervous system activation and/or dysfunction in response to emotional or psychological stress may constitute a trait vulnerability for neuroleptic malignant syndrome, which, when coupled with state variables such as acute psychic distress or dopamine receptor antagonism, produces the clinical syndrome of neuroleptic malignant syndrome. This hypothesis provides a more comprehensive explanation for existing clinical data than do the current alternatives.

Diaphoresis and dehydration during neuroleptic malignant syndrome: preliminary findings

Serum osmolality and its relationship to diaphoresis and polydipsic behavior were examined in a series of 38 episodes of neuroleptic malignant syndrome (NMS) in 29 patients. Clinical variables were associated with significantly higher serum osmolality, and diaphoresis tended to emerge earlier than polydipsia in the course of NMS. The findings of this study are consistent with the hypothesis that, at least in some NMS patients, diaphoresis leads to dehydration followed by physiologically appropriate thirst and increased oral water intake. It appears that intravenous hydration is often necessary to correct the significant free water deficit that can occur during the course of NMS.

Thermoregulatory dysfunction in neuroleptic malignant syndrome

Hyperthermia is the central feature of neuroleptic malignant syndrome (NMS), but its etiology remains elusive. Two competing hypotheses implicate either hypothalamic dysfunction (inappropriate "set point") or direct myotoxicity (excessive peripheral heat production). These two models have distinct implications for thermoregulatory activity in NMS. The first predicts that the individual should respond as to a hypothermic threat or infection (the hypothalamus signals the body to raise its temperature). The second implies that an excessive heat load is perceived by the hypothalamus, which responds to this hyperthermic threat (it signals the body to lower its temperature). To assess the validity of these two hypotheses the thermoregulatory responses of a series of NMS patients (36 patients, 46 episodes) were examined using standard statistical methods. In contrast to normal mammalian thermoregulatory behavior, thermoeffector responses were not organized into either mode, but appeared to function somewhat independently and paradoxically. We conclude that neither hypothesis is sufficient to explain altered thermoregulation in NMS, and that the loss of integrated thermoeffector activity may be unique to this disorder.

Platelet monoamine oxidase activity and deficit syndrome schizophrenia

Measures of affective flattening that combine self-reported emotional experience with observed affect may identify deficit syndrome patients better than ratings based on observed affect alone. In this study, we examined 23 clinically stable but chronically ill schizophrenic patients, 15 of whom were found to have a deficit syndrome. After exclusion of patients with self-reported depressed mood from the deficit syndrome group, the remaining patients with a deficit syndrome not accompanied by self-reported depressed mood showed a strikingly homogeneous distribution of platelet monoamine oxidase activity. Results suggest that inclusion of self-reported emotional experience in clinical definitions of the deficit syndrome will increase the specificity of diagnosis.

Enzyme elevations in the neuroleptic malignant syndrome

Enzyme elevations are frequently observed in neuroleptic malignant syndrome (NMS), but their significance is unknown and their source is uncertain. In this study the relationship of serum enzymes to creatine phosphokinase (CPK) in NMS is examined. Thirty-seven patients with at least one probable episode of NMS were studied, and 83 consecutive newly admitted psychiatric patients constituted a comparison group. Serum levels of lactate dehydrogenase (LDH), glutamic oxaloacetic transaminase (GOT), aldolase, and alkaline phosphatase (AP) were compared to serum CPK levels in each patient group. Except for AP, all enzymes were significantly correlated with CPK in both groups. However, correlations were much higher in the NMS group, and regression lines for CPK-LDH and CPK-GOT pairs differed significantly between patient groups. These data strongly suggest that a common process underlies the enzyme elevations frequently seen in NMS, that these enzymes originate in muscle tissue, and that these findings are not caused solely by agitation or psychological stress. It is likely that increased production and selective "leakage" of enzymes from myocytes play a role in this process.

Sensation seeking and novelty seeking. Are they the same?

Responses to Zuckerman's Sensation Seeking Scale (SSS) and Cloninger's Tridimensional Personality Questionnaire (which consists of novelty seeking, harm avoidance, and reward-dependence dimensions) have been linked to a variety of behavioral and psychiatric variables. The relationship of these two measures to one another has not been examined previously and, in the present study, is evaluated in a group of men briefly hospitalized for treatment of alcohol and chemical dependence. Total sensation seeking scale scores were significantly correlated (Pearson r) with total novelty seeking scale scores. Set correlation analysis revealed significant overall relationships between sensation seeking and both high novelty seeking and low harm avoidance. Most of these overall relationships were attributable to six subscales, although broad relationships were observed between the SSS disinhibition and novelty seeking subscales, and between a harm avoidance subscale and all SSS subscales. Neither statistical approach identified an association between reward dependence and sensation seeking.

Sympathoadrenomedullary activity in the neuroleptic malignant syndrome

Many clinical features of the neuroleptic malignant syndrome suggest that sympathetic nervous system hyperactivity is involved in the pathophysiology of this disorder. Only a few studies have examined levels of catecholamines or their metabolites in patients with NMS; results so far have been inconclusive. In the present study urinary catecholamine metabolites obtained during the course of NMS were studied with respect to frequently reported signs and symptoms of NMS. The principal findings are that (1) elevated urinary catecholamines and metabolites are a frequent but inconstant feature of NMS; (2) it is likely that sympathetic nervous system hyperactivity contributes to the picture of fulminant NMS; and (3) the role of the adrenal medulla in producing excess catecholamines during NMS is uncertain.

A comparison of diagnostic criteria for neuroleptic malignant syndrome

BACKGROUND

A variety of diagnostic criteria for neuroleptic malignant syndrome (NMS) have been used in clinical studies of this disorder, but it is not known if different criteria consistently identify NMS. This study examines agreement between three frequently used sets of diagnostic criteria in a series of possible NMS episodes.

METHOD

All clinically suspected NMS episodes occurring at a large tertiary psychiatric facility during a 6-year period were evaluated by three different sets of diagnostic criteria. Agreement among these criteria was quantified statistically by means of the kappa and intraclass correlation coefficients.

RESULTS

The NMS diagnostic criteria examined generally demonstrated only fair agreement with one another in the diagnosis of NMS. Agreement was best among these criteria when the "probable" category was employed. A complex interaction involving both definition and structure of individual diagnostic criteria and designation of criteria as major or minor appears to contribute to these findings.

CONCLUSION

The published diagnostic criteria used in this study do not consistently identify NMS episodes and demonstrate different thresholds for assigning this diagnosis. These differences are not due solely to different definitions of individual criteria (e.g., fever). Possible implications of these findings for clinical practice and research are discussed.

Some biological and behavioral features associated with clinical personality types

The author reviews supporting evidence for the existence of two personality prototypes that correspond to two DSM-III-R personality "clusters." These hypothetical personality prototypes are characterized by extreme variations along several interrelated personality trait dimensions and by differences in two biological measures. The possibility that individual differences in central serotonin and/or catecholamine activity may underlie some of the features associated with these prototypes is discussed in light of current data. The usefulness of this conceptualization as a supplemental axis of personality classification is suggested.