Association of polygenic score and the involvement of cholinergic and glutamatergic pathways with lithium treatment response in patients with bipolar disorder

Lithium is regarded as the first-line treatment for bipolar disorder (BD), a severe and disabling mental health disorder that affects about 1% of the population worldwide. Nevertheless, lithium is not consistently effective, with only 30% of patients showing a favorable response to treatment. To provide personalized treatment options for bipolar patients, it is essential to identify prediction biomarkers such as polygenic scores. In this study, we developed a polygenic score for lithium treatment response (Li+PGS) in patients with BD. To gain further insights into lithium's possible molecular mechanism of action, we performed a genome-wide gene-based analysis. Using polygenic score modeling, via methods incorporating Bayesian regression and continuous shrinkage priors, Li+PGS was developed in the International Consortium of Lithium Genetics cohort (ConLi+Gen: N = 2367) and replicated in the combined PsyCourse (N = 89) and BipoLife (N = 102) studies. The associations of Li+PGS and lithium treatment response - defined in a continuous ALDA scale and a categorical outcome (good response vs. poor response) were tested using regression models, each adjusted for the covariates: age, sex, and the first four genetic principal components. Statistical significance was determined at P < 0.05. Li+PGS was positively associated with lithium treatment response in the ConLi+Gen cohort, in both the categorical (P = 9.8 × 10-12, R2 = 1.9%) and continuous (P = 6.4 × 10-9, R2 = 2.6%) outcomes. Compared to bipolar patients in the 1st decile of the risk distribution, individuals in the 10th decile had 3.47-fold (95%CI: 2.22-5.47) higher odds of responding favorably to lithium. The results were replicated in the independent cohorts for the categorical treatment outcome (P = 3.9 × 10-4, R2 = 0.9%), but not for the continuous outcome (P = 0.13). Gene-based analyses revealed 36 candidate genes that are enriched in biological pathways controlled by glutamate and acetylcholine. Li+PGS may be useful in the development of pharmacogenomic testing strategies by enabling a classification of bipolar patients according to their response to treatment.

Association of early life stress and cognitive performance in patients with schizophrenia and healthy controls

As core symptoms of schizophrenia, cognitive deficits contribute substantially to poor outcomes. Early life stress (ELS) can negatively affect cognition in patients with schizophrenia and healthy controls, but the exact nature of the mediating factors is unclear. Therefore, we investigated how ELS, education, and symptom burden are related to cognitive performance. The sample comprised 215 patients with schizophrenia (age, 42.9 ± 12.0 years; 66.0 % male) and 197 healthy controls (age, 38.5 ± 16.4 years; 39.3 % male) from the PsyCourse Study. ELS was assessed with the Childhood Trauma Screener (CTS). We used analyses of covariance and correlation analyses to investigate the association of total ELS load and ELS subtypes with cognitive performance. ELS was reported by 52.1 % of patients and 24.9 % of controls. Independent of ELS, cognitive performance on neuropsychological tests was lower in patients than controls (p < 0.001). ELS load was more closely associated with neurocognitive deficits (cognitive composite score) in controls (r = -0.305, p < 0.001) than in patients (r = -0.163, p = 0.033). Moreover, the higher the ELS load, the more cognitive deficits were found in controls (r = -0.200, p = 0.006), while in patients, this correlation was not significant after adjusting for PANSS. ELS load was more strongly associated with cognitive deficits in healthy controls than in patients. In patients, disease-related positive and negative symptoms may mask the effects of ELS-related cognitive deficits. ELS subtypes were associated with impairments in various cognitive domains. Cognitive deficits appear to be mediated through higher symptom burden and lower educational level.

Changing the Antipsychotic in Early Nonimprovers to Amisulpride or Olanzapine: Randomized, Double-Blind Trial in Patients With Schizophrenia

BACKGROUND AND HYPOTHESIS

Meta-analyses have shown that the majority of patients with schizophrenia who have not improved after 2 weeks of treatment with an antipsychotic drug are unlikely to fully respond later. We hypothesized that switching to another antipsychotic with a different receptor binding profile is an effective strategy in such a situation.

STUDY DESIGN

In total, 327 inpatients with an acute exacerbation of schizophrenia were randomized to double-blind treatment with either olanzapine (5-20 mg/day) or amisulpride (200-800 mg/day). Those patients who had not reached at least 25% Positive-and-Negative-Syndrome-Scale (PANSS) total score reduction from baseline after 2 weeks (the "non-improvers") were rerandomized double-blind to either staying on the same compound ("stayers") or to switching to the other antipsychotic ("switchers") for another 6 weeks. The primary outcome was the difference in the number of patients in symptomatic remission between the combined "switchers" and the "stayers" after 8 weeks of treatment, analyzed by logistic regression.

STUDY RESULTS

A total of 142 nonimprovers were rerandomized at week two. 25 (45.5 %) of the 'stayers' compared to 41 (68.3 %) of the "switchers" reached remission at endpoint (p = .006). Differences in secondary efficacy outcomes were not significant, except for the PANSS negative subscore and the Clinical-Global-Impression-Scale. "Switchers" and "stayers" did not differ in safety outcomes.

CONCLUSIONS

Switching "non-improvers" from amisulpride to olanzapine or vice-versa increased remission rates and was safe. The superiority in the primary outcome was, however, not paralleled by significant differences in most secondary efficacy outcomes and the effect was only apparent at the last visit making replications of longer duration necessary.

Polygenic risk scores across the extended psychosis spectrum

As early detection of symptoms in the subclinical to clinical psychosis spectrum may improve health outcomes, knowing the probabilistic susceptibility of developing a disorder could guide mitigation measures and clinical intervention. In this context, polygenic risk scores (PRSs) quantifying the additive effects of multiple common genetic variants hold the potential to predict complex diseases and index severity gradients. PRSs for schizophrenia (SZ) and bipolar disorder (BD) were computed using Bayesian regression and continuous shrinkage priors based on the latest SZ and BD genome-wide association studies (Psychiatric Genomics Consortium, third release). Eight well-phenotyped groups (n = 1580; 56% males) were assessed: control (n = 305), lower (n = 117) and higher (n = 113) schizotypy (both groups of healthy individuals), at-risk for psychosis (n = 120), BD type-I (n = 359), BD type-II (n = 96), schizoaffective disorder (n = 86), and SZ groups (n = 384). PRS differences were investigated for binary traits and the quantitative Positive and Negative Syndrome Scale. Both BD-PRS and SZ-PRS significantly differentiated controls from at-risk and clinical groups (Nagelkerke's pseudo-R2: 1.3-7.7%), except for BD type-II for SZ-PRS. Out of 28 pairwise comparisons for SZ-PRS and BD-PRS, 9 and 12, respectively, reached the Bonferroni-corrected significance. BD-PRS differed between control and at-risk groups, but not between at-risk and BD type-I groups. There was no difference between controls and schizotypy. SZ-PRSs, but not BD-PRSs, were positively associated with transdiagnostic symptomology. Overall, PRSs support the continuum model across the psychosis spectrum at the genomic level with possible irregularities for schizotypy. The at-risk state demands heightened clinical attention and research addressing symptom course specifiers. Continued efforts are needed to refine the diagnostic and prognostic accuracy of PRSs in mental healthcare.

Interplay between the genetics of personality traits, severe psychiatric disorders and COVID-19 host genetics in the susceptibility to SARS-CoV-2 infection

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, with its impact on our way of life, is affecting our experiences and mental health. Notably, individuals with mental disorders have been reported to have a higher risk of contracting SARS-CoV-2. Personality traits could represent an important determinant of preventative health behaviour and, therefore, the risk of contracting the virus.

AIMS

We examined overlapping genetic underpinnings between major psychiatric disorders, personality traits and susceptibility to SARS-CoV-2 infection.

METHOD

Linkage disequilibrium score regression was used to explore the genetic correlations of coronavirus disease 2019 (COVID-19) susceptibility with psychiatric disorders and personality traits based on data from the largest available respective genome-wide association studies (GWAS). In two cohorts (the PsyCourse (n = 1346) and the HeiDE (n = 3266) study), polygenic risk scores were used to analyse if a genetic association between, psychiatric disorders, personality traits and COVID-19 susceptibility exists in individual-level data.

RESULTS

We observed no significant genetic correlations of COVID-19 susceptibility with psychiatric disorders. For personality traits, there was a significant genetic correlation for COVID-19 susceptibility with extraversion (P = 1.47 × 10^-5; genetic correlation 0.284). Yet, this was not reflected in individual-level data from the PsyCourse and HeiDE studies.

CONCLUSIONS

We identified no significant correlation between genetic risk factors for severe psychiatric disorders and genetic risk for COVID-19 susceptibility. Among the personality traits, extraversion showed evidence for a positive genetic association with COVID-19 susceptibility, in one but not in another setting. Overall, these findings highlight a complex contribution of genetic and non-genetic components in the interaction between COVID-19 susceptibility and personality traits or mental disorders.

Medication Adherence in a Cross-Diagnostic Sample of Patients From the Affective-to-Psychotic Spectrum: Results From the PsyCourse Study

INTRODUCTION

According to the World Health Organization, medication adherence is defined as the extent to which a person's behavior corresponds with an agreed recommendation from a healthcare provider. Approximately 50% of patients do not take their medication as prescribed, and non-adherence can contribute to the progress of a disease. For patients suffering from mental diseases non-adherence plays an important role. Various factors have been proposed as contributing to non-adherence, however the literature remains heterogeneous dependent on the analyzed patient subgroups. This study comprehensively evaluates the association of sociodemographic, clinical, personality and quality of life related factors with medication adherence by analyzing data from the PsyCourse study. The PsyCourse study is a large and cross-diagnostic cohort of psychiatric patients from the affective-to-psychotic spectrum.

METHODS

The study sample comprised 1,062 patients from the PsyCourse study with various psychiatric diagnoses (mean [SD] age, 42.82 [12.98] years; 47.4% female). Data were analyzed to identify specific factors associated with medication adherence, and adherence was measured by a self-rating questionnaire. Odds ratios (OR) were estimated by a logistic regression for binary outcomes. Missing data were imputed using multiple imputation.

RESULTS

The following factors showed the strongest association with medication adherence: never having used illicit drugs (OR, 0.71), number of prescribed antipsychotics (OR, 1.40), the personality trait conscientiousness (OR, 1.26), and the environmental domain of quality of life (OR, 1.09).

CONCLUSION

In a large and cross-diagnostic sample, we could show that a higher level of conscientiousness, a higher number of antipsychotic medication, a better quality of life within the environmental domain, and the absence of substance abuse contribute to a better medication adherence independent of the underlying disorder.

An Investigation of Psychosis Subgroups With Prognostic Validation and Exploration of Genetic Underpinnings: The PsyCourse Study

IMPORTANCE

Identifying psychosis subgroups could improve clinical and research precision. Research has focused on symptom subgroups, but there is a need to consider a broader clinical spectrum, disentangle illness trajectories, and investigate genetic associations.

OBJECTIVE

To detect psychosis subgroups using data-driven methods and examine their illness courses over 1.5 years and polygenic scores for schizophrenia, bipolar disorder, major depression disorder, and educational achievement.

DESIGN, SETTING, AND PARTICIPANTS

This ongoing multisite, naturalistic, longitudinal (6-month intervals) cohort study began in January 2012 across 18 sites. Data from a referred sample of 1223 individuals (765 in the discovery sample and 458 in the validation sample) with DSM-IV diagnoses of schizophrenia, bipolar affective disorder (I/II), schizoaffective disorder, schizophreniform disorder, and brief psychotic disorder were collected from secondary and tertiary care sites. Discovery data were extracted in September 2016 and analyzed from November 2016 to January 2018, and prospective validation data were extracted in October 2018 and analyzed from January to May 2019.

MAIN OUTCOMES AND MEASURES

A clinical battery of 188 variables measuring demographic characteristics, clinical history, symptoms, functioning, and cognition was decomposed using nonnegative matrix factorization clustering. Subtype-specific illness courses were compared with mixed models and polygenic scores with analysis of covariance. Supervised learning was used to replicate results in validation data with the most reliably discriminative 45 variables.

RESULTS

Of the 765 individuals in the discovery sample, 341 (44.6%) were women, and the mean (SD) age was 42.7 (12.9) years. Five subgroups were found and labeled as affective psychosis (n = 252), suicidal psychosis (n = 44), depressive psychosis (n = 131), high-functioning psychosis (n = 252), and severe psychosis (n = 86). Illness courses with significant quadratic interaction terms were found for psychosis symptoms (R2 = 0.41; 95% CI, 0.38-0.44), depression symptoms (R2 = 0.28; 95% CI, 0.25-0.32), global functioning (R2 = 0.16; 95% CI, 0.14-0.20), and quality of life (R2 = 0.20; 95% CI, 0.17-0.23). The depressive and severe psychosis subgroups exhibited the lowest functioning and quadratic illness courses with partial recovery followed by reoccurrence of severe illness. Differences were found for educational attainment polygenic scores (mean [SD] partial η2 = 0.014 [0.003]) but not for diagnostic polygenic risk. Results were largely replicated in the validation cohort.

CONCLUSIONS AND RELEVANCE

Psychosis subgroups were detected with distinctive clinical signatures and illness courses and specificity for a nondiagnostic genetic marker. New data-driven clinical approaches are important for future psychosis taxonomies. The findings suggest a need to consider short-term to medium-term service provision to restore functioning in patients stratified into the depressive and severe psychosis subgroups.

A longitudinal approach to biological psychiatric research: The PsyCourse study

In current diagnostic systems, schizophrenia and bipolar disorder are still conceptualized as distinct categorical entities. Recently, both clinical and genomic evidence have challenged this Kraepelinian dichotomy. There are only few longitudinal studies addressing potential overlaps between these conditions. Here, we present design and first results of the PsyCourse study (N = 891 individuals at baseline), an ongoing transdiagnostic study of the affective-to-psychotic continuum that combines longitudinal deep phenotyping and dimensional assessment of psychopathology with an extensive collection of biomaterial. To provide an initial characterization of the PsyCourse study sample, we compare two broad diagnostic groups defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification system, that is, predominantly affective (n = 367 individuals) versus predominantly psychotic disorders (n = 524 individuals). Depressive, manic, and psychotic symptoms as well as global functioning over time were contrasted using linear mixed models. Furthermore, we explored the effects of polygenic risk scores for schizophrenia on diagnostic group membership and addressed their effects on nonparticipation in follow-up visits. While phenotypic results confirmed expected differences in current psychotic symptoms and global functioning, both manic and depressive symptoms did not vary between both groups after correction for multiple testing. Polygenic risk scores for schizophrenia significantly explained part of the variability of diagnostic group. The PsyCourse study presents a unique resource to research the complex relationships of psychopathology and biology in severe mental disorders not confined to traditional diagnostic boundaries and is open for collaborations.

Investigating polygenic burden in age at disease onset in bipolar disorder: Findings from an international multicentric study

OBJECTIVES

Bipolar disorder (BD) with early disease onset is associated with an unfavorable clinical outcome and constitutes a clinically and biologically homogenous subgroup within the heterogeneous BD spectrum. Previous studies have found an accumulation of early age at onset (AAO) in BD families and have therefore hypothesized that there is a larger genetic contribution to the early-onset cases than to late onset BD. To investigate the genetic background of this subphenotype, we evaluated whether an increased polygenic burden of BD- and schizophrenia (SCZ)-associated risk variants is associated with an earlier AAO in BD patients.

METHODS

A total of 1995 BD type 1 patients from the Consortium of Lithium Genetics (ConLiGen), PsyCourse and Bonn-Mannheim samples were genotyped and their BD and SCZ polygenic risk scores (PRSs) were calculated using the summary statistics of the Psychiatric Genomics Consortium as a training data set. AAO was either separated into onset groups of clinical interest (childhood and adolescence [≤18 years] vs adulthood [>18 years]) or considered as a continuous measure. The associations between BD- and SCZ-PRSs and AAO were evaluated with regression models.

RESULTS

BD- and SCZ-PRSs were not significantly associated with age at disease onset. Results remained the same when analyses were stratified by site of recruitment.

CONCLUSIONS

The current study is the largest conducted so far to investigate the association between the cumulative BD and SCZ polygenic risk and AAO in BD patients. The reported negative results suggest that such a polygenic influence, if there is any, is not large, and highlight the importance of conducting further, larger scale studies to obtain more information on the genetic architecture of this clinically relevant phenotype.

Severe clinical events in 100 patients with schizophrenia: a retrospective clinical description using a system-specific psychopathological approach

Catatonic states and numerous other severe clinical events can complicate the course of schizophrenia. Whether these severe courses are associated with particular system-specific symptom dimensions remain unclear. Aim is to assess the frequency of severe clinical events in a clinical population and to investigate the association of these events with sociodemographic data and system-specific psychopathology, combining qualitative and quantitative data. We performed a comprehensive retrospective description of a well-described and geographically stable sample of 100 patients with schizophrenia or schizoaffective disorder and linked severe clinical events with sociodemographic data at inclusion into the study (as indicators of social functioning) and symptoms at first admission, classified with the Bern Psychopathology Scale (BPS). We found 12 mentions of catatonic stupor or excitement, 45 of suicide attempts, 26 of suicidality, 18 of deliberate self-harm, 18 of self-threatening behaviour other than deliberate self-harm, 34 of violence against other persons, 18 of violence against objects and six of sexual harassment. Disinhibited language on first admission seemed to be a protective factor against suicidality and disinhibited motor behaviour seemed to predict self-threatening and violent behaviour. Catatonia and violence in particular seemed to be socially disabling. This exploratory study showed that the BPS is a promising instrument and might represent a system-specific approach in identifying patients at risk for severe sequelae of schizophrenia. This will have to be tested in future prospective studies.

Psychosis Is Mutable over Time: A Longitudinal Psychopathology Study

BACKGROUND

A neurobiologically informed, system-specific psychopathological approach has been suggested for use in schizophrenia. However, to our knowledge, such an approach has not been used to prospectively describe the course of schizophrenia.

SAMPLING AND METHODS

We assessed psychopathology in a well-described sample of 100 patients with schizophrenia or schizoaffective disorder with the Bern Psychopathology Scale (BPS) at 6-month intervals for up to 18 months. The BPS groups symptoms into the 3 domains language, affectivity and motor behaviour; each domain is rated as being normal, inhibited or disinhibited. In addition, we collected qualitative psychopathological data in the form of case reports.

RESULTS

Forty-eight patients completed at least 2 assessments over the course of at least 1 year. Of these, 16 patients (33.3%) showed a bipolar course pattern (i.e., a switch from inhibited to disinhibited or vice versa) in 1 domain and 6 patients (12.5%) in more than 1 domain. Shifts from 1 dominant domain to another were seen frequently (n = 20, 41.7%), but shifts between 1 dominant domain and a combination of dominant domains were more common (n = 33, 68.8%).

CONCLUSIONS

The course of schizophrenia is heterogeneous and shows frequent changes in psychopathology. This should be taken into account in the communication with patients and in the research on underlying illness mechanisms and treatment. A major limitation of this study is the small sample size.

[Illness Concepts of Patients with Schizophrenia: A Triangulation Study]

Objective Therapists' and patients' concepts of illness often show severe discrepancies. This study explores the illness concepts of patients with schizophrenic disorders (n = 40). Methods Two German scales were used, the "Causal Belief Questionnaire" and the "Illness Concept Scale for Schizophrenic Patients". We compared our data with data published previously. A semi structured interview was performed in a convenience sample (n = 7). Results The domains "trust in medication" and "trust in the treating physician" yielded high scores, yet in comparison with data published 30 years ago, trust in medication is unaltered, while trust in psychiatrists is even slightly lower. Recent psychosocial factors scored high as a possible cause of mental illness. Several patients felt responsible for being mentally ill. No patient in the interview mentioned the neurotransmitter hypothesis of schizophrenia. Conclusion Illness concepts of patients with schizophrenic disorders are a complex phenomenon. Triangulation of quantitative and qualitative methods proves to be a promising approach for future studies.

Comparison of psychopathological dimensions between major depressive disorder and schizophrenia spectrum disorders focusing on language, affectivity and motor behavior

This study tested whether patients with major depressive disorder (MDD) and schizophrenia spectrum disorders would differ in three dimensions of psychopathology (language, affectivity and motor behavior) as assessed by the Bern Psychopathology Scale (BPS) in a cohort of 58 patients with MDD and 146 patients with schizophrenia spectrum disorders. The overall estimation of severity of each of the three dimensions was rated on a seven-point Likert scale from severely inhibited to severely disinhibited. Here, more than half of the patients endorsed ratings that showed normal or mildly (dis-)inhibited behavior. At group level more pronounced negative ratings of affect were seen in MDD. Group comparisons of the severity ratings on language or motor behavior yielded no differences between schizophrenia spectrum disorders and MDD. At the individuals' levels, extreme ratings in the language and motor dimensions were more frequent in schizophrenia spectrum disorders and in the affectivity dimension more frequent in MDD. Shared psychopathological features could be seen across diagnoses, supporting a dimensional approach to psychopathology in endogenous psychoses. However, the groups differ in the severity of affect ratings as well as in the distribution of language, affectivity and motor ratings with more variance among the group of schizophrenia spectrum disorders.

[Are Depressed People Aggressive People? Differences Between General Population and Depressive Patients]

IntroductionThe study aimed to investigate the relationship between depression and aggression. Material and Methods681 depressive and non-depressive subjects of the general population as well as 132 depressive patients completed the Beck Depression Inventory Revised (BDI-II) as well as the Short Questionnaire for Gathering Factors of Aggressiveness (K-FAF). ResultsDepressive patients and depressive subjects of the general population did not merely report the highest levels of self-aggressiveness but also reached the highest scores on the scales of reactive and proactive aggression, indicating a high level of externalizing aggressiveness. DiscussionThe results support the neurobiological approach of the etiology of depressive disorders. Conclusions For future research of depressive disorders and aggression the investigation of the mediating roles of a low serotonin-level is recommended.

Suicidality in emergency medicine: Results from a retrospective analysis of emergency documentation forms

BACKGROUND

To analyze suicidal care episodes in emergency medical responses in Germany.

METHOD

Anonymized data from emergency care episodes in Ulm from 2004 to 2013 were analyzed retrospectively.

RESULTS

158 of 933 psychiatric emergencies (16 %) were suicide related, including 14 completed suicides, 25 care episodes with suicidal ideation, and 119 suicide attempts. Significantly more men than women completed suicide (χ²(2,N = 934) = 12.70, p = 0.02). 93 % of the total psychiatric emergencies received any medication at all, and only about 33 % were transported to a psychiatric hospital.

CONCLUSION

Psychiatric treatment for suicidality in emergency medicine requires improvement to ensure that patients receive adequate therapy.

Psychopathological Course Typology in Schizophrenia Spectrum Disorders: A Heuristic Approach in a Sample of 100 Patients

BACKGROUND

Despite several previous attempts at subtyping schizophrenia, a typology that reflects neurobiological knowledge and reliably predicts course and outcome is lacking. We applied the system-specific concept of the Bern Psychopathology Scale (BPS) to generate a course typology based on three domains: language, affectivity, and motor behaviour.

SAMPLING AND METHODS

A cohort of 100 patients with schizophrenia or schizoaffective disorders according to DSM-IV criteria underwent psychopathological assessment, and all their available medical records were retrospectively analysed on the basis of the BPS.

RESULTS

Overall, 39% of the patients showed dominant abnormalities in only one domain, 37% in two domains, and 24% in all three domains. The motor domain was affected in the majority of patients (76%), followed by affectivity (63%) and language (46%). Eighty-six percent of patients showed a bipolar course pattern in at least one domain.

CONCLUSIONS

In a retrospective analysis of 100 patient records we described system-specific course patterns of schizophrenia by using a neurobiologically informed psychopathological assessment. The results showed a surprisingly high proportion of bipolar courses and a pattern of pure and mixed subtypes, which speaks for an overlap of domains with regards to psychopathological symptoms. A limitation of this heuristic and retrospective approach is that it was largely based on clinical judgement. Prospective studies with more rigorous threshold definitions are needed to clarify the neurobiological and clinical implications of the proposed reorganization of psychotic disorders.

Psychopathological Symptoms Assessed by a System-Specific Approach Are Related to Global Functioning in Schizophrenic Disorders

BACKGROUND

By mostly using a positive-negative approach, several studies have identified factors that influence day-to-day functioning. We applied a different, system-specific approach to expand the knowledge of this issue.

SAMPLING AND METHODS

We recruited a sample of 100 inpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Psychopathological characteristics were assessed with the Bern Psychopathology Scale (BPS) and functional characteristics with the Global Assessment of Functioning (GAF) scale. Linear regression analyses were performed with the GAF score as the dependent variable and the global values of the BPS subscores as independent variables. The model was controlled for confounding variables. Spearman rank correlation analyses were used to identify associations between the relevant BPS subdomains and global functioning.

RESULTS

Higher absolute global values of the BPS domains language (px2009; = x2009;0.038) and motor behavior (px2009; = x2009;0.049) were significantly associated with lower GAF scores. These findings remained stable after adjusting for potential confounding variables. A statistically significant negative correlation was found between both qualitative symptoms (rx2009; = x2009;-0.273, px2009; = x2009;0.006) and indirect signs (rx2009; = x2009;-0.269, px2009; = x2009;0.007) of the language domain and GAF scores. Also, quantitative (rx2009; = x2009;-0.211, px2009; = x2009;0.035) and qualitative symptoms (rx2009; = x2009;-0.214, px2009; = x2009;0.033) in the motor behavior domain were associated with poorer functioning.

CONCLUSIONS

A system-specific approach can describe subgroups of patients with poor functioning. Identifying such subgroups could help to utilize targeted treatment opinions in a timely manner. Another goal of future research is to clarify the underlying neurobiological deficits.

[Psychiatric Day Clinics--Evidence for and Importance of Patient-Centered Care]

OBJECTIVE

The aim of the study was to summarize and evaluate the recent literature on treatment in psychiatric day clinics, and to assess the importance of such clinics in the current healthcare system.

METHOD

We conducted a systematic review of recent studies in order to compare the efficacy and cost effectiveness of day clinics in relation to in- and outpatient treatment.

RESULTS

The evidence is still sparse and inconclusive.

CONCLUSION

Psychiatric day clinics act as a link between inpatient and outpatient treatment in community mental healthcare. However, evidence in support of the efficacy and cost-effectiveness of day clinics is still sparse.

[Innovative patient-centered care systems: International perspectives]

BACKGROUND

The "Psychiatrie-Enquete" (German Report on the State of Psychiatry) is 40 years old this year. It has always been inspirational; also internationally.

OBJECTIVE

Which innovative elements of community mental health services can be found in an international perspective?

MATERIALS AND METHODS

Narrative review.

RESULTS

Community mental health care is a lively field with much research and innovative practice. With assertive community treatment (ACT) and home treatment (HT), internationally well-evaluated forms of community mental health care are available.

CONCLUSION

Recovery-based and peer-to-peer approaches hold promise for the future. In terms of mid- and long-term perspectives, an increase in patient-centering via individualization of mental health care and a better implementation of community mental health interventions would be desirable in Germany.

Factor structure of the Bern Psychopathology Scale in a sample of patients with schizophrenia spectrum disorders

BACKGROUND

The Bern Psychopathology Scale (BPS) is based on a system-specific approach to classifying the psychopathological symptom pattern of schizophrenia. It consists of subscales for three domains (language, affect and motor behaviour) that are hypothesized to be related to specific brain circuits. The aim of the study was to examine the factor structure of the BPS in patients with schizophrenia spectrum disorders.

METHODS

One hundred and forty-nine inpatients with schizophrenia spectrum disorders were recruited at the Department of Psychiatry II, Ulm University, Germany (n=100) and at the University Hospital of Psychiatry, Bern, Switzerland (n=49). Psychopathology was assessed with the BPS. The VARCLUS procedure of SAS(®) (a type of oblique component analysis) was used for statistical analysis.

RESULTS

Six clusters were identified (inhibited language, inhibited motor behaviour, inhibited affect, disinhibited affect, disinhibited language/motor behaviour, inhibited language/motor behaviour) which explained 40.13% of the total variance of the data. A binary division of attributes into an inhibited and disinhibited cluster was appropriate, although an overlap was found between the language and motor behaviour domains. There was a clear distinction between qualitative and quantitative symptoms.

CONCLUSIONS

The results argue for the validity of the BPS in identifying subsyndromes of schizophrenia spectrum disorders according to a dimensional approach. Future research should address the longitudinal assessment of dimensional psychopathological symptoms and elucidate the underlying neurobiological processes.

[Schizophrenic Psychoses with Motor-Dominant Symptoms: Considerations for a System-Specific Approach]

In order to reduce heterogeneity in schizophrenia, a system-specific approach consisting of the domains "language", "affect" and "motor behavior" has been proposed. We examined this system-specific approach for its applicability to clinical practice in the motor behavior domain, using the methodological approach of case studies, and discuss here the differences to the positive/negative concept. We analyzed eight cases with stable motor-dominant symptoms, and also quantitatively assessed motor behavior by using the Bern Psychopathology Scale (BPS), a standardized psychopathological assessment instrument, as well as actigraphic data. Characterization of cases using the positive/negative approach was not helpful. We found an overlap of the motor behavior domain with the other two domains. This complicates the application of the system-specific approach in the sense of a typology. Furthermore, we found both relapsing courses with full remission and chronic courses with deterioration within the motor-dominant subtype. Nevertheless, the system-specific approach has heuristic utility for the future.

Subtyping schizophrenia: A comparison of positive/negative and system-specific approaches

BACKGROUND

Schizophrenia is a heterogeneous disorder. Over the years, different approaches have been proposed to approach this heterogeneity by categorizing symptom patterns. The study aimed to compare positive/negative and system-specific approaches to subtyping.

METHODS

We used the Positive and Negative Syndrome Scale (PANSS) and Bern Psychopathology Scale (BPS), which consists of subscales for three domains (language, affect and motor behavior) that are hypothesized to be related to specific brain circuits, to assess cross-sectional psychopathological characteristics in a sample of 100 inpatients with schizophrenia spectrum disorders. We then categorized participants into positive/negative and system-specific subgroups to allow comparisons of the two approaches.

RESULTS

The analyses revealed correlations between the PANSS positive subscore and the BPS affective subscore (r=.446, p<.001) and between the PANSS negative subscore and the BPS motor behavior subscore (r=.227, p=.023). As regards the positive and negative subtype, more participants were classified as positive in the language-dominant subtype (30.3%) and affect-dominant subtype (30.3%), whereas more were classified as negative in the motor behavior-dominant subtype (44.4%). However, most patients met the criteria for the mixed subtype.

CONCLUSIONS

The results suggest that the positive/negative and system-specific approaches can be regarded as complementary. Future studies should examine both approaches in a longitudinal assessment of psychopathological symptoms and link them with qualitative-phenomenological approaches.

[Convergent validity of SCID-II and TCI: categorical vs. dimensional diagnostics of personality disorders using the example of short-term prisoners]

In order to objectify the diagnostics of personality disorders, questionnaires and structured interviews are used. Nevertheless, due to different methodological approaches even those instruments arrive at different results very often. Therefore, this study aimed to check the convergent validity of two frequently used instruments - the Structured Clinical Interview for DSM IV Axis II Disorders (SCID-II) and the Temperament and Character Inventory (TCI) - the first one representing the categorical and the latter one the dimensional approach for diagnosing personality disorders. The diagnostic concordances were statistically described with Cohen's Kappa, Yule's Y, and correlations. The results indicate that there are striking differences in diagnoses and that the SCID-II rather tends to diagnose a personality disorder earlier than the TCI.

[Organic personality disorder: conceptual principles, clinical symptoms and treatment]

The organic personality disorder is primarily characterized by a change of premorbid behavior due to an organic impairment or disease of the central nervous system. German psychopathological preliminary work had a determining influence on the current diagnostic concepts in the international classification of diseases 10 (ICD-10) and the diagnostic and statistical manual of mental disorders 5 (DSM-5). An analysis of the literature in the MEDLINE database shows that most studies can be found for traumatic brain injury and epilepsy. The most common symptoms described were symptoms of depression, emotional instability, irritability and impulsive behavior. Psychopathological symptoms were not related to the etiopathogenesis but showed some relation to the neuroanatomical location of functional disorders or damages. Only few publications on treatment strategies were found. The empirical findings point to the necessity of multiaxial diagnostic measures to distinguish between the levels of etiology and symptomatology. Therapeutic interventions should be planned on the basis of psychopathological symptoms.

[Impulsiveness Among Short-Term Prisoners with Antisocial Personality Disorder]

OBJECTIVE

The study aimed to investigate the correlation between impulsiveness and the antisocial personality disorder among short-term prisoners.

METHOD

The impulsiveness was diagnosed by the Barratt Impulsiveness Scale (BIS).

RESULTS

Short-term prisoners with antisocial personality disorder scored significant higher marks on the BIS total scale than those without any personality disorder. In detail, they scored higher marks on each subscale regarding attentional, motor and nonplanning impulsiveness. Moderate and high effects were calculated.

CONCLUSION

It is to be considered to regard impulsivity as a conceptual component of antisociality.

[Course typologies of schizophrenic psychoses]

The "group of schizophrenias" describes a heterogeneous nosological construct with a variable course of the illness. Against this background, several historical approaches to course typologies of schizophrenic psychoses have been described (Bleuler; Huber; Leonhard; Watt, Katz and Shepherd). These concepts, however, differ considerably from each other, in particular with respect to the definition of outcomes. This mainly results from the reference to different psychopathological traditions. The possible codings of subgroups and course types of schizophrenic psychoses in ICD-10 and DSM-5 are compromises in order to combine the different aspects. The empirical examination and the advancement of course typologies of schizophrenic disorders using modern instruments and analyses are important tasks for current psychiatric research. Such efforts should combine quantitative-statistical analyses with a casuistic approach.

[Karl Jaspers and the challenges of social psychiatry]

Karl Jaspers, in his book "General Psychopathology", argued for methodological pluralism rather than theoretical dogmatism. He formulated a methodological order of psychopathology with a distinction between "explanation" (objective psychopathology) and "understanding" (subjective psychopathology, psychopathology of meaning). The latter approach focused on patients' subjective experience and biographical issues. Karl Jaspers emphasised social factors in the genesis and course of mental disorders. Following a multiperspective concept, from Jaspers' viewpoint social psychiatry should consider itself of equal importance with biological and psychotherapeutic psychiatry. Therefore, uncritical generalization of one of these perspectives should be avoided. Personalized psychiatry, apart from searching biological markers to tailor treatment should identify psychosocial factors and subjective meaning. Concepts of recovery should not ignore biological foundations in mental disorders.

[Psychopathological differentiation of depressive syndromes]

The historical contributions of Kurt Schneider, Karl Leonhard, Hans-Jörg Weitbrecht and Hubertus Tellenbach provide different concepts for a psychopathological differentiation of depressive syndromes. The current diagnostic systems ICD-10 and DSM-5 also contain categories for a differentiated classification of depressive disorders that trace back to the above historical concepts. The extensive diagnostic concepts of "depressive episode" or "major depression", however, are mainly based on the severity of symptomatology in terms of the number of symptoms and on their temporal duration. This approach could result in a lack of psychopathological differentiation and the limitation to a more syndromal and dimensional view of depression. In contrast, a differentiated typology of depressive phenomenology based on traditional psychopathological concepts could be useful both for clinical treatment decisions and for neurobiological research.

[Changing attitude towards schizophrenia by psychiatric training of medical students]

OBJECTIVE

The aim of the study was to examine if psychiatric training of medical students is appropriate to change their attitude towards schizophrenia and reduce stigma.

METHOD

Students at Ulm University were asked to answer five questions regarding a short case vignette about a patient suffering from schizophrenia at the beginning and at the end of a two-week psychiatric training within their undergraduate medical education. For this purpose, the Attitudes to Mental Illness Questionnaire was used. Differences between attitudes before and after the training were examined (paired t-test) and effect sizes were calculated (Cohen's d).

RESULTS

Data were available of 100 students, 34 men and 66 women. There was a statistically significant improvement in the total means of the AMIQ score from - 3.09 at the beginning to - 2.31 at the end of the psychiatric training. The effect size (d) was 0.35. No significant differences were found with respect to the participants' age and gender.

CONCLUSION

A two-week psychiatric training appears to be an appropriate and effective teaching tool to reduce stigma. This is important because health care for patients with schizophrenia is strongly influenced by the practitioner's attitude towards them.

Psychopathological long-term outcome of schizophrenia -- a review

OBJECTIVE

In the past, the comparability of empirical studies that examined the course and outcome of schizophrenia was limited by their use of different diagnostic systems. Focussing on the psychopathological long-term outcome, the present article aims to review follow-up studies that used modern operationalized diagnostic criteria for schizophrenia (DSM-III, DSM-III-R, DSM-IV and ICD-10).

METHOD

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and PSYNDEX for relevant studies up to the year 2011. Twenty-one studies were included in the final analysis.

RESULTS

The long-term outcome of schizophrenia was heterogeneous and included full remissions as well as severe chronic states. Schizophrenia, however, showed a considerably more unfavourable outcome than other diagnostic groups such as schizoaffective or affective disorders. Psychopathological symptoms remained relatively stable in the course of illness. Several predictors for a poor outcome were identified, such as male gender or pronounced negative symptoms.

CONCLUSION

Recent studies using modern diagnostic systems largely confirm the results of earlier studies. Current diagnostic criteria for schizophrenia identify a heterogeneous sample of patients. The influence of therapeutic interventions on long-term outcome remains unclear.

[Schizophrenic psychoses with bipolar course--implications for nosology and treatment]

Based on a description of the psychopathological symptoms and clinical course of three patients, the diagnostic classification of schizophrenia, schizoaffective disorder and bipolar affective disorder is discussed. The reported cases are characterised by a rapid change of cognition, affect and psychomotor domain with fluctuations in two opposite directions and an incomplete remission of symptoms between acute episodes of illness. Such cases are not adequately represented in the current diagnostic systems ICD-10 and DSM-IV. This renders both the diagnostic classification and the development of evidence-based treatment guidelines more difficult. In accordance with the historical concepts of Emil Kraepelin and Kurt Schneider, the reported patients can be considered to suffer from a subtype of schizophrenia with bipolar course. The identification of such psychopathological course types could help to develop more concise and individualised treatment guidelines. In contrast, the characterisation of the reported cases using dimensional models seems doubtful.

[Schizophrenia and aggressive behaviour: the impact of catatonic phenomena]

OBJECTIVE

Patients suffering from schizophrenic psychoses show an increased risk for aggressive and violent behaviour. This raises the question if such acts are associated with specific psychopathological symptoms such as catatonic features.

METHODS

Based on clinical case reports, psychopathological symptoms and clinical course in five patients with schizophrenic psychoses and episodes of aggressive behaviour are described. In this connection, the role of catatonic features is analysed.

RESULTS

In the reported cases, aggressive behaviour patterns can be described as stable catatonic symptoms. Attempts to provide community-based treatment failed in each of these five patients.

CONCLUSIONS

General adult psychiatry should provide effective treatment strategies and adequate care systems for patients with psychosis, catatonic symptoms and aggression.

[Obstructive sleep apnoea syndrome as the cause of atypical depression]

Sleep apnoea is a common disorder presenting with somatic comorbidities and psychiatric symptoms. This case report describes a 43-year-old man with an organic depressive disorder due to obstructive sleep apnoea. Initially, an atypical depressive episode or schizophrenic residual syndrome had been considered likely diagnoses; subsequent polysomnography results, however, suggested obstructive sleep apnoea instead. Upon nasal continuous positive airway pressure (nCPAP), the respiratory distress symptoms improved. The case report highlights the association between sleep disturbances and depressive symptoms. In patients presenting with symptoms of atypical depression and excess body weight sleep apnoea should be considered.