Acute polymorphic psychotic disorder: diagnostic stability over 3 years

OBJECTIVE: Acute polymorphic psychotic disorder without symptoms of schizophrenia (APPD) in ICD-10 is unique in many characteristics. This study aimed at investigating the diagnostic stability of APPD over 3 years. METHOD: Forty-five patients with first episode APPD were followed up and assessed at regular intervals over a period of 3 years. RESULTS: Thirty-two patients were females. Average age of the sample was 26.9 years. Thirty-three cases retained their index diagnosis of APPD, while 12 cases required diagnostic revision: 10 to bipolar affective disorder and the rest to unspecified non-organic psychosis. Shorter duration of illness (<1 month) and abrupt onset (<48 h) predicted a stable diagnosis of APPD. CONCLUSION: APPD is a relatively stable diagnosis and argues for a distinct diagnostic entity.     

Presentation and stability of cognitive and noncognitive symptom patterns in patients with Alzheimer's disease. Disease course over a two-year period under constant treatment conditions with rivastigmine

The course of behavioural and psychotic features of patients with Alzheimer's disease treated with an inhibitor of the acetylcholinesterase (rivastigmine), and their association to cognitive impairment is presented in the study. Standardized examination of global functional deterioration (GDS), cognitive impairment (MMSE) and behavioural or psychotic symptoms (Behave-AD) were performed over two years. We could analyse the complete data from 44 of initially 91 patients with mild to moderate Alzheimer's disease. The cognitive component (measured by MMSE, ADAS-cog) and the functional assessment (GDS) showed a continuous decline after a one year period of stabilization, in contrast with behavioural and psychotic symptoms, especially delusions, which still improved after treatment of two years. While cognitive items in correlation with functional aspects formed a homogeneous factor over the two-year period, psychotic features displayed more variability over time evaluated by factor analysis. Nevertheless mood and anxiety disorder in combination with aggressive behaviour as well as hallucinations formed an independent factor in the course of Alzheimer's disease. In addition to other studies of the course of Alzheimer's disease we could demonstrate that distinct behavioural and psychotic symptoms may also present as independent factors in Alzheimer patients under constant treatment conditions with an inhibitor of the acetylcholinesterase (rivastigmine).     

Heterogeneity in dementia of the Alzheimer type: evidence of subgroups

We reviewed records of 121 consecutive patients with dementia of the Alzheimer type. Patients with myoclonus or extrapyramidal signs had greater intellectual decline and functional impairment in daily activities. Among patients studied over 4 years, there were four groups: benign--little to no progression; myoclonic--severe intellectual decline and frequent mutism after younger onset; extrapyramidal--severe intellectual and functional decline and frequent psychotic symptoms; typical--a gradual progression of intellectual and functional decline, but without other distinguishing features. Except for the group with myoclonus, no subgroup was segregated by age at onset or other demographic variables. This study suggests that dementia of the Alzheimer type is heterogeneous, and that certain clinical manifestations may be useful in predicting outcome.     

Social outcomes in adulthood of children with intellectual impairment: evidence from a birth cohort

Background Social Policy for people with intellectual disabilities (ID) continues to evolve, but little is known about the lives to which such policies are applied. We aimed to use a prospective follow-up of a British birth cohort to identify children with mild and more severe intellectual impairment, and compare a range of social outcomes in adulthood with people in the rest of the cohort. Method We used data from the MRC National Survey for Health and Development. Intellectual impairment was identified by intelligence tests and educational history. Adult outcome measures included employment and social class, education, marriage and children, home ownership, social networks and community use. Results We identified 111 people with mild intellectual impairment (2.7%) and 23 with severe intellectual impairment (0.6%) at age 15/16. By the age of 43, there were 52 people remaining in the mild impairment group and 14 in the severe impairment group. In adulthood those with intellectual impairment enjoyed contact with friends and family, and joined in informal social activities. Although the mild intellectual impairment group were less likely to attain the following social outcomes than people with normal intellectual functioning, 67% had jobs, 73% were married, 62% had children and 54% owned their own homes. 12% participated in adult education. People with more severe intellectual impairment were less likely to attain these outcomes. Conclusions These outcomes highlight issues in current social policy and suggest efforts should be directed particularly towards promoting educational opportunities and developing social inclusion for people with ID.     

Predictors of admission to a high-security hospital of people with intellectual disability with and without schizophrenia

Admission to secure hospital facilities is a rare outcome for people with intellectual disability with or without concomitant psychosis. The present study compares people with mild intellectual disability with and without schizophrenia resident in the Scottish and Northern Irish State Hospital, Carstairs, to matched mild intellectual disability controls, also with and without schizophrenia, in the community. It is hoped that this study may identify socio‐demographic, clinical or historical predictors which may lead to admission to secure hospital facilities for people with mild intellectual disability. One hundred and eight subjects were identified from two previous studies which concerned State Hospital patients and patients with intellectual disability with and without schizophrenia. Four experimental groups were derived: (1) 14 individuals with comorbid intellectual disability and schizophrenia who had been resident in the State Hospital; (2) 34 comorbid community control subjects; (3) 33 individuals with intellectual disability and no psychosis who had been resident in the State Hospital; and (4) 27 community control subjects with mild intellectual disability. The four groups were compared on a range of socio‐demographic, historical and clinical variables obtained from case records and subject interviews. Relative to community controls, people with intellectual disability and no psychosis in the State Hospital are likely to be single, to have a later age of first psychiatric hospital admission, and to have a history of previous suicide attempts, alcohol abuse or drug misuse. Subjects with comorbid intellectual disability and schizophrenia in the State Hospital are more likely to be male, to have an early age of first psychiatric admission, and to have no family history of either schizophrenia or intellectual disability. Strategies aimed at addressing suicidal behaviour, alcohol and drug misuse amongst people with intellectual disability may facilitate a reduction in the number of admissions to high‐security hospitals in the UK. In people with comorbid intellectual disability and schizophrenia, males with an early age of onset and no known family history are more likely to require care and treatment in a secure psychiatric setting. Such comorbid subjects may be suffering from a particular malignant form of schizophrenia, manifesting in childhood as cognitive impairment prior to the early onset of psychosis in teenage years.     

Proposal for a new five-axis classification scheme for psychoses of epilepsy

Based on an overview of the literature and a multicenter study in Japan, we propose a new five-axis classification scheme for psychoses of epilepsy: (1) epilepsy variables, (2) psychopathology variables, (3) ictus/EEG variables, (4) precipitating factors of psychoses, (5) organic background. A total of 128 patients, 63 males and 65 females, with epilepsy and psychoses were recruited from five treatment centers. A wide heterogeneity of psychoses of epilepsy was demonstrated and categorization by a single axis was shown to be inadequate. Cluster analysis revealed four subgroups characterized by their psychopathology, temporal relationship to seizure occurrence, and EEG changes during psychoses. By comparing with the control epileptic group without psychoses, higher rates of mild intelligence disturbance and abnormal findings by brain imaging were proven among the psychotic group. The scheme involves a dimensional representation of individual patients to capture the complexity of their clinical background and to relay clinical information accurately and systematically. It is believed to hold direct therapeutic implications and to contribute to promoting research by enabling accumulation of a large number of patients on a multicenter basis.     

Psychiatric diagnoses in relation to severity of intellectual disability and challenging behaviors: a register study among older people

ABSTRACT

Objective: To investigate the possible association between severity of intellectual disability (ID) and presence of challenging behavior, respectively, on diagnoses of psychiatric disorders among older people with ID.

Methods: People with a diagnosis of ID in inpatient or specialist outpatient care in 2002–2012 were identified (n = 2147; 611 with mild ID, 285 with moderate ID, 255 with severe or profound ID, and 996 with other/unspecified ID). Moreover, using impairment of behavior as a proxy for challenging behavior, 627 people with, and 1514 without such behavior were identified.

Results: Severe/profound ID was associated with lower odds of diagnoses of psychotic, affective, and anxiety disorders than was mild/moderate ID. People with moderate ID had higher odds than those with mild ID of having diagnoses of affective disorders. Diagnoses of psychotic, affective, and anxiety disorders, and dementia were more common among people with challenging behavior than among those without.

Conclusions: People with severe/profound ID had lower odds of receiving psychiatric diagnoses than those with mild and moderate ID. Whether this is a result of differences in prevalence of disorders or diagnostic difficulties is unknown. Further, challenging behaviors were associated with diagnoses of psychiatric disorders. However, the nature of this association remains unclear.     

Does operational diagnosis of schizophrenia significantly impact intellectual deficits in psychotic disorders?

Background Evidence suggests that, as a group, patients with schizophrenia have intellectual deficits that may precede the manifestation of psychotic symptoms; however, how successfully intelligence tests are able to discriminate schizophrenia from other psychotic disorders has yet to be investigated in detail. Methods Using Wechsler Adult Intelligence Scale – Revised (WAIS‐R) data for 55 inpatients with schizophrenia and 28 inpatients with non‐schizophrenic psychotic disorders (NSPD) (schizophreniform disorder, brief psychotic disorder, delusional disorder, psychotic disorder due to a general medical condition, and psychotic disorders not otherwise specified), intelligence performance was compared between schizophrenia and NSPD and among different subtypes of schizophrenia. Results There were no significant differences in intelligence quotient (IQ), verbal IQ (VIQ) and performance IQ (PIQ) discrepancy, and subtest scores of WAIS‐R between the patients with schizophrenia and those with NSPD. These diagnostic groups were not discriminated well by any WAIS‐R variables. Schizophrenia patients with prominent negative symptoms, on the other hand, had a significantly larger IQ discrepancy (VIQ > PIQ) than those without prominent negative symptoms and NSPD patients. Intelligence performance in schizophrenia did not differ with respect to diagnostic subtypes and longitudinal courses. Conclusions The current study failed to show diagnostic usefulness of WAIS‐R in discriminating schizophrenia and other psychoses. A diagnosis of schizophrenia does not significantly impact intellectual deficits in psychotic disorders.     

Major depressive disorder with psychotic features may lead to misdiagnosis of dementia: a case report and review of the literature

Major depressive disorder (MDD) with psychotic features is relatively frequent in patients with greater depressive symptom severity and is associated with a poorer course of illness and greater functional impairment than MDD without psychotic features. Multiple studies have found that patients with psychotic mood disorders demonstrate significantly poorer cognitive performance in a variety of areas than those with nonpsychotic mood disorders. The Mini Mental State Examination (MMSE) and the Dementia Rating Scale, Second Edition (DRS-2) are widely used to measure cognitive functions in research on MDD with psychotic features. Established total raw score cut-offs of 24 on the MMSE and 137 on the DRS-2 in published manuals suggest possible global cognitive impairment and dementia, respectively. Limited research is available on these suggested cut-offs for patients with MDD with psychotic features. We document the therapeutic benefit of electroconvulsive therapy (ECT), which is usually associated with short-term cognitive impairment, in a 68-year-old woman with psychotic depression whose MMSE and DRS-2 scores initially suggested possible global cognitive impairment and dementia. Over the course of four ECT treatments, the patient's MMSE scores progressively increased. After the second ECT treatment, the patient no longer met criteria for global cognitive impairment. With each treatment, depression severity, measured by the 24-item Hamilton Rating Scale for Depression, improved sequentially. Thus, the suggested cut-off scores for the MMSE and the DRS-2 in patients with MDD with psychotic features may in some cases produce false-positive indications of dementia.     

Magnetic resonance imaging in dementia of Parkinson''s disease.

The possibility that dementia in Parkinson's disease is associated with specific cerebral abnormalities identifiable by magnetic resonance imaging (MRI) was examined. Sixty eight patients with Parkinson's disease and 28 age and education matched normal controls were evaluated using neuropsychological procedures that included assessment of language, memory, cognition, visuospatial skills and mood. Twenty three patients (34%) were found to have developed significant impairment in at least three of the five areas, thus meeting criteria for a dementia syndrome. Eleven patients (16%) had no intellectual impairment and thirty four patients (50%) had a mild to moderate intellectual disturbance. Patients with (n = 10) and without dementia (n = 20), matched for severity of Parkinson's disease, and normal controls (n = 10) matched for age with the two patients groups, were evaluated by MRI. MRI scans were analysed for evidence of generalised cerebral atrophy, ventricular enlargement, visualisation of the substantia nigra and severity of focal brain lesions. Results indicated that the presence of dementia in patients with Parkinson's disease was not associated with any specific pattern of MRI abnormalities.     

Issues of separation related to psychosis in twins

The subject of twins has been surrounded by a mystique from ancient times. The literature on twins is reviewed. A case study of a pair of schizophrenic twins is presented and issues involving separation as a precipitating factor in the decompensation of twins are identified and discussed. Feelings of ambivalence, rivalry, competition, diffusion of ego boundaries, mutual complementariness, and a sense of one being incomplete without the other are reviewed and illustrated in the clinical material. Normal unconscious fantasies in twins may become concrete and delusional in psychotic twins. The inpatient treatment of the two patients emphasizing their separateness was not effective. A change in technique in which they were permitted to resume their mutual clinging and were treated as a unit was followed by resolution of symptoms. In contrast to advice in the literature that attempts be made to separate psychotic twins in order to promote their individuation, the authors suggest that the need for fusion be reinforced in psychotic twins as a therapeutic maneuver during the acute episode.     

Psychiatric Disorders in Outpatients With Borderline Intellectual Functioning: Comparison With Both Outpatients From Regular Mental Health Care and Outpatients With Mild Intellectual Disabilities

Objective:

In the Netherlands, patients with borderline intellectual functioning are eligible for specialized mental health care. This offers the unique possibility to examine the mix of psychiatric disorders in patients who, in other countries, are treated in regular outpatient mental health care clinics. Our study sought to examine the rates of all main Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Axis I psychiatric diagnoses in outpatients with borderline intellectual functioning of 2 specialized regional psychiatric outpatient departments and to compare these with rates of the same disorders in outpatients from regular mental health care (RMHC) and outpatients with mild intellectual disabilities (IDs).

Method:

Our study was a cross-sectional, anonymized medical chart review. All participants were patients from the Dutch regional mental health care provider Rivierduinen. Diagnoses of patients with borderline intellectual functioning (borderline intellectual functioning group; n = 235) were compared with diagnoses of patients from RMHC (RMHC group; n = 1026) and patients with mild ID (mild ID group; n = 152).

Results:

Compared with the RMHC group, psychotic and major depressive disorders were less common in the borderline intellectual functioning group, while posttraumatic stress disorder and V codes were more common. Compared with the mild ID group, psychotic disorders were significantly less common.

Conclusion:

Mental health problems in people with borderline intellectual functioning may not be well addressed in general psychiatry, or by standard psychiatry for patients with ID. Specific attention to this group in clinical practice and research may be warranted lest they fall between 2 stools.     

The neurocognitive signature of psychotic bipolar disorder.

BACKGROUND: Psychotic bipolar disorder may represent a neurobiologically distinct subgroup of bipolar affective illness. We sought to ascertain the profile of cognitive impairment in patients with bipolar disorder and to determine whether a distinct profile of cognitive deficits characterizes bipolar patients with a history of psychosis. METHODS: Sixty-nine outpatients with bipolar I disorder (34 with a history of psychotic symptoms and 35 with no history of psychosis) and 35 healthy comparison subjects underwent a comprehensive neurocognitive battery. All three groups were demographically matched. RESULTS: Despite preserved general intellectual function, bipolar I patients overall showed moderate impairments on tests of episodic memory and specific executive measures (average effect size = .58), and moderate to severe deficits on attentional and processing speed tasks (average effect size = .82). Bipolar I patients with a history of psychosis were impaired on measures of executive functioning and spatial working memory compared with bipolar patients without history of psychosis. CONCLUSIONS: Psychotic bipolar disorder was associated with differential impairment on tasks requiring frontal/executive processing, suggesting that psychotic symptoms may have neural correlates that are at least partially independent of those associated with bipolar I disorder more generally. However, deficits in attention, psychomotor speed, and memory appear to be part of the broader disease phenotype in patients with bipolar disorder.     

Investigating the association between neurocognition and psychosis in bipolar disorder: further evidence for the overlap with schizophrenia

Objectives: In schizophrenia, a distinction is made between psychosis with developmental and cognitive impairment on the one hand and psychosis without developmental impairment and positive symptoms on the other. In this study, we investigated whether this model can be extended to bipolar disorder by testing the hypothesis that neurocognitive functioning is inversely related to positive psychotic symptoms in bipolar disorder. Methods: Neurocognitive functioning and psychopathology were assessed in (i) 76 patients with bipolar disorder, (ii) 39 of their healthy first‐degree relatives, and (iii) 61 healthy controls. Cognitive performance of bipolar patients and their first‐degree relatives was investigated, taking into account the possible moderating effect of the level of expression of psychosis in patients and relatives. Results: Bipolar patients showed impaired cognitive performance on multiple cognitive domains, whereas performance of their relatives was comparable to that of controls. A history of psychotic symptoms in patients was suggestive of less likelihood of cognitive alterations in relatives, and the presence of subclinical psychotic symptoms within the group of relatives predicted better cognitive performance. Conclusions: The finding of similar psychosis‐cognition associations in bipolar disorder as implied by the two pathways leading to nonaffective psychotic disorders suggests that this model might be extended to the continuum spanning affective and nonaffective psychosis. This is in line with the idea of a partially overlapping vulnerability to bipolar disorder and schizophrenia and provides an explanation for the apparent differences in cognitive alterations in those at risk for the two disorders.     

A comparison study of adults with intellectual disability and psychiatric disorder with and without forensic involvement

The current study describes and compares profiles of patients in the same specialized hospital program for patients with intellectual disability with and without forensic involvement. A retrospective chart review of 78 individuals (39 forensic and 39 non-forensic) served between 2006 and 2008 was completed. The forensic sample was more likely to have a diagnosis of borderline to mild IQ and psychotic disorder was more common. Forensic patients were also more likely to have previously used drugs or alcohol. Forensic inpatients had significantly longer lengths of stay, and were more likely to change residence from admission to discharge than the non-forensic inpatients but the GAF scores did not differ between the two groups at admission or discharge. Although there are many similarities between the two groups, there are also some important differences that exist which should be considered in the design of inpatient and outpatient mental health and intellectual disability services.     

Does intellectual disability affect the development of dental caries in patients with cerebral palsy?

The aim of this study was to evaluate if the severity of intellectual disability is a factor that affects the development of dental cavities in patients with cerebral palsy. This cross-sectional study was conducted on 165 individuals who were selected from a physical rehabilitation center, a special public school and a regular public school. Of these, 76 individuals had been diagnosed with spastic cerebral palsy and 89 had no neurological impairment. The subjects were matched based on age and gender and selected randomly by lottery. All patients were examined to determine the number of dental cavities, and tested for their intellectual functioning (Raven Test) and motor abilities. The study showed that children with CP who presented with intellectual disabilities had a larger number of dental cavities than children with CP without intellectual disabilities. Considering intellectual functioning and motor impairment in the multivariate logistic regression, only intellectual functioning was found to have a significant effect on the development of dental cavities. These results suggest that intellectual disability can be considered a contributing factor for the development of dental caries in patients with cerebral palsy.     

Analysis of neuropsychological functioning in patients with chronic fatigue syndrome.

Memory impairment dominates the cognitive complaints of patients with chronic fatigue syndrome (CFS). Twenty CFS patients were available for studies with a clinical and experimental battery composed of memory and cognitive tests. The results on objective testing indicated that the CFS patients had some mild memory impairment, but only on tasks requiring conceptually driven encoding and retrieval processes. There were no associations between the nature of the precipitating illness, self ratings of fatigue, physical findings, or laboratory determination and objective memory performance or self report of memory functioning. These generally negative results indicate that memory impairment in CFS patients is typically mild and involves memory processes that participate in conceptualising information.     

Effects of polydipsia-hyponatremia on seizures in patients with epilepsy

Aggravation of seizures due to hyponatremia was investigated in five patients with epilepsy and polydipsia-hyponatremia. They experienced marked increases in the frequency of their complex partial seizures with a decrease in the serum sodium level to 118-127 mEq/L. In all cases, the serum sodium level returned to normal through restriction of fluids, and the clinical seizures improved. All patients had shown intellectual impairment and/or psychotic episodes, and all had been given antipsychotics. Hyponatremia caused by polydipsia appears to be a risk factor for aggravation of habitual seizures in patients with epilepsy.     

Sequence analysis of P21-activated kinase 3 (PAK3) in chronic schizophrenia with cognitive impairment

The P21-activated kinase PAK3 is critical for cognitive development and truncating mutations cause non-syndromic mental retardation (MR). Missense mutations are also associated with psychotic disorders, most commonly with schizophrenia involving premorbid MR, namely "pfropfschizophrenie". We set out to measure the frequency of sequence variants in PAK3 in schizophrenia without premorbid MR. We conducted complete gene reseqeuncing of all coding exons and exon-intron boundaries in patients with schizophrenia with cognitive impairment but without premorbid MR. Deleterious variants in schizophrenia alone were rare (<1/159 or 0.6%). Thereby, while PAK3 remains a strong biological candidate in psychosis, evidence from human genetics provides strongest support for a link to pfropfschizophrenie and not to schizophrenia without premorbid intellectual disability.     

Intellectual Disability and Psychotic Disorders of Adult Epilepsy

Summary:  Purpose: To investigate the prevalence, psychopathology, and cognitive functions associated with psychotic disorders among adult epilepsy patients with intellectual disability (ID) based on a multicenter study in Japan.
Methods: The study was divided into three phases; a prevalence study of psychotic disorders among new referrals of epilepsy, a polydiagnostic comparative study of patients with psychotic epilepsy and those with schizophrenia, and a neuropsychological study of patients with psychotic epilepsy and education level–matched controls.
Results: Among 336 new referrals of epilepsy, a higher prevalence of psychotic disorders was found among patients with ID (24%) than among those with normal intelligence (6%). The psychotic symptoms and operational diagnoses of psychotic epilepsy patients with ID were similar to those of patients with normal intelligence. A wide range (7–86%) of psychotic epilepsy patients was diagnosed as having schizophrenia, depending on the operational criteria used. Patients with psychotic epilepsy had more disturbances in verbal memory and attention functions than did the controls.
Conclusions: Epilepsy patients with ID show a predisposition to develop psychotic disorders. Distinguishing their psychotic symptoms from those of schizophrenia is difficult. Subtle cognitive disturbances predispose to psychotic disorders in epilepsy.