Psychotic and nonpsychotic bipolar mixed states: comparisons with manic and schizoaffective disorders

Summary We studied 259 female inpatients with bipolar spectrum disorders, of whom 26 (10%) were schizoaffective. Of the remaining 233, 61 (27%) met our conservatively set criteria for index mixed expisodes (simultaneous presence of depressive and manic syndromes). These patients with rigorously defined mixed states were, in turn, about equally divided between psychotic and non-psychotic subgroups. The psychotic mixed patients (n=32) were closer to the bipolar I pattern, and more often seem to come from a familial background of psychotic mood disorders; the nonpsychotic mixed patients (n=29) conformed more closely to the bipolar II pattern, and more often had a hyperthymic and cyclothymic temperament and a family background of non-psychotic disorders and substance abuse. A three-way comparison between psychotic manic (n=24), psychotic mixed (n=32), and schizoaffective (n=26) patients revealed few significant differences in temperamental, familial and course patterns. As expected, psychotic manic patients more often arose from a hyperthymic base and pursued a predominantly manic course; psychotic mixed patients were less likely to arise from such a base and more likely to pursue a mixed course. Finally, schizoaffective had earlier age at onset and longer duration of illness, suggesting that these patients had a more severe illness. Otherwise, interepisodic social adaptation was comparable in the three psychotic groups. The findings overall suggest that the presence of psychosis had relatively little impact on mixed states, which appear more based on temperamental characteristics.     

Incidence of obsessive-compulsive phenomena in the course of acute schizophrenia and schizoaffective disorder.

Studies examining OC phenomena in schizophrenic and schizoaffective disorders have shown a prevalence of such phenomena in 1 to 60% of schizophrenic or schizoaffective patients. In this prospective study, about 10% of 150 male patients suffering from acute psychotic disorders (fulfilling DSM-IV criteria for Schizophrenia or Schizoaffective Disorder) were found to have OC symptoms. These symptoms showed no correlation to the type and severity of psychosis. As only 19% of the patients with obsessions and compulsions during acute psychosis showed an obsessive-compulsive personality disorder prior to their psychotic episodes, it may be concluded that there is no clear linkage between intrapsychotic OC phenomena and premorbid anancastic personality traits.     

Standardized assessment of personality disorders in obsessive-compulsive disorder

We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment methods or sampling.     

Premorbid and social markers of patients with schizoaffective psychoses

The present study reports on findings in international literature regarding premorbid and social factors of schizoaffective patients and also own findings of the Cologne study (72 schizoaffective patients with a mean follow-up period of 25.6 years). Altogether it can be said that more women suffer from schizoaffective disorders than men. The mean age at first manifestation is higher than that of schizophrenic patients and lower than that of affective disorders, although schizoaffective disorders can occur at any age. Premorbid social adjustment and ability to form a stable heterosexual partnership before onset are good in schizoaffective patients. There seems to be no special premorbid personality of schizoaffective patients. Education and level of vocational training are generally good. Only a few schizoaffective patients belong to the lower social classes. Most schizoaffective patients do not come from a "broken home". Although "life events" are frequent in a schizoaffective population, the relevance of this finding has to be limited: If we evaluate "life events" in regard to single episodes, we find that most episodes, especially episodes occurring during the later course, do not have precipitating factors. In conclusion, it can be said that - besides the already known better prognosis of schizoaffective disorders - several differences exist regarding premorbid and social factors, between schizoaffective disorders and schizophrenia.     

Clinical features of illness in siblings with schizophrenia or schizoaffective disorder

Evidence implicating genetic or prenatal-perinatal environmental causes in the familial aggregation of schizophrenia led us to study 53 sets of siblings, two or more of whom had chronic psychosis, either schizophrenia or schizoaffective disorder. We looked for similarities in clinical features and concordance of diagnosis within sibships to test for shared familial causes. Clinical variables, including diagnosis, specific symptoms, age at onset, and nongenetic perinatal factors, were studied. Auditory hallucinations, paranoid delusions, thought disorder, negative symptoms, and poor premorbid social adjustment did not significantly correlate in siblings. Concordance was found for schizoaffective disorder and history of major depressive episodes, suggesting that schizophrenia with a depressive component and Research Diagnostic Criteria schizoaffective illness may represent a specific etiologic subtype(s) of the illness, whereas the other noted symptoms may represent the variable expression of the disorder. Age at onset and at first hospitalization were significantly correlated, consistent with genetic or other familial factors on time of onset. Birth complications were significantly more frequent among the schizophrenic compared with non-psychotic siblings, had a familial component, and tended to be associated with an earlier age at onset. Thus, nongenetic perinatal factors may increase the risk for schizophrenia in a familial form of the illness and contribute to the correlation of ages at onset in siblings.     

Gender differences in affective, schizoaffective, and schizophrenic disorders

This study examines gender differences in the clinical profiles and long-term outcomes of chronic DSM-III Axis I psychotic inpatients from the Chestnut Lodge followup study. Diagnostic groups include schizophrenia, schizoaffective psychosis, and unipolar affective disorder. Sex differences were frequent, especially in schizophrenia. Females with schizophrenia, for example, had superior premorbid social, sexual, and marital adjustments. They presented at index hospitalization with more depression, self-destructive behaviors, and troubled interpersonal relationships. Their long-term outcomes were better than males in terms of social activity, work competence, time symptomatic, substance abuse, and marital and parental status. Baseline gender differences were comparatively sparse for the schizoaffective and unipolar cohorts. Outcome differences were virtually nonexistent among the schizoaffective patients but unipolar females received better ratings than males in work competence and substance abuse. Females had a later onset of illness and males presented with more antisocial behaviors across all three diagnostic groups. Results highlight the importance of analyzing data by gender in studies of the psychotic disorders.     

Diagnostic specificity of poor premorbid adjustment: Comparison of schizophrenia, schizoaffective disorder, and mood disorder with psychotic features

Individuals with schizophrenia have significant deficits in premorbid social and academic adjustment compared to individuals with non-psychotic diagnoses. However, it is unclear how severity and developmental trajectory of premorbid maladjustment compare across psychotic disorders. This study examined the association between premorbid functioning (in childhood, early adolescence, and late adolescence) and psychotic disorder diagnosis in a first-episode sample of 105 individuals: schizophrenia (n=68), schizoaffective disorder (n=22), and mood disorder with psychotic features (n=15). Social and academic maladjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. Worse social functioning in late adolescence was associated with higher odds of schizophrenia compared to odds of either schizoaffective disorder or mood disorder with psychotic features, independently of child and early adolescent maladjustment. Greater social dysfunction in childhood was associated with higher odds of schizoaffective disorder compared to odds of schizophrenia. Premorbid decline in academic adjustment was observed for all groups, but did not predict diagnosis at any stage of development. Results suggest that social functioning is disrupted in the premorbid phase of both schizophrenia and schizoaffective disorder, but remains fairly stable in mood disorders with psychotic features. Disparities in the onset and time course of social dysfunction suggest important developmental differences between schizophrenia and schizoaffective disorder.     

Social competence in schizophrenia: premorbid adjustment, social skill, and domains of functioning

The relations between premorbid adjustment, social skill, and domains of functioning (symptoms, social adjustment) were examined in a group of 107 schizophrenic, schizoaffective, and affective disorder patients. Premorbid sexual adjustment was moderately correlated with social skill in the schizophrenic and schizoaffective patients. Schizophrenic patients had the lowest premorbid adjustment and social skill, followed by schizoaffectives, and then affective patients. Within the schizophrenic group, social skill was significantly related to both current social adjustment and negative symptoms, but not positive symptoms. Similar but weaker effects were found for premorbid adjustment. The results suggest that deficits in social skill are correlated with poor premorbid and morbid social adjustment of schizophrenics.     

Borderline personality disorder and unipolar affective disorder. Long-term effects of comorbidity

This study tracks the baseline clinical presentation and long-term course (average 15 years) of three patient groups defined largely by DSM-III from the Chestnut Lodge follow-up study: unipolar affective disorder (UNI, N = 22), borderline personality disorder (BPD, N = 55), and a comorbid cohort (UNI/BPD, N = 21). Comorbid BPD effects on UNI include earlier onset and absence of psychotic symptoms at baseline and more substance abuse and use of psychiatric treatment at follow-up. Comorbid UNI effects on BPD include better premorbid instrumental functioning, later onset at baseline, and a higher risk for suicide over the long term. Other noteworthy findings are a low rate of suicide (2%) among the noncomorbid BPD patients and a high rate of diagnostic instability (68%) among the noncomorbid UNI patients. Findings demonstrate a lack of syndromal stability within and among all three study groups and highlight the shortcomings of DSM-III for the investigation of comorbidity.     

Schizoaffective disorders with and without onset in the puerperium

Summary The premorbid and sociodemographic features, long-term course and long-term outcome (on average 23.8 resp. 26.8 years after onset of illness) were compared in 30 female schizoaffective patients with onset of their illness during the puerperium and 60 female schizoaffective patients with onset at other times. The majority of premorbid and sociodemographic variables as well as course parameters were similar in the two groups. Most of the few differences (in age at first manifestation, marital state at onset, presence of stable heterosexual relationship before onset, acuteness of onset, presence of life events) are closely connected with the inclusion and exclusion criteria applied for the puerperal disorders (exclusion of patients with preexisiting illness or psychiatric symptoms during pregnancy, inclusion only if onset was within 6 weeks of parturition). The puerperal schizoaffective disorders began more frequently with a schizomanic episode and less frequently with a schizodepressive episode than did the non-puerperal schizoaffective disorders, a finding which perhaps reflected the pathoplastic role of the puerperium on psychotic disorders. Several significant differences were found regarding the long-term outcome (frequency of persistent alterations, level of global functioning and disability, non-achievement of the expected social development, loss of autarky), confirming earlier findings that puerperal disorders generally have a better outcome than other psychotic disorders.     

Early onset psychotic disorders: Diagnostic stability and clinical characteristics

To examine the clinical features and diagnostic stability of early-onset psychotic disorders. These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year’s follow-up. Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50% of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90% of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.     

Remitting brief psychotic disorder in a 15-year-old male

We present a case of remitting brief psychotic disorder in a 15 year old male, who had 4 phenomenologically alike episodes consisting of the following symptoms; sudden onset, unstructured delusions, hallucinations, clouding of consciousness, and a rapid return to his premorbid level of functioning. No evidence was found indicating a metabolic disease or a neurological disorder. The diagnostic criteria of brief psychotic disorder were fulfilled, although the clinical picture could not be described adequately by using only DSM-IV criteria. Remitting brief psychosis and the validity of different diagnostic systems are discussed.     

The child and adolescent first-episode psychosis study (CAFEPS): design and baseline results

OBJECTIVE: The child and adolescent first-episode psychosis study (CAFEPS) is a multicenter, two-year, longitudinal project aiming to evaluate different clinical, neuropsychological, neuroimaging, biochemical, immunological, and genetic variables and treatment and prognostic factors in these patients. This paper describes the methods and rationale behind the study and the general characteristics of the sample. METHOD: At six different centers, from March 2003 through November 2005, we consecutively recruited 110 patients, ages 9-17 years, who presented with a first psychotic episode. Controls were recruited from the same geographic areas and were matched for gender and age. RESULTS: Patients had lower socioeconomic status (SES) (p=0.018) and parental years of education (p<0.001) than controls. The percentage of patients recruited increased with age (p<0.001) and there was a higher percentage of males (p<0.001). The total mean PANSS score was 89.03+/-20.1, the positive score 23.8+/-6.5 and the negative score 20.02+/-8.8. There were no significant differences between the genders with respect to age, parental years of education, SES, or scores in premorbid adjustment or general functioning. There were statistically significant positive correlations between age and positive symptoms and between all PANSS subscales and the Disability Assessment Schedule, and negative correlations between positive symptoms and global functioning. Diagnoses after the baseline evaluation were: psychotic disorder not otherwise specified (NOS) 35.5%, schizophreniform disorder 24.5%, mood disorder with psychotic symptoms 22.7%, schizophrenia 10%, schizoaffective disorder 2.7%, and other psychotic disorders 4.5%. Patients had worse premorbid adjustment (p<0.001) and global functioning (p<0.001) than controls after controlling for SES. CONCLUSIONS: Infancy and adolescence adjustment and global functioning are lower in children and adolescents with psychotic disorders than in controls, severity of symptoms are related to general disability, and the most frequent diagnoses are psychotic disorders NOS.     

An empirical study of psychosis in borderline personality disorder

To assess the nature and prevalence of psychotic symptoms in borderline personality disorder, the authors reviewed the cases of 33 patients meeting DSM-III criteria for borderline personality disorder, using both "narrow" and "broad" definitions of psychosis. Only eight patients displayed psychotic symptoms meeting the "narrow" DSM-III definition; in all of these cases, the symptoms appeared to be attributable to either severe drug abuse or major affective disorder, present simultaneously with borderline personality disorder. The remaining patients displayed only "broadly defined" psychotic symptoms or symptoms that appeared to be under voluntary control. These findings weigh against the assumption that borderline personality disorder lies "on the border" of classical psychotic disorders.     

Long-term course and outcome in unipolar affective and schizoaffective psychoses

ABSTRACT– Of 301 first-time admitted patients with delusional psychoses, 50 met DSM-III criteria for major depressive disorder (MDD), 33 schizoaffective disorder, depressive type (SADD), and 94 schizophrenia. At personal follow-up after 3–39 (mean 22) years, the SADD group was recorded in between on course and outcome variables, but closer to MDD. The findings in MDD and SADD were respectively: remission 66% vs. 42%, personality disorders 14% vs. 12%, anxiety disorder or alcohol abuse 2% vs. 6%, psychosis 18% vs. 36% (with bipolar development in 2% vs. 6%, paranoid disorder 2% vs. 3%, schizophrenia 4% vs. 3%). Chronic psychosis was recorded in 10% vs. 27%. No significant outcome difference was found between early onset MDD and SADD cases and those who fell ill at a higher age. The assumption that antidepressants may induce mania could not be confirmed. Normal premorbid personality seemed to predict a favourable course.     

Early onset psychotic disorders: Diagnostic stability and clinical characteristics

Objectives: To examine the clinical features and diagnostic stability of early-onset psychotic disorders. Methods: These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year's follow-up. Results: Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50 % of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90 % of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment. Conclusions: Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.     

Rediagnosis of schizophrenia as bipolar affective illness

Ten patients in a Veterans Administration hospital who had been diagnosed and treated as schizophrenic were rediagnosed as having bipolar affective illness and were shown to be responsive to lithium. The authors feel that the diagnosis of schizophrenia is made too frequently and often is made with inadequate information. A further complicating factor in diagnosis is that some patients exhibit schizophrenia-like symptoms during the acute manic phase. The authors found that valuable aids to rediagnosis of such patients include a good premorbid and interepisodic adjustment, a history of depressive episodes, a family history of affective disorder, and a favorable response to a therapeutic trial on lithium carbonate.     

The effect of cannabis use and cognitive reserve on age at onset and psychosis outcomes in first-episode schizophrenia

Objective: Cannabis use is associated with a younger age at onset of psychosis, an indicator of poor prognosis, but better cognitive function, a positive prognostic indicator. We aimed to clarify the role of age at onset and cognition on outcomes in cannabis users with first-episode schizophrenia as well as the effect of cannabis dose and cessation of use.Methods: Ninety-nine patients without alcohol or substance abuse other than cannabis were divided into lifetime users and never-users of cannabis and compared on measures of premorbid function, cognition, and clinical outcome.Results: Cannabis users demonstrated better cognition at psychosis onset, which was explained by higher premorbid IQ. They also showed better social function and neither measure changed over the subsequent 15 months. Cannabis users had an earlier age at onset of psychosis, and there was a strong linear relationship between age at first cannabis use and age at onset of both prodromal and psychotic symptoms. Cannabis use spontaneously declined over time with 3-quarters of users giving up altogether. Later age at first cannabis use predicted earlier cessation of use and this in turn was linked to fewer positive psychotic symptoms and days in hospital during the first 2 years.Conclusions: Cannabis use brings forward the onset of psychosis in people who otherwise have good prognostic features indicating that an early age at onset can be due to a toxic action of cannabis rather than an intrinsically more severe illness. Many patients abstain over time, but in those who persist, psychosis is more difficult to treat.     

Risk factors for transition to first episode psychosis among individuals with 'at-risk mental states'

Recently developed criteria have been successful at identifying individuals at imminent risk of developing a psychotic disorder, but these criteria lead to 50-60% false positives. This study investigated whether measures of family history, peri-natal complications, premorbid social functioning, premorbid personality, recent life events and current symptoms would be able to improve predictions of psychosis in a group of young, help-seeking individuals who had been identified as being at risk. Individuals (N=74) were followed up at least 1 year after initial assessment. Half the sample went on to develop a psychotic disorder. The most reliable scale-based predictor was the degree of presence of schizotypal personality characteristics. However, individual items assessing odd beliefs/magical thinking, marked impairment in role functioning, blunted or inappropriate affect, anhedonia/asociality and auditory hallucinations were also highly predictive of transition, yielding good sensitivity (84%) and specificity (86%). These predictors are consistent with a picture of poor premorbid functioning that further declines in the period up to transition.