Is there a schizophasia? A study applying the single case approach to formal thought disorder in schizophrenia

It has been suggested that formal thought disorder, the incoherent speech of schizophrenia, may involve a language disturbance among other abnormalities, or even be a form of dysphasia. Six patients with and seven without formal thought disorder were evaluated on an aphasia test battery. Spontaneous speech was also analysed using Brief Syntactic Analysis. Poor performance on the aphasia test battery was found to be associated with general intellectual impairment but not with formal thought disorder. Naming was preserved in both groups. Patients with formal thought disorder, but not those without, produced semantic errors in their spontaneous speech, and these were unrelated to general intellectual status. The disorder of language in formal thought disorder thus appears to be one of expressive semantic abnormality, which, however, spares naming. Further analysis of two intellectually preserved patients suggested that formal thought disorder may be associated with an additional difficulty in constructing an appropriate model for generating one's own speech.     

Landau-Kleffner and autistic regression: the importance of differential diagnosis

Some neurological disorders may present psychiatric signs and symptoms, therefore the search for an etiological diagnosis is crucial. The aim of this study is to report the case of a patient with a neurological disorder, diagnosed during a psychiatric admission. A boy with normal neuropsychomotor development until the age of 3 years, started presenting epileptic seizures, followed by behavioral disorder and language deterioration. During neurologic follow-up, the patient was referred to the Psychiatry Department with a diagnosis of autism, in this case an autistic regression (AR). During his admission, diagnosis of Landau-Kleffner syndrome (LKS) was established on clinical and EEG grounds. LKS is characterized by acquired aphasia, epilepsy, EEG abnormalities and behavioral changes, including autistic traits. Language regression is observed LKS and AR. We stress the main differences between these two entities because misdiagnosis may postpone early intervention and consequent benefits, as observed in our case.     

Status Epilepticus Manifesting as Reversible Wernicke''s Aphasia

Ictal aphasia in adults is a rare phenomenon, with the majority of reported cases showing a nonfluent Broca's or mixed aphasic speech pattern associated with disturbances of level of consciousness. There is usually only one prolonged episode of aphasia with evidence of lateralized neurological findings and structural pathology on CAT scan. We describe a patient with intermittent episodes over a 10-year period of a fluent Wernicke's aphasia associated with paroxysmal posterior temporoparietal spike-wave activity on the EEG. Interictally, the patient was clear of neurologic signs and symptoms. These episodes were repeatedly misdiagnosed as psychotic breaks and treated with antipsychotic medication and psychiatric hospitalization. Unless language performance is assessed, these cases of focal epilepsy may be diagnosed as schizophrenic "word-salad," leading to delay of appropriate treatment.     

The diagnostic dilemma of myxedema and madness, axis I and axis II: a longitudinal case report

A patient with presumed chronic paranoid schizophrenia had chronic thyroiditis and Grade I hypothyroidism. Psychosis cleared following treatment with thyroid replacement. The probable presence of two axis II disorders may have contributed to the missed medical diagnosis and the patient's eventual suicide. The personality disorders were a major problem in the patient's medical and psychiatric care. The differential diagnosis among hypothyroidism and primary axis I psychotic and depressive psychopathology has always been problematic. When axis II pathology is also present, the diagnostic dilemma is increased.     

When a duck is not a duck: non-organic bases for aphasia and dementia

Background: There are numerous reports in the literature describing cases of non-organic speech and language disorders. Most reports do not contain specific diagnoses (other than a “psychogenic” disorder); however, establishing which of the many psychogenic disorders are at play may be important for management and prognosis. This paper is inspired by 10 patients who presented to speech–language pathology (SLP) services with speech, language and/or cognitive impairments incongruent with organically based disorders. Non-organic symptoms are neurological complaints thought to be incompatible with recognised neurological or medical conditions. The patients, discussed here, presented with abnormal speech (stuttering, backward speech), language (aphasia) and/or cognition (dementia) that were ultimately reconciled in the psychiatric context.

Aims: The aim is to provide empirical and clinical evidence that supports multidisciplinary assessment of patients who present with speech, language and cognitive impairments that do not seem to have a clear organic basis. The clinical data are discussed in the context of “non-organic” disorders and include exploration of relevant assessment and management issues.

Methods and Procedures: Clinical files of 10 patients diagnosed with psychogenic disorders were retrospectively reviewed and evaluated on several factors contributing to their profiles. They included analysis of speech, language, neuroimaging, social and medical histories and psychological stressors reported by each patient.

Outcomes and Results: Based on assessment results, a number of psychiatric conditions were identified, including conversion, factitious disorder, malingering and Ganser syndrome. Performance on language and cognitive tests was inconsistent with neurological disorders. Each patient appeared to be dealing with some sort of emotional conflict (e.g., unexpected obligation to take care of disabled parents or returning to an extremely stressful workplace). While those with the diagnosis of malingering, factitious or conversion disorders did not show imaging abnormalities, patients with abnormal imaging were initially diagnosed with Ganser syndrome and were found on a follow-up assessment to exhibit signs suggestive of behavioural variant fronto-temporal dementia.

Conclusions: The literature suggests that as many as 30–60% of patients with seemingly non-organic symptoms end up with a neurological diagnosis that explains their initial somatic complaints, a proportion large enough to treat all non-organic disorders seriously. In addition to SLP, successful management of somatic communication disorders requires a multidisciplinary approach and an understanding that they may represent an alternative mode of communicating socially unacceptable feelings or thoughts. Additionally, regardless of questionable veracity of presenting symptoms, presence of abnormal neuroimaging findings should raise concerns of a neurodegenerative disorder.     

Do you hear what I hear? Neural correlates of thought disorder during listening to speech in schizophrenia

Thought disorder is a fundamental symptom of schizophrenia, observable as irregularities in speech. It has been associated with functional and structural abnormalities in brain regions involved in language processing, including left temporal regions, during language production tasks. We were interested in the neural correlates of thought disorder during receptive language processing, as this function is relatively preserved despite relying on the same brain regions as expressive language. Twelve patients with schizophrenia and 11 controls listened to 30-s speech samples while undergoing fMRI scanning. Thought disorder and global symptom ratings were obtained for each patient. Thought disorder but not global symptomatology correlated positively with the BOLD response in the left posterior superior temporal lobe while listening to comprehensible speech (cluster-level corrected p=.023). The pattern of brain activity associated with thought disorder during listening to comprehensible speech differs from that seen during language generation tasks, where a reduction of the leftward laterality of language has often been observed. As receptive language is spared in thought disorder, we propose that the increase in activation reflects compensatory processing allowing for normal performance.     

Les marqueurs linguistiques dans l’amélioration du modèle prédictif de la transition vers la schizophrénie

Over the past twenty years, research in psychiatry has focused primarily on the early detection of schizophrenia. The objective has been to engage the patient with prodromal symptoms in a trajectory of care. It has also been a question of being able to offer treatment as soon as the patient “at risk” of schizophrenia triggered a possible first psychotic episode. Standardized clinical tools were developed and now allow identification of subjects at risk of developing psychotic disorders. However, the reliability of predictions of the psychotic transition, which is between 15 and 25%, remains insufficient. In order to improve care, it is now necessary to highlight markers to refine the prediction of the risk of developing schizophrenia. Some teams are trying to identify linguistic anomalies in UHR subjects (disorganized speech, illogical thoughts, poor speech, altered semantic verbal fluencies…). Some of these abnormalities could be specific to the transition to psychosis. The severity of these markers could be proportional to the progressive stage of the disorder, consistent with the hypothesis of a continuum from normal to pathological in schizophrenia. In addition, automated speech analysis techniques in UHR subjects allow identification of subtle semantic and syntactic anomalies (a decrease in semantic coherence, but also the use of possessive pronouns and a poverty of speech) predictive in 79% of cases of psychotic transition. Some authors demonstrate the value of using linguistic markers and automated speech analysis methods to improve the predictive model of the transition to schizophrenia. However, from reification of language to desubjectification of the individual, this transformation in clinical practice raises ethical and epistemological challenges.     

Geriatric Psychosis

This article reviews diagnostic and treatment issues which merit special consideration in the elderly psychotic patient. Psychoses are serious psychiatric disorders and can present in different forms in the elderly. The important ones include schizophrenia, psychosis in patients with dementia, psychosis in patients with depression and delusional disorder. Typical and atypical antipsychotic medications remain the treatment of choice for psychotic disorders but special considerations are warranted when prescribed to elderly patients. We have highlighted differences between younger and older adults in terms of clinical characteristics and treatment of psychotic disorders.     

Clinical predictors of acute response with quetiapine in psychotic mood disorders

BACKGROUND: In controlled studies of patients with schizophrenia, the atypical antipsychotic quetiapine, 300 mg/day, has been shown to be as effective in the treatment of positive and negative symptoms as haloperidol. However, little is known about the efficacy of quetiapine in patients with psychotic mood disorders. The purpose of this study was to assess the efficacy of quetiapine in the treatment of psychotic mood disorders in comparison with nonaffective psychotic disorders and identify clinical factors associated with quetiapine response. METHOD: In a naturalistic setting, by reviewing medical records, we assessed response to quetiapine and factors associated with response to quetiapine in 145 consecutive patients newly treated with the drug at a nonprofit academic psychiatric hospital. These patients had received a discharge diagnosis of bipolar disorder (manic, mixed, or depressive type), major depression with psychotic features, schizophrenia, schizoaffective disorder (bipolar or depressive type), delusional disorder, or psychosis not otherwise specified (NOS) according to DSM-IV criteria. RESULTS: Patients with a diagnosis of bipolar disorder, manic, mixed, or depressed and schizoaffective disorder, bipolar type displayed higher response rates (> 74%) compared with patients with schizophrenia. However, this finding did not achieve statistical significance. A diagnosis of major depression with psychotic features (p = .02) and longer duration of illness (p = .03) were associated with less chance of responding. CONCLUSION: Quetiapine may be a useful alternative or adjunctive treatment for patients with bipolar and schizoaffective disorders.     

The course and clinical correlates of dysfunctions in visual perceptual organization in schizophrenia during the remission of psychotic symptoms

This study evaluated deficits in visual perceptual organization in schizophrenia over the course of inpatient treatment, in relation to the remission of particular psychotic symptoms. Disorganized (n=14) and non-disorganized (n=33) schizophrenia patients were tested upon admission to an inpatient psychiatric unit, and again after 3 weeks of treatment, on two measures of visual perceptual organization. Performance of schizophrenia patients was compared to groups of patients with psychotic disorders other than schizophrenia (n=19) and non-psychotic psychiatric disorders (n=25). Symptom ratings were collected at both assessment points. Deficits in visual perceptual organization were observed for both tasks in disorganized schizophrenia patients at index and these deficits improved during the course of treatment. Moreover, improvement in visual perceptual organization correlated significantly with reductions in disorganized symptoms in the schizophrenia group. We interpret these data as further support for the hypothesis that the disorganization syndrome in schizophrenia reflects a widespread deficit in the cognitive coordination of contextually related stimuli, leading to dysfunctional organization of stimulus features in vision, thought and language.     

Quantifying incoherence in speech: an automated methodology and novel application to schizophrenia

Incoherent discourse, with a disjointed flow of ideas, is a cardinal symptom in several psychiatric and neurological conditions. However, measuring incoherence has often been complex and subjective. We sought to validate an objective, intrinsically reliable, computational approach to quantifying speech incoherence. Patients with schizophrenia and healthy control volunteers were administered a variety of language tasks. The speech generated was transcribed and the coherence computed using Latent Semantic Analysis (LSA). The discourse was also analyzed with a standard clinical measure of thought disorder. In word association and generation tasks LSA derived coherence scores were sensitive to differences between patients and controls, and correlated with clinical measures of thought disorder. In speech samples LSA could be used to localize where in sentence production incoherence occurs, predict levels of incoherence as well as whether discourse "belonged" to a patient or control. In conclusion, LSA can be used to assay disordered language production so as to both complement human clinical ratings as well as experimentally parse this incoherence in a theory-driven manner.     

Psychosis in a pediatric mood and anxiety disorders clinic: phenomenology and correlates

OBJECTIVES: To examine the demographics and phenomenology of psychosis in a sample of children and adolescents referred to a mood and anxiety disorders clinic. METHOD: Patients (N = 2,031) were assessed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode version and classified as definite, probable, or nonpsychotic. Clinical and demographic characteristics of the groups were compared,and symptoms of psychosis were analyzed using factor analysis. RESULTS: Definite psychotic symptoms were seen in approximately 90 (4.5%) patients: 80% of these reported hallucinations (mainly auditory), 22% delusions, and 3.3% thought disorder. Of the patients with definite psychotic symptoms, 24% had bipolar disorder, 41% had major depression, 21% had subsyndromal depression, and 14% had schizophrenia spectrum disorders (schizophrenia and schizoaffective disorders). Factor analysis of the definite psychotic symptoms yielded 4 factors: hallucinations, thought disorder, delusions, and manic thought disorder. Psychotic patients had a higher frequency of comorbid disorders and suicidal ideation than nonpsychotic patients. CONCLUSIONS: Outpatient youngsters with mood disorders frequently present with psychotic symptoms, in particular auditory hallucinations. These patients commonly have comorbid psychiatric disorders and suicidal ideation.     

Neurodevelopmental Pathways in Schizophrenia

We examined early-onset schizophrenia as a neurodevelopmental disorder. These data are from a 2-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic and neuropsychological assessments include: Structured Clinical Interview for Diagnostic and Statistical Manual (DSM)-IV; Diagnostic Interview for Children and Adolescents, Revised; Premorbid Adjustment Scale; Wechsler Intelligence Scale for Children-III; the Wisconsin Card Sorting Test (WCST), and the California Verbal Learning Test. Pertinent family and developmental history are obtained via parent interviews and chart review. Forty-eight subjects have been recruited to date; 17 with schizophrenia, 13 with bipolar disorder, 10 with psychosis nos, seven with schizoaffective disorder, and one with an organic psychosis. Subjects with schizophrenia had higher ratings of premorbid social withdrawal and dysfunctional peer relationships. All groups had high rates of cognitive impairment, prenatal/perinatal complications, and comorbid psychiatric disorders. Homotypic family psychiatric history was associated with diagnosis in youth. Our data are consistent with a neurodevelopmental model, whereby specific genetic/neurological risk factors and nonspecific biologic/environmental modulating factors interact in the development of schizophrenia and other psychotic disorders.     

Psychiatric Symptoms Endorsed by Somatization Disorder Patients in a Psychiatric Clinic

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. However, prior studies have not addressed whether these endorsed symptoms reflect underlying psychiatric illness or whether they represent symptom overendorsement mirroring somatic complaints in patients with SD. Thirty-two female outpatients with SD and 101 with other psychiatric disorders completed a checklist of current and lifetime psychiatric symptoms. These findings were analyzed with respect to the diagnoses given by their treating psychiatrists. Patients with SD displayed significantly more current and lifetime psychiatric symptoms than did patients without either SD or cluster B personality disorder. Patients with SD endorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however, they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsed by patients with SD did not reflect their clinical diagnoses: only two patients with SD carried an additional clinician diagnosis of either schizophrenia or bipolar disorder, despite high rates of endorsed symptoms by the group. Patients with cluster B personality disorders but without SD showed a symptom profile similar to that of patients with SD. Psychiatric outpatients with SD endorse many more psychiatric symptoms than do other psychiatric patients. Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses; therefore, SD should be considered in the differential diagnosis for a wide variety of psychiatric illness, including psychotic and mood disorders     

The brain,language, and schizophrenia

Language is a defining and prominent feature in humans. This faculty is impaired in those with schizophrenia. Individuals with schizophrenia show numerous abnormalities in language function, including symptoms of disorganized speech, auditory hallucinations, thought disorders, and verbal memory impairments. Structural and functional brain imaging with neurocognitive testing shows various aspects of brain structure and function associated with language that also are abnormal in schizophrenia. This article comparatively reviews this research and relates it to understanding the symptoms and pathophysiologic features of schizophrenia. Understanding the neural basis of language and its disruption in schizophrenia provides a guide for diagnosis, subtyping, treatment, and future research.     

Attitudes of patients toward the first psychotic episode and the start of treatment

Consecutively admitted patients with recent-onset schizophrenia disorders (n = 56) were interviewed about their awareness of mental disorder at first occurrence of psychotic symptoms, their views about the necessity of psychiatric treatment, their perception of the role of others in initiating psychiatric treatment, and suggestions they might have about getting treatment started at an earlier point in time. About 57 percent of the patients had at least some awareness of having a mental disorder at onset of psychotic symptoms, and 61 percent of the sample believed psychiatric help was unnecessary prior to the start of psychiatric treatment. A majority of the patients (91%) perceived others to be essential in initiating treatment. Most patients (82%) thought that no change is needed on the part of professional caregivers in order to facilitate early treatment. Some awareness of mental disorder at onset was related to a shorter duration of untreated psychosis (DUP). Delaying treatment until patients themselves become aware of the need for treatment may enlarge DUP.     

Recovery and treatment of aphasia after stroke: functional imaging studies

PURPOSE OF REVIEW: In this review of papers published between May 2006 and May 2007, we discuss functional neuroimaging studies of recovery and treatment of patients with aphasia after stroke. RECENT FINDINGS: Studies of recovery of aphasia have highlighted the importance of right inferior frontal gyrus activation, especially early after stroke, when it correlates with language recovery. In contrast, in the later stages after stroke left hemisphere activations predict chronic aphasia; speech production recovery appears to depend on left frontal activation, whereas speech comprehension depends on left temporal activation. There have been few studies of treatment of aphasia, but preliminary evidence suggests that treatment of speech production difficulties, even years after stroke, may be effective and deserves further study. SUMMARY: Recent studies of aphasia recovery allow a deeper appreciation of the changing neuronal activation patterns associated with time after stroke. The distinction between neuronal reorganization that does and does not sustain recovery in the chronic phase after stroke, either spontaneous or in response to treatment, remains controversial and further studies are necessary. Clinical diagnosis and treatment of aphasia requires many more longitudinal studies with larger patient numbers and more detailed behavioural and lesion characterization of stroke patients.     

Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features.

BACKGROUND: The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions. AIMS OF THE STUDY: To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania. METHODS: One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD). RESULTS: There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania. CONCLUSION: Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.     

Psychiatric manifestations accompanying interferon therapy for patients with chronic hepatitis C: An overview of cases in Japan

Abstract  Thirty case reports published in Japan that refer to psychiatric symptoms accompanying interferon (IFN) therapy were examined. These papers covered a total of 49 cases. We categorized these 49 cases into 35 cases of mood disorder, 10 of delirium and four of psychotic disorder. The key findings of our study of these cases are as follows: (i) in total, 11 patients had psychiatric past histories: five patients in the mood disorders group were susceptible to the influence of social or psychological factors; (ii) whereas the symptoms of mood disorder or delirium appeared soon after IFN was administered, the symptoms of psychotic disorders appeared later. The patients with delirium displayed many neurological abnormalities, which were reduced by suspending IFN therapy. This suggests the neurological toxicity of IFN; (iii) the outcome of most patients was good; and (iv) we suspect that IFN-induced psychiatric symptoms other than delirium are connected with psychoneuroimmunological functions.