Schizophrenia: a 13-year follow-up. Diagnostic and psychopathological aspects

In Denmark about 11-12 per 100,000 population are diagnosed as schizophrenics for the first time each year. Less than half of these receive this diagnosis at first admission and therefore only 5-6 per 100,000 are included in the official schizophrenia incidence figures. In a cohort (n = 53), predictors for diagnosis of schizophrenia at the first admission were analysed (vs. first schizophrenia diagnosis only at a later admission). In accordance with the Danish concept of schizophrenia, affective flattening was found to have a significant correlation with the initial diagnosis of schizophrenia. Long duration of disease prior to the initial admission was also significantly correlated, indicating that a criterion of chronicity forms part of the Danish concept of schizophrenia. Schneider's first-rank symptoms also were more weakly correlated with the initial schizophrenia diagnosis. The probands were followed up personally and by case records (13 years). Good outcome was found in 23% of the probands and poor outcome in 50%. Affective flattening and Schneiderian first-rank symptoms at initial admission were correlated with poor outcome (NS). Schneiderian first-rank symptoms and social unease at initial admission were significantly correlated with schizophrenia as follow-up diagnosis. The initial clinical diagnosis of schizophrenia was not correlated with clinical outcome or with follow-up diagnosis.     

"First rank" schizophrenia and research diagnosable schizophrenic and affective illness

The case record data for 83 first-admissions of schizophrenics with first rank symptoms (Schneider-hospitalized in a strongly Schneider-oriented German University Psychiatric Clinic during the years 1962 through 1971) were reviewed in the light of the rigorous research criteria of some Neo-Kraepelinean American centers, and the ratings of first-rank phenomena employed formal definitions. In this manner, 66.3% (55 cases) of Schneider-positive schizophrenics could be given a psychiatric research diagnosis. By far, the larger portion of the research-positive patients was contributed by those 43 cases demonstrating research diagnosable schizophrenia, which comprised 51.8% of the entire sample. Indeed, 18 cases even shared both the St. Louis/Iowa and Taylor research criteria for this latter illness. However, the Schneider-positive sample also contained 14.4% (12 cases) of research diagnosable affective disorder, depression making up 6% and mania 8.4% of this figure. The findings suggest that Schneider-oriented German schizophrenics with first-rank symptoms, although containing a high percentage of research diagnosable schizophrenia, do not clearly represent an homogeneous and “uncontaminated” sample of schizophrenics.     

Symptom differences in reactive psychoses and schizophrenia with poor prognosis.

Genetic and clinical studies dealing with reactive psychoses are reviewed briefly. Diagnostic criteria are defined, and patients diagnosed as reactive psychoses and schizophrenia with poor prognosis are compared for differences in cross-sectional symptomatology. Symptoms were systematically recorded in the Present State Examination. Emotional blunting, auditory hallucinations in clear consciousness, tactile hallucinations, thought broadcasting, voices commenting, and “any first-rank symptom of schizophrenia” were noted to occur more often in schizophrenia with poor prognosis. Dysphoric mood, sleep disturbance, and irritability occurred more often in reactive psychoses. These findings are considered to offer additional support for the clinical differentiation of reactive psychoses from schizophrenia.     

Frequency and predictive values of first rank symptoms at baseline among 362 young adult patients with first-episode schizophrenia Results from the Danish OPUS study

AIM: To investigate the frequency of the Schneiderian First Rank Symptoms (FRSs) in a representative group of patients with first-episode schizophrenia and to analyse the predictive value of these symptoms in relation to psychopathology, work situation, depression, dependency and admission after 2 years of treatment. METHOD: 547 patients were included in the Danish OPUS trial. A subgroup of these, namely the 388 patients who fulfilled the diagnostic criteria for schizophrenia (ICD-10), was included in this study. Data from SCAN interviews were used to describe the frequency of the different first rank symptoms and to compare the characteristics of the patients with and without FRSs. RESULTS: FRSs were very common among these patients with first-episode schizophrenia. Only 16% reported no FRSs at all. Almost half of the patients had experienced commenting or discussing voices, and more than 40% had experienced loud thoughts. More patients with than without FRSs had some kind of substance abuse. FRSs at baseline did not predict the level of scores in the psychotic, negative or disorganized dimension after 2 years. Having FRSs at baseline was related to a significantly lower number of days of admission during the two-year period, but was not associated with antipsychotic medication or depression after 2 years. CONCLUSION: FRSs are very common among first-episode psychosis patients, but their predictive value seems to be limited with respect to outcome measures like psychopathology, work or substance abuse. However, FRSs did predict a lower mean of days of admission.     

The 'diagnostic history' of schizophrenia. A retrospective study of 84 Swedish inpatients.

Since few studies have focused on the diagnostic process foregoing a case record diagnosis of schizophrenia, the present study was undertaken with the aims to examine the time interval between the onset of the illness, the first admission as inpatient, and the timepoint of a case record diagnosis of schizophrenia. Further, the study aimed at analyzing the influence of demographic and clinical variables on an 'early' or 'late' diagnosis of schizophrenia. The records of 84 inpatients treated during the calendar year 1986, were retrospectively analyzed. Only 21.4% of the patients had received a case record diagnosis of schizophrenia at their first admission into hospital, and additionally 16.7% after two admissions. Those patients with 'early' diagnosis differ significantly from patients with 'late' diagnosis, being more frequently men, having longer admission latency, higher frequency of Schneiderian first-rank and negative symptoms, a longer stay at hospital at their first admission, and lower levels of working capacity at the onset of the illness. The data suggest a propensity to include course and social functioning aspects of poor outcome in the diagnostic process. Confining the diagnosis of schizophrenia to the severe cases indicates a conservative, perhaps tautological, approach to this diagnosis.     

Childhood traumatic events and types of auditory verbal hallucinations in first-episode schizophrenia patients

ObjectiveEvidence is accumulating that childhood trauma might be associated with higher severity of positive symptoms in patients with psychosis and higher incidence of psychotic experiences in non-clinical populations. However, it remains unknown whether the history of childhood trauma might be associated with particular types of auditory verbal hallucinations (AVH).MethodWe assessed childhood trauma using the Early Trauma Inventory Self-Report — Short Form (ETISR-SF) in 94 first-episode schizophrenia (FES) patients. Lifetime psychopathology was evaluated using the Operational Criteria for Psychotic Illness (OPCRIT) checklist, while symptoms on the day of assessment were examined using the Positive and Negative Syndrome Scale (PANSS). Based on ETISR-SF, patients were divided into those with and without the history of childhood trauma: FES(+) and FES(−) patients.ResultsFES(+) patients had significantly higher total number of AVH types and Schneiderian first-rank AVH as well as significantly higher PANSS P3 item score (hallucinatory behavior) in comparison with FES(−) patients. They experienced significantly more frequently third person AVH and abusive/accusatory/persecutory voices. These differences remained significant after controlling for education, PANSS depression factor score and chlorpromazine equivalent. Linear regression analysis revealed that the total number of AVH types was predicted by sexual abuse score after controlling for above mentioned confounders. This effect was significant only in females.ConclusionOur results indicate that the history of childhood trauma, especially sexual abuse, is associated with higher number AVH in females but not in males. Third person AVH and abusive/accusatory/persecutory voices, representing Schneiderian first-rank symptoms, might be particularly related to childhood traumatic events.     

Organic factors and the clinical features of late paranoid psychosis: a comparison with Alzheimer's disease and normal ageing

The diagnostic allocation and aetiological basis of paranoid psychoses with late onset is controversial. We examined the clinical features of patients with a diagnosis of paranoid psychosis and we compared their cranial computed tomography (CT) scans and electroencephalographic (EEG) recordings with findings from matched samples of patients with Alzheimer's disease and non-demented elderly controls. During a 5-year period, 81 patients (15 men and 66 women) with a diagnosis of paranoid psychosis and onset after age 50 were referred to our Institute. They represent 5.4% of the patients older than 50 admitted during the same period. More than half of these patients had first-rank symptoms. The ventricles, anterior and sylvian fissures of the paranoid group were larger than in non-demented controls but smaller than in Alzheimer's disease. The posterior dominant alpha EEG rhythm was slower than in normal ageing and faster than in Alzheimer's dementia. If paranoid patients with first-rank symptoms were distinguished from the ones without, the former had less severe brain atrophy and faster posterior dominant rhythm, although they received higher doses of neuroleptics. This could be explained by the existence of at least 2 subgroups of late paranoid psychosis: late-onset schizophrenia and organic paranoid syndrome, the former characterized by first-rank symptoms and less severe brain atrophy, the latter by more severe EEG and CT scan changes with a closer resemblance to degenerative brain disease.     

First-rank symptoms of schizophrenia in Schneider-oriented German centers.

First-rank symptoms of schizophrenia, such as thought insertion, thought broadcasting, "made" volition, and delusional perception, were introduced for purposes of diagnosis into a German university clinic. Such "Schneiderian" criteria were evaluated in 210 case records. Ratings employed formal definitions. Of 210 records examined, 69 (33%) of the schizophrenic patients had first-rank symptoms. The frequency of finding such symptoms in a group of schizophrenics is compared to other reports. There are considerable differences in frequency of individual symptoms as well as total number of such symptoms across centers, but the use of precisely agreed on definitions of first-rank symptoms may lead to better agreement.     

Computer-assisted CT measurements in late paraphrenics with and without Schneiderian first-rank symptoms: A preliminary report

Computer-assisted measurements were made on the computed tomography (CT) scans of 14 patients meeting ICD-9 diagnostic criteria for late paraphrenia, seven of whom had exhibited one or more first-rank symptoms during their illness. When the CT scans of all 14 late paraphrenics were compared with those of an age-matched healthy control group, there were no significant differences with regard to planimetric measurements of brain and ventricle areas. Comparison of the scans of late paraphrenics with first-rank symptoms and those without them demonstrated that late paraphrenics without first-rank symptoms had a greater degree of cerebral atrophy, which was significantly so for the left frontal lobe. The findings support the observation that late paraphrenia is a heterogeneous condition which is comprised of a group with first-rank symptoms who probably represent late-onset schizophrenia and a group without first-rank symptoms who have structural brain abnormalities and a presumed organic substrate for their symptoms that is impossible to exclude through clinical evaluation.     

Changes in Negative Symptoms of Schizophrenic Patients Two Years Later†

Abstract: This study investigated the course of negative symptoms by examining the psychiatric symptoms of 59 new schizophrenic patients at the first consultation and again two years later using a structured interview–the Present State Examination. An examination of the total score of the nine negative symptoms, included in the “Chronic Schizophrenic Syndrome” by Wing, showed that 27 out of the 59 patients (45.8%) had lower symptom scores two years later than they did at the first consultation (“negative symptom improvement” group), while 20 patients (33.9%) had higher scores two years after the first consultation (“negative symptom deterioration” group). There were 12% more patients in the improvement group than in the deterioration group. No significant differences were observed between the “improvement group” and “deterioration group” in relation to the following factors–subclassification of schizophrenia, mode of onset, age at the first consultation, marital status at the time of onset, academic history, employment status prior to the onset, the history of hospitalization after the onset and maintenance therapy of neuroleptics. In relation to psychiatric symptoms at the first consultation, the patients in the “improvement group” had a variety of symptoms compared to the patients in the “deterioration group,” and the presence of “incoherence of thought,”“delusion of reference” and “special features of depression” was significantly higher in the improvement group than in the deterioration group.     

Anorectic behavior,mood, and metabolic and endocrine adaptation to starvation in anorexia nervosa during inpatient treatment

Twenty-two patients with anorexia nervosa were studied at 2-week intervals during treatment on psychiatric wards. In order to characterize the metabolic situation in starvation, levels of free fatty acids, beta-hydroxybutyric acid, and acetoacetate were measured. The endocrine adaptation to starvation was studied by measuring triiodothyronine, noradrenaline, and cortisol. Anorectic symptoms were assessed by the Anorexia Nervosa Inventory Scale (ANIS) and mood changes on the basis of a “Befindlichkeits” Scale (BF). Only half of the patients showed metabolic and endocrine signs of starvation on admission to the hospital, despite low body weight. This group had significantly more severe anorectic symptoms (ANIS) and gained weight at a lesser rate. Metabolic signs of starvation disappeared during the first 4 weeks of therapy in most of the patients. The endocrine indicators for starvation normalized much more slowly, with noradrenaline having the slowest pace. “Bulimics” and “restricters” could not be distinguished from one another by metabolic or endocrine observations. The “bulimics”, however, showed more severe anorectic symptoms (ANIS) and a more depressed mood.     

Atypical psychosis in relation to the schizophrenia spectrum: Report of a family and review of the literature

The genetic concepts of genotypes, phenotypes, and phenocopies, when put into use in psychiatry, could offer a new perspective that needs to be validated or invalidated by future research. The sharing of a common genotype or genotypes by distinct phenotypes underlies the basic concept of schizophrenia spectrum. In this article, the following hypothesis will be considered: Certain “atypical” psychotic conditions, sometimes difficult to distinguish clinically and by family histories from mania, may share a common genotype or genotypes with “typical” schizophrenia. In other words can the schizophrenia spectrum include phenocopies of manic states?The pedigree method has been used extensively in the study of schizophrenic disorders but no mode of transmission, Mendelian or other type, has been demonstrated.^1,2 Despite this negative result, the pedigree method can offer insight into the relationship of the different types of psychosis when they occur in the same family.This report is about a family in which the proband had a “manic-depressive-like” disorder. Her initial diagnosis was that of a schizo-affective disorder, but 16 months after her first admission she displayed and experienced manic signs and symptoms. She was placed on Lithium carbonate and a four month follow-up on this drug has shown her to be asymptomatic. The proband's sister has a schizophrenic disorder. The case histories of each affected member are summarized.     

Differences in the difficulty of subtasks comprising the toileting task among patients with subacute stroke: A cohort study

IntroductionToileting comprises multiple subtasks, and the difficulty of each is critical to determining the target and priority of intervention. The study aimed to examine the difficulty of subtasks that comprise toileting upon admission and the reacquisition of skills of subtasks during hospitalization.Materials and methodsThis was a single-center prospective cohort study. We enrolled 101 consecutive stroke patients (mean age: 69.3 years) admitted to subacute rehabilitation wards. The independence in each of the 24 toileting subtasks was assessed using the Toileting Tasks Assessment Form (TTAF) every two or four weeks. The number of patients who were independent upon admission, as well as those who were not independent upon admission but became independent during hospitalization, was examined in each subtask.ResultsThe most difficult subtask upon admission was “Lock the wheelchair brakes” (16.8% of patients were independent), followed by “Turn while standing (before urination/defecation)” (17.8%), “Pull the lower garments down” (18.0%), “Turn while standing (after urination/defecation)” (18.8%), “Pull the lower garments up and adjust them” (18.8%), and “Maintain a standing position (before urination/defecation)” (18.8%). The most difficult subtask for those who were not independent but became independent was “Dispose of incontinence pad/sanitary items” (19.3%), followed by “Press the nurse call button (after urination/defecation)” (28.3%), “Take the foot off the footrest and place it on the ground” (28.6%), and “Clean up after urination/defecation” (29.0%).ConclusionsThe difficult subtasks upon admission and those for reacquired skills were different. The most difficult subtasks upon admission were main tasks, and the difficult subtasks in reacquiring skills were preparatory tasks.     

Primary and secondary affective disorder: Part II. Differences in usual state self-perceptions

Thirty-five primary affective disorder and 32 secondary affective disorder patients rated themselves in comparison to the average person on 74 depressive symptoms. They were instructed to rate themselves as they are in their “usual” state. Secondaries reported they usually have significantly more depressive symptoms than did primaries (14.25 versus 3.28, p < 0.00005). Using 49 symptoms not characteristic of nonaffective disorders, a discriminant function analysis correctly classified all patients. A stepwise analysis identified the 18 most powerful symptoms. Ten of these were used with a simple weighting scheme to classify correctly 85% of the patients. The possibility of a simple confirmatory test for psychiatric diagnosis was discussed.     

Schneider's first-rank symptoms of schizophrenia. An association with increased growth hormone response to apomorphine

Growth hormone and prolactin (PRL) responses to 0.75 mg of apomorphine hydrochloride were measured in 19 newly admitted psychotic patients who had been untreated by neuroleptic or antidepressant drugs for at least nine months. We compared hormonal responses between subgroups of patients who were distinguished using the diagnostic criteria of Feighner et al and Spitzer et al, and by the presence or absence of Schneider's first-rank symptoms of schizophrenia. We included nine healthy subjects who were matched by age and sex with the schizophrenic patients. Growth hormone responses to apomorphine were greater in patients with Schneider's first-rank symptoms than in those without first-rank symptoms, and were also greater than in control subjects. Suppression of plasma PRL was also greater in schizophrenic patients than in control subjects. These results support the dopamine hypothesis of schizophrenia.     

Schizophrenic symptomatology and cerebral dominance patterns: A comparison of EEG,AER, and BPRS measures

The relationship of behavior to left or right cerebral hemisphere function has been of considerable interest recently. Due to our recent findings that various EEG frequencies were abnormally prominent over the left hemisphere in some schizophrenic patients, it appeared logical to examine the relationship of EEG and AER asymmetries to schizophrenic symptoms, presumed to be related to left or right cerebral functioning.Thirty male schizophrenic patients were rated on the BPRS for symptoms that were deemed to be so related. Eight patients had “left” related symptoms (mainly thought disorder) and six had only “right” hemisphere symptoms (mainly anxiety-depression). Subjects were recorded for ongoing resting EEG and visual (flash) averaged evoked response asymmetries. Those with “left” symptoms showed significant asymmetries in the beta II band, with left hemisphere amplitude values being highest. Patients with “right” symptoms showed evoked response asymmetries, with the right hemisphere amplitude values being the highest. It appears, thus, that different schizophrenic symtomatologies are characterized by different electrophysiological patterns.     

Clinical characteristics of myocardial stunning in acute stroke

Neurogenic stunned myocardium (NSM) after subarachnoid hemorrhage (SAH) is well known, but there is a paucity of data regarding its occurrence following acute stroke. The aim of this study is to investigate the clinical characteristics of NSM in acute non-hemorrhagic stroke. We performed an electronic literature search with Medline and Google Scholar for English-language articles using the terms “ischemic stroke” along with “stunned myocardium” or “Takotsubo cardiomyopathy”. The search resulted in seven case reports/series, but no prospective studies. The mean age of patients with myocardial stunning following ischemic stroke was 72.5 years and 77% of these patients were females. Insular cortex was involved in 38.4% of cases. Mean National Institutes of Health Stroke Scale (NIHSS) score at admission was 12.6 and mean NIHSS at discharge was 10.8. T-wave inversions and ST-segment elevations were noted in 84.6% and 69.2% of patients, respectively. Mean troponin elevation was 0.64 mcg/dL and mean left ventricular ejection fraction (LVEF) was 34.4%. In terms of outcomes, 84.6% of patients had significant improvement in LVEF, mostly within 4 weeks of onset of symptoms. To summarize, NSM was more common in females, with favorable prognosis. Less than half the patients with NSM following stroke had insular involvement. The mean troponin level in NSM after stroke was only half of that seen in SAH. While the lack of prospective studies on NSM in stroke patients precludes drawing further conclusions, more studies are warranted to investigate the risk factors for NSM and the effect on stroke outcomes.