Self-control in psychotic disorders

Our follow-up study of 20 psychiatric patients and a review of the relevant literature support the idea that some persons may be able to exert control over their own psychiatric symptoms. This self-regulation process consists of three phases: In the first phase, persons become aware of the existence of psychotic or prepsychotic behavior by self-monitoring. In the second phase, self-evaluation, the person recognizes the implications of these behaviors as a signal of disorder. In these phases, detecting early affective signals that may herald the onset of psychotic symptoms and noting the sequences of events often followed by symptoms are particularly important. Once these symptoms or their precursors are detected, phase 3 occurs in which mechanisms of self-control are employed. Three such mechanisms are particularly common: self-instruction, reduced involvement in activity, and increased involvement in activity.     

Migration and psychotic disorders

The incidence of psychotic disorders is extremely high in several immigrant groups in Europe. This article describes the epidemiological evidence for increased incidence rates among immigrants compared with nonimmigrant populations and explores possible explanations for this excess risk. Potential causes not only involve factors acting at the level of the individual, but encompass the broader social context of neighborhoods and ethnic groups. Growing up and living in a disadvantaged ethnic minority position, characterized by a low social status, high degree of discrimination against the group and low neighborhood ethnic density, may lead to an increased risk of psychotic disorders, especially when individuals reject their minority status and when their social resources are insufficient to buffer the impact of adverse social experiences. Future research should refine measures of the social context, adopt a life-course perspective and should integrate social and neurobiological pathways.     

Estradiol levels in psychotic disorders

Estradiol has been postulated to constitute a protective factor for schizophrenia, which could provide women at risk to experience a psychotic episode with a relative protection in phases of high estradiol levels, i.e. before menopause and during the peri- and postovulatory phases of their cycle. Women suffering from schizophrenia have been reported to show significantly lower estradiol levels than the normal population and to experience first onset or recurrence of a psychotic episode significantly more often in low estrogen phases of the cycle with low estradiol levels. We examined estradiol levels in an open prospective study in 43 women admitted with a diagnosis of an acute psychotic episode and could confirm these findings for schizophrenia as well as other psychotic disorders. Only 28% of the women exhibited estradiol and progesterone levels indicating a peri- or postovulatory phase and all of the estradiol levels on admission were either within the lower part of the cycle-dependent normal range or below normal; comparison with a control group of healthy volunteers and patients admitted with different psychiatric diagnoses confirmed their estradiol levels to be significantly higher. However, when splitting this control group, the statistical difference would only hold between the study group of psychotic patients and the healthy control group. The group of patients with other diagnoses than a psychotic episode fell in between of the other two groups and did not differ significantly from either. Thus, an unspecific effect, i.e. a hypothalamic downregulation due to the stress of acute hospitalization must be born in mind when assessing hormone levels in acutely psychotic women.     

Neuroprotection in emerging psychotic disorders

Aim: The emerging phase of psychotic disorders is pleomorphic and fluctuates in presentation. Hence, from a clinical perspective, treatment modalities are often unclear. This paper investigates the rational and potential use of neuroprotective agents in emerging psychotic disorders. Methods: Medline databases were searched from 1966 to 2006 followed by the cross‐checking of references using following keywords: neuroprotection, apoptosis, natural cell death, neurodevelopment, plasticity, neurogenesis, combined with brain and schizophrenia. Results: Agents such as atypical antipsychotics, antidepressants, omega‐3 fatty acids, modulators of glutamateric neurotransmission (e.g. ampakines, glycine, memantine), erythropoietin, N‐acetylcysteine, COX‐2 inhibitors or antioxidants have neuroprotective (anti‐apoptotic) properties and may therefore be able to protect brain maturational processes disturbed in emerging psychotic disorders. Clinical trials suggest that atypical antipsychotics, antidepressants, omega‐3 fatty acids and low‐dose lithium as sole treatments were able to improve symptoms and functioning, and delay or in some cases even prevent the onset of frank psychosis. Initially these substances have been chosen because they have been used either as sole or augmentation treatments in established psychotic disorders. However, chronicity and already effective treatments may overshadow their potential clinical use in emerging (prodromal) psychosis. Conclusion: Neuroprotection as a new treatment paradigm for at‐risk mental states seems to be promising and pilot data are suggestive that more benign interventions may already be sufficient to delay or even prevent the onset of frank psychosis. A coordinated research effort will be necessary to address the question which agents should be used under which circumstances.     

Genetic consultation in psychotic disorders

The author gives an account of the problem of psychotic diseases in the practice of a genetic department. She mentions the specificity of decision taking on the reproduction in psychotic subjects, where in addition to the empirical risk of affection of the offspring and the possible teratogenic effect of medication, the load associated with the disease from the medical and socio-economical aspect must be considered. These factors are subject to the subjective interpretation by the family. The task of the geneticist is to help a rational solution of the situation in close cooperation with the psychiatrist.     

The significance of psychotic affective disorders.

A study of 253 patients with primary and secondary affective disorders disclosed that psychotic features were more frequent among bipolar patients. Except for more frequent psychiatric hospitalization among unipolar patients with psychotic features, no demographic, family history, or parental home variable was found to distinguish between those with and without psychotic features. Chance variation probably accounted for the few symptoms whose frequencies were different depending on the presence or absence of psychotic features. The results failed to support the validity of a classification of affective disorders based on the presence or absence of psychotic features.     

Acute and transient psychotic disorders

Psychotic disorders with acute onset, a dramatic and polymorphous symptomatology and rapid resolution have been described in different countries and by different psychiatric schools. They have been called cycloid psychosis, bouffée délirante, psychogenic psychosis or good prognosis schizophrenia. ICD-10 has given an operational definition under the name "acute and transient psychotic disorders" (F23). Their nosological status is unclear. The Halle-Study of acute and transient psychotic disorders (ATPD) has investigated in a prospective manner clinical, para-clinical features and course of illness in 42 patients with ATPD and matched controls with positive schizophrenia, bipolar schizoaffective disorders as well as mentally healthy patients with acute surgical conditions. First results of our study show that ATPD amount to 4% of psychotic in-patients, prefer female sex, show short prodromi, marked affective disturbances within the episode and much better outcome as schizophrenic psychoses according to psychopathological, social, psychological and biographical criteria. Though ATPD may still be an inhomogeneous group, their clinical delineation from schizophrenia seems justified.     

The general fertility rate in women with psychotic disorders

OBJECTIVE: This study determined the general fertility rate and age-specific fertility rates for women with psychotic disorders. METHOD: This historical matched-cohort study of patient records from a primary care database (the General Practice Research Database) was carried out for women of childbearing age (15-44 years) with psychotic disorders. RESULTS: The women with psychotic disorders (N=7,936) had a lower overall general fertility rate than the normal comparison subjects (N=23,023), although fertility was only significantly lower in the women aged 25 and above. This lower fertility rate was less marked in women with affective psychoses. There was no evidence that treatment with neuroleptics influenced the fertility rate in women with non-affective psychoses. CONCLUSIONS: This study found markedly lower fertility rates in women with psychotic disorders than in matched normal comparison subjects, particularly in women with non-affective disorders. Knowledge of fertility rates in women with psychotic disorders is fundamental for clinicians and researchers, since it has implications for family planning services, prevention of obstetric complications, child-care support, and hypotheses about the etiology of these disorders.     

Symptom factors in early-onset psychotic disorders

OBJECTIVE: To examine the factor structure of symptom ratings in early-onset psychotic illnesses. METHOD: Subjects were drawn from a 2-year prospective study of early onset psychotic disorders. Principal components analysis with orthogonal (varimax) rotation was used to create factors from baseline ratings on the Schedule for Positive Symptoms, the Schedule for Negative Symptoms, and the Brief Psychiatric Rating Scale for Children. RESULTS: Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (n = 20) were included. Four symptom factors were identified: negative symptoms, positive symptoms, behavioral problems, and dysphoria. Negative symptoms were predictive of the diagnosis of schizophrenia and treatment with antipsychotic medications. Neither behavior problems nor dysphoria were predictive of diagnosis. In subjects who completed follow-up assessments at year 1 (n = 49) and year 2 (n = 39), negative symptoms and behavioral problems predicted poorer functioning. CONCLUSIONS: The four factors are clinically relevant, with both treatment planning and prognostic implications. Negative symptoms best differentiated schizophrenia from the other disorders. Behavior problems and dysphoria were nonspecific problems that occurred in all three disorders, which likely leads to misdiagnosis in community settings.     

Premorbid functioning in early-onset psychotic disorders

OBJECTIVE: To examine the premorbid characteristics of youths with early-onset psychotic disorders. METHOD: Subjects with early-onset psychotic disorders received an extensive diagnostic evaluation upon entry into the study, including a historic review of premorbid functioning using the Premorbid Adjustment Scale. RESULTS: Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (NOS) (n = 20) were included. High rates of premorbid behavioral problems and academic difficulties were noted across all subjects. Youths with schizophrenia had higher rates of premorbid social withdrawal and global impairment. They also tended to have fewer friends. The psychosis NOS group had significantly higher rates of abuse histories and posttraumatic stress disorder. CONCLUSIONS: Premorbid abnormalities are common features of early-onset psychotic disorders. The social withdrawal and peer problems specific to youths with schizophrenia likely represent early manifestations of negative symptoms. The abuse histories in the psychosis NOS group may explain the atypical nature of their reported psychotic symptoms, which in many cases are likely posttraumatic phenomena.     

The concept of recovery and secondary prevention in psychotic disorders.

The concept of recovery is embedded in the current classification of functional psychosis, an unfortunate fact which has obscured important therapeutic and preventive opportunities for patients and their relatives. A range of theoretical perspectives is reviewed which could be drawn upon to extend research, and develop and evaluate new forms of intervention in this area. The major tasks facing patients and their families at different stages of illness are described, and a series of principles is then proposed to guide the clinical care of recovering psychotic patients.     

The psychosocial outcome of pregnancy in women with psychotic disorders

OBJECTIVE: To investigate the psychosocial outcome of pregnancies in women with a history of psychotic disorder in an epidemiologically representative sample and to determine the predictors of having a baby looked after by social services in the first year of life. METHOD: Historical matched controlled cohort study and nested case control study using the General Practice Research Database (GPRD), an anonymised primary care database, in women with a history of psychotic disorders who gave birth in 1996-1998 (199 cases and 787 controls). RESULTS: Twenty-seven percent of cases had a psychotic episode and a further 38% had nonpsychotic depression in the first year after birth. Women with nonaffective psychoses were at a significantly higher risk of postnatal depression compared with controls (adjusted rate ratio 2.07, 95% CI 1.45-2.96, p<0.001). Cases were well supported with 72% in a cohabiting relationship and only 38% on benefits. The only significant predictor of parenting difficulties was recent contact with psychiatric services. CONCLUSIONS: Women with a history of psychotic disorder are at high risk of psychiatric illness postpartum, particularly a twofold risk of postnatal depression, even if they have not been in contact with psychiatric services during pregnancy. However, this epidemiologically representative sample has better parenting outcomes than has been previously reported for specialist treated cases. Liaison between all professionals involved in the care of mothers with psychotic disorders during and after pregnancy is essential to optimise care for them and their families.     

Future classification of psychotic disorders

Reclassifying psychotic disorders in the upcoming revisions of the mental disorders section of ICD-10 and DSM-IV will first necessitate the development of a unified and operationalized definition of the term “psychosis”. Ideally, such a definition would be harmonized between both groups of diagnostic classification systems and become part of a glossary of terms. Conceptually and based on epidemiological and some genetic work, incorporating dimensional criteria and criteria for prodromal high-risk symptoms may become feasible. Considering the currently available evidence from genetic, neuroimaging and neurophysiological studies, none seems yet sufficiently validated to warrant major changes. However, further research in these areas promises to yield important new insights which may become relevant for the classification of psychotic disorders in the near future. Given the rapid progress in these fields, regular updates of the classification criteria at shorter intervals than in the past may become necessary.