Psychopathology and outcome of first-admission schizophrenic patients: hypochondriac-cenestopathic symptoms as predictors of an unfavorable outcome

The outcome of first-admission schizophrenic patients at Jichi Medical School Hospital was investigated to identify outcome predictors of schizophrenia among the symptoms at the time of the first hospitalization. The subjects were 62 schizophrenic patients, 29 females and 33 males, consecutively discharged from the Department of Psychiatry, Jichi Medical School Hospital, between June 1983 and May 1988. The mean interval between first admission and follow-up was 13 years. Eguma's Social Adjustment Scale was used to measure social outcome. The subjects were divided into two groups according to their rating on Eguma's Scale; a favorable outcome group and an unfavorable outcome group. Information on premorbid status and psychopathology at the time of the first hospitalization was obtained from clinical records and analyzed by comparing them between the two groups. Of the 62 patients, 56 were followed-up. Nine of the 56 patients followed-up had died. While 47 patients were alive; 39 were receiving psychiatric treatment and eight were not. The 47 patients who were still living were divided into two groups; a favorable outcome group (n = 22), and an unfavorable outcome group (n = 25). No significant differences in premorbid status were found. Comparison of psychopathology at the time of the first hospitalization between the outcome groups revealed significant differences in lack of spontaneity and hypochondriac-cenestopathic symptoms. Lack of spontaneity may reflect negative symptomatology, while hypochondriac-cenestopathic symptoms may reflect a serious disturbance of ego function. There is a strong possibility that evaluation of body-related symptoms in schizophrenia will be helpful in predicting outcome.     

近20年来精神分裂症亚型及症状变迁

作者对１９７４，１９８４，１９９４三个年度内首次住院的精神分裂症病人进行了随机抽样调查，发现近年来精神分裂症亚型中青春型，紧张型明显减少，未定型增多。精神症状中情感淡漠，思维贫乏，意志缺乏，被控体验，被洞悉感，非血统妄想和夸大妄想等症状增多，思维破裂及散漫，情感倒错，离奇行为和冲动伤人等症状减少，表明近年来精神分裂症已趋于不典型化，并对其原因进行了探讨。     

Subtypes in schizophrenic disorders: frequencies in long-term course and premorbid features

Summary The subclassification of schizophrenic disorders according to four diagnostic systems (DSM-III-R, ICD-10, the positive vs. negative dichtomy and Schneider's first rank symptoms) was compared over the long-term course of the disease in 148 narrowly defined schizophrenic patients. A total of 595 episodes were classified over a mean observation period of 23 years (range 10–50 years). Initially, paranoid/positive subtypes predominated, while later in the course episodes fulfilling the symptomatological criteria of residual/negative subtypes became more frequent. Disorganised/hebephrenic and catatonic subtypes were found to be rare. Some premorbid features were investigated as non-symptomatological validators for subclassification. Significant differences were found with regard to age at onset. Patients whose first episode was paranoid or positive had the highest age at onset. Patients with initial disorganised/hebephrenic or residual episodes had the most unfavourable premorbid social adjustment, even when the influence of age at onset was discounted. The diagnostic systems investigated showed similarities and differences as a result of the underlying concepts. Methodological implications are discussed.     

A long-term follow-up study of schizophrenia: psychiatric course of illness and prognosis.

A systematic psychiatric follow-up study of 502 schizophrenics was carried out using the same well-defined criteria to evaluate the patients throughout the investigation. After an average course of disease of 22.4 years, 22.1% of the patients showed complete psychopathological remission, 43.2% had non-characteristic types of remission and 34.7% suffered from characteristic schizophrenic deficiency syndromes. At the time of the last follow-up investigation, 86.7% of the patients were living at home, while 13.3% were permanently hospitalized. Of the entire sample, 55.9% were found to be "socially recovered". Higher education, psychoreactive provocation, depressive traits, perception of delusions, catatonic agitation, non-characteristic thought disorders and symptoms of depersonalization at the onset of the illness tended to carry with them a favorable prognosis. On the other hand, low intelligence, abnormal primary personality, premorbid disturbances in social behavior, broken homes, prolonged prodromal stages, pneumoence-phalographically measurable atrophic or dysplastic changes in the brain ventricles as well as somatic and auditory hallucinations and predominance of hebephrenic symptoms at the onset of the illness tended to lead to an unfavorable prognosis. The principle of the basic reversibility of typical schizophrenic symptoms and the extensive irreversibility of the non-characteristic defect is important for the psychopathological and social long-term prognosis.     

Cortical sulcal enlargement in catatonic schizophrenia: a planimetric CT study.

To determine whether patients with catatonic schizophrenia have specific alterations in brain morphology, internal (ventricles) and external (frontal, temporal, parieto-occipital) components of the cerebrospinal fluid (CSF) spaces were examined morphometrically. Planimetric measurements of computed tomographic (CT) scans from 37 patients with catatonic schizophrenia, 28 patients with hebephrenic schizophrenia, and 39 patients with paranoid schizophrenia, all diagnosed according to DSM-III-R criteria, were compared with separate age- and sex-matched non-psychiatric control groups, respectively. The areas of the frontal sulci, the parieto-occipital sulci, the inter-hemispheric fissure, and the lateral and third ventricles were measured separately for the right and left hemispheres. Catatonic patients showed significant enlargements in almost all CSF spaces, especially in the left fronto-temporal area which, in addition, correlated significantly with illness duration. Hebephrenic patients showed selective enlargements in left temporal and left/right lower frontal cortical sulci, whereas paranoid schizophrenic patients showed no enlargements but significant correlations between left temporal cortical sulcal volume and illness duration. Alterations in temporal cortical areas were present in all three sub-types of schizophrenia. In addition to temporal alterations, hebephrenic schizophrenia was characterised by lower frontal (i.e. orbitofrontal) enlargement. Catatonic schizophrenia, the most severe sub-type with regard to clinical symptomatology and brain pathology, showed fronto-parietal cortical alterations.     

精神分裂症患者血清肌酸磷酸激酶活性与临床类型关系的研究

目的　探讨精神分裂症患者各临床亚型的血清肌酸磷酸激酶 (CPK)活性水平。方法　对 178例精神分裂症患者在入院次日、4周末及 8周末分别进行血清CPK检测 ,并与 6 0例正常人对照。结果　精神分裂症偏执型、青春型、紧张型在发病期 (入院次日 )的血清CPK活性显著高于正常对照组 (P <0 0 1) ,且治疗痊愈后显著下降 (P <0 0 1)。而单纯型的血清CPK值显著低于对照组 (P <0 0 5 )。未定型的血清CPK值与对照组间无显著性差异 (P >0 0 5 ) ,且发现未定型和单纯型治疗前后血清CPK值无显著性改变 (P >0 0 5 )。结论　精神分裂症在发病期的血清CPK活性水平与临床亚型有关 ,各亚型间存在差异 ;定期检测血清CPK ,对了解病情变化及其诊治有重要意义     

Validity of the ICD-9 schizophrenia classification: A blind family history study

ABSTRACT– Within the framework of the multifactorial-polygenic model of inheritance, multiple threshold strategy was applied to a large set of pedigree data to examine the clinico-genetical position of some subtypes within the ICD-9 classification of schizophrenic psychoses. It appeared highly probable that the ICD-9 subtypes examined, oased mainly on the classical Kraepelin-Bleulerian classification (simplex, hebephrenic, catatonic, paranoid, schizo-affective) are not homogeneous from the clinico-genetical point of view and genetical factors cannot be held primarily responsible for the clinical differences between the subtypes.     

Six-Month Clinical Status as a Predictor of 24-Month Clinical Outcome in First-Admission Patients with Schizophrenia

The aim of this study was to determine whether clinical status at 6-month follow-up is a predictor of 2-year clinical status in first-admission schizophrenic patients. If short-term status is indeed a strong predictor of subsequent functioning, the relationship would support earlier initiation of aggressive interventions. An epidemiologically based sample of 162 first-admission schizophrenic patients was examined at index hospitalization and at 6- and 24-month follow-up, using a variety of diagnostic and clinical assessment instruments. Respondents were divided into three groups based on their 6-month clinical status: delusions or hallucinations present at 6-month follow-up with or without negative symptoms (n = 63); moderate to high levels of negative symptoms (but not positive symptoms) present (n = 42); neither positive nor negative symptoms present (n = 57). Differences in 24-month clinical functioning were evaluated (GAF scores, BPRS factors, role functioning, number of rehospitalizations, and illness course). No significant differences were found among the three groups on demographic characteristics, substance abuse history, or extent of treatment during the follow-up. At 24-month follow-up, respondents with positive psychotic symptoms at 6-month follow-up had the worst, and those with no positive or negative symptoms the best functioning, with the negative-symptom group intermediate on most indices. Thus, among schizophrenic patients, poor 6-month clinical status identified a patient subgroup at high risk for continued poor clinical status at 24 months, suggesting the need for earlier intensive intervention in an attempt to prevent this progression.     

Subtype stability in schizophrenia

The authors examine the long-term stability of the subtypes of schizophrenia defined by four diagnostic systems. When all patients were considered, agreement between subtype assigned at index and follow-up was modest. This agreement increased considerably when only patients diagnosed as paranoid, hebephrenic, or catatonic at both index and follow-up were considered. As for individual subtypes, stability was highest for paranoid schizophrenia, intermediate for hebephrenia, and virtually absent for undifferentiated schizophrenia. The stability of paranoid schizophrenia was greatest when onset occurred after age 30. As length of follow-up increased, a larger proportion of patients were diagnosed as undifferentiated or residual.     

Long-term course of acute reactive paranoid psychosis. A follow-up study

ABSTRACT The study comprises a retrospective evaluation of the case records of 49 first-admission patients with acute reactive paranoid psychosis and of the subsequent follow-up almost 10 years later, with special reference to clinical and social course and outcome. Ten of the 41 followed-up patients were diagnosed schizophrenic in the observation period and a further five fulfilled the Catego Class S⁺ at a PSE interview. Three patients were diagnosed affective psychosis and one fulfilled Class MT. Three patients were diagnosed paranoid psychosis and four more fulfilled Class P7PT while six patients had reactive psychosis relapses but were non-psychotic at follow-up. During the observation period the number of disabled pensioners increased from three to 21, and at follow-up only seven patients were well-adjusted in their family and work. The need is stressed for valid predictors in the prognosis of acute paranoid psychoses with or without associated stressful life events.     

Outcome in untreated schizophrenia: a search for symptoms and traits with prognostic meaning in patients admitted to a mental hospital in the preneuroleptic era.

A cohort of schizophrenic patients consecutively admitted to a mental hospital for the first time in 1925 was investigated in search of symptoms and traits with prognostic meaning. Since Leonhard's diagnostic system was applied, cases with mixed symptoms and a favourable outcome were excluded as being neither schizophrenic nor manic-depressive. Owing to the admission policy then prevailing, cases with clinically less striking and socially less deleterious features were underrepresented. The sample (n = 70), so demarcated, was still considered fairly appropriate for the purpose of a differential study of outcome in nuclear schizophrenia with a life-long follow-up. The best outcome group consisted of 33% of the sample; 24% formed an intermediate group, and 43% profoundly deteriorated with continuous psychotic symptoms and a total loss of social function. Marriage before index admission was the only characteristic related to a favourable outcome. Nuclear schizophrenic symptoms, thought disturbance, blunted affect and all catatonic symptoms listed in DSM-III were related to an unfavourable outcome. When prognostic subgroups were compared pairwise, no favourable trait was detectable, and there were no decisive differences between the group with the best outcome and the intermediate group. When these 2 groups were compared with the group with worst outcome, however, significant differences arose with respect to unfavourable characteristics. Predictions using a discriminant analytic procedure yielded the same results. The hypothesis that affective and atypical signs would also have prognostic meaning in nuclear schizophrenia was disproved.     

Evaluation trial on the efficacy of neuroleptics on the outcome of schizophrenia]

Feasible and ideal methodological conditions lacking, we have tried an evaluation concerning the efficacy of neuroleptics upon the course of schizophrenia by comparing the evolution of homogeneous studies before and since the neuroleptic period. On the short term, neuroleptics are significantly more effective than the placebo upon schizophrenic symptoms and prevent the relapses in an noteworthy manner. On the long term, the evolution is significantly better for follow-up studies treated by neuroleptics (60% of patients improved) than for the non-treated follow-up studies i.e. before neuroleptic period (27.5% of patients improved). The time of the follow-up has an effect on the course of schizophrenia. Before neuroleptic periods, the schizophrenic process beyond 6 to 10 years was either stabilized or worsened. On the contrary, since the neuroleptic period, the number of improvements continued to increase after 12 years time (79.5% of patients improved for the follow-up beyond 12 years time versus 60% under 12 years). These improvements include paranoid and hebephrenic forms. On the contrary, catatonic forms had decreased very much since the utilization of neuroleptics (they moved from 18 to 28% before neuroleptic periods to 2% after the beginning of utilization of neuroleptics). If neuroleptics have undeniable action upon the schizophrenic symptomatology, they also act, on the long term, upon the social course of schizophrenia (30% of social remission before neuroleptic period versus 50% since neuroleptic period).     

Classical subtypes for schizophrenia: literature review for DSM-IV.

The classical subtypes of schizophrenia include the paranoid, hebephrenic, undifferentiated, residual, catatonic, and simple. This review of studies, especially those conducted during the last decade, supports the validity of the subtypes, particularly the paranoid subtype. To a lesser degree, the same holds for the hebephrenic and undifferentiated subtypes. The catatonic subtype has seldom been studied, perhaps because it is so rare. The residual and simple subtypes have not been the focus of any studies of note. Subtype criteria for DSM-IV are suggested based on the review. The paranoid and undifferentiated subtypes should be retained with criteria identical to those in DSM-III-R. The disorganized subtype also should be retained but with modified criteria that are somewhat more stringent than those in DSM-III-R. Catatonia and residual schizophrenia should remain, but insufficient data exist upon which to base any changes in criteria. Given its historical precedence, as well as the emerging importance of deficit processes in schizophrenia, simple schizophrenia should be renamed and reintroduced as a subtype in DSM-IV. Two variations in criteria are offered.     

The Kraepelinian dichotomy: preliminary results of a 15-year follow-up study on functional psychoses: focus on negative symptoms

In a 15-year follow-up study, we used a comparative approach to assess course and outcome for all functional psychoses. The presented results focus on negative symptoms and refer to a sample of 76 patients with schizophrenia, 38 patients with a schizoaffective disorder and 32 patients with an affective disorder according to ICD-9. These patients were assessed at their first psychiatric hospitalization and 15 years later. In summary, the findings indicate that the course and outcome of schizophrenia is less favorable than that of affective and schizoaffective disorders. Negative symptoms occurred in all functional psychoses, but were more frequent and prominent in the schizophrenic group than in the other two diagnostic groups at any time of assessment. Narrower concepts of negative symptoms, conceptualized as the deficit syndrome, seem to be specific for schizophrenia and appear quite rarely in patients with affective psychoses. Overall, our study supports Kraepelin's original hypothesis that bifurcated the psychoses into the affective psychoses and schizophrenia, whereby the latter have a more deleterious long-term course and outcome.     

Catatonic schizophrenia has a shorter pre-hospitalisation interval than other types of schizophrenia

Summary. The time elapsed between the first onset of symptoms and the onset of first hospitalisation was analysed in 355 participants diagnosed with paranoid, simple, hebephrenic and catatonic schizophrenia and shizoaffective disorder. The real onset of the disease was assessed from interviews with reliable relatives and by reviewing medical records in general practices and out-patient psychiatric services. In 184 patients a family history of schizophrenia was identified. A positive family history was found to significantly increase the interval preceding first hospitalisation in all analysed types, except in catatonic schizophrenia. Possible reasons causing this prolongation are discussed, as well as repercussions of the results to studies using age of first hospitalisation as the leading indicator. Received May 24, 2000; accepted October 17, 2001     

Glucose-6-phosphate dehydrogenase deficiency and schizophrenic behavior

It was recently reported that a statistically significant difference existed between catatonic and paranoid negro schizophrenic subjects with regard to the prevalence of deficiency of the enzyme glucose-6-phosphate dehydrogenase in erythrocytes. We have repeated this study, surveying 562 male subjects and 235 female subjects at five State Hospitals in New York. Our results indicated: (1) no association between schizophrenic subtype and enzyme deficiency for the females (p#620·5); (2) a statistically significant association (p<0·025) for the males at four of the hospitals; and (3) at the fifth hospital, once again a statistically significant association for the males (p<0·05), but in the opposite direction from the other four hospitals. It is not possible to come to any definite conclusions from these results. We believe that these discrepant findings are due mainly to the unreliability of the classification of patients into paranoid and catatonic categories.     

Prognosis and outcome using broad (DSM-II) and narrow (DSM-III) concepts of schizophrenia

The classical prognostic indicators of Vaillant and Stephens, the acute onset of psychotic symptoms, and key demographic factors were investigated as predictors of outcome in a prospective study of 153 schizophrenic patients defined using broad (DSM-II) and narrow (DSM-III) concepts of schizophrenia. Findings indicate: Several established prognostic items did not show strong predictive utility in DSM-II or DSM-III schizophrenia when young, nonchronic patients were studied. For both DSM-II and DSM-III schizophrenic patients, longitudinal assessments of psychotic symptoms, work history, and social functioning predicted their respective assessments at followup. However, the predictive utility of some key prognostic indicators shifted for narrow vs. broad concepts of schizophrenia. Most importantly, sex, which was the most powerful predictor of overall outcome among patients with DSM-II schizophrenia, failed to predict outcome among patients with DSM-III schizophrenia, primarily because many women with favorable outcome did not meet the DSM-III criteria for schizophrenia. DSM-III schizophrenia comprises a more homogeneous group of poor prognosis patients in comparison to DSM-II schizophrenia. Educational level, age at first hospitalization, and work history were successful predictors of outcome (p less than .01) when a new, narrow concept of schizophrenia was used.     

Clinical subtypes of schizophrenic disorders: a cluster analytic study

Two hundred and fifty-five psychiatric inpatients with a definite diagnosis of DSM-IV schizophrenic disorder were examined by means of the Structured Clinical Interview and rated on the 30 main items of the Positive and Negative Syndrome Scale (PANSS). Patients' scores were subjected to a cluster analysis, using Ward's method. Cluster analysis indicated the existence of five groups. The first group (n = 46) comprised patients with overall psychopathology of minimal severity, the second group (n = 39) patients with severe positive symptoms along with symptoms of psychomotor excitement, the third group (n = 58) patients with severe positive psychopathology only, the fourth group (n = 34) patients with severe positive negative depressive and cognitive symptoms and, finally, the fifth group (n = 78) patients with severe negative symptoms only. Patients in the first and third groups were older and their illnesses were of longer duration compared to those of the remaining groups. With respect to DSM-IV clinical types of schizophrenic disorders, the paranoid type predominated in the second and the third groups, whereas the disorganized and catatonic types were markedly overpresented in the fifth group.     

The impact of diagnostic criteria on the prevalence of schizophrenic subtypes

The distribution of schizophrenic subtypes shows a high range of cross-cultural and historical variations. Our study aimed to investigate the effect of different diagnostic criteria on the prevalence of schizophrenic subtypes. A sample of 220 consecutively admitted schizophrenic patients from 3 different psychiatric institutions was classified according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, International Statistical Classification of Diseases, 10th Revision, and Bleuler's and Leonhard's criteria. Especially, the frequency of catatonic (10%-22%) and hebephrenic (5%-20%) subtypes of schizophrenia varied within a broad range depending on the diagnostic system applied. The comparison of International Statistical Classification of Diseases, 10th Revision and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition with "classical" criteria (Bleuler, Leonhard) for the different schizophrenic subtypes showed a reduction of typical symptoms and the introduction of criteria of prominence during the last century. These changes caused 2 trajectories ("paranoidization" and "shift into residual categories") explaining these cross-sectional variations.     

Eleven-year clinical outcome of schizophrenia in Bali

OBJECTIVE: To contrast the short-term and long-term outcome of schizophrenia in Bali. METHOD: The clinical outcomes of 46 schizophrenic patients (DSM-IV-TR) consecutively admitted to Bangli Mental Hospital were evaluated by Positive and Negative Syndrome Scale (PANSS) and Eguma's Social Adjustment Scale (ESAS) at a 11-year follow-up, which was subsequent to a 5-year follow-up. RESULTS: Neither the PANSS score nor the ESAS score were significantly different, and there was a significant correlation between the two follow-up data. Subjects categorized into either the best or worst outcome group at the 5-year follow-up tended to be classified into the same category at the 11-year follow-up more often than those who were categorized into the medium outcome groups at the 5-year follow-up. CONCLUSION: The 5-year outcome of schizophrenia strongly predicted the 11-year outcome, especially for subjects who had gone into either a remissive or severe deterioration state within 5 years.