Computed tomography of the brain in patients with acute psychosis and in healthy volunteers

Evidence has been obtained by computed tomography (CT) that some chronic schizophrenic patients have enlarged cerebral ventricles and other brain abnormalities when compared to other patient groups and to healthy controls (Johnstone et al. (1976), Weinberger et al. (1979)). In order to investigate whether structural brain abnormalities can be demonstrated also in younger patients with acute psychosis we have undertaken a CT study in 46 patients and 46 healthy volunteers. Twenty-eight of the patients fulfilled the Research Diagnostic Criteria for schizophrenia. Nineteen had not been hospitalized for psychiatric reasons before. The lateral and third ventricles were significantly wider in the patients than in the volunteers. In the volunteers there was a significant positive correlation between age and size of the lateral ventricles, whereas in the patients, particularly those fulfilling the criteria for schizophrenia, no such correlation was obtained. These results indicate that schizophrenia may be associated with pathophysiological processes which interfere with the normal age-related enlargement of the ventricles. Signs of cortical atrophy, CSF circulation disturbances and reversed asymmetry of the occipital lobes were more frequent in the patient group than among the controls. These results are in accordance with previously published findings and indicate that structural brain abnormalities can be found in relatively young patients with acute psychosis.     

Computerized tomography of the brain in schizophrenic patients

Computer tomography (CT) of the brain was carried out in 49 schizophrenic patients and 38 controls in order to study the organic characteristics of the brain in schizophrenia. Between the schizophrenic and control groups aged 21 to 40 years, there was no marked difference in ventricular size or cortical atrophy. In the groups aged 41 to 60 years, however, enlargement of the ventricular system and cortical atrophy were highly significant in the schizophrenic group. Positive correlation was observed (P < 0.05) between enlargement of the third ventricle and duration of illness. There was a high frequency of cortical atrophy in the frontal and temporal lobes in the schizophrenic group.     

Aggression in Asian patients with first-episode psychosis

AIMS: The aims of this study were to examine the prevalence and severity of aggression in patients with first-episode psychosis and to identify the association between aggression and sociodemographic and clinical factors. METHODS: Consecutive patients with first-episode psychosis admitted to the Early Psychosis Intervention Programme, Singapore, were assessed for a history of aggressive acts. Diagnosis was confirmed using the Structured Clinical Interview for DSM-IV and psychopathology was assessed using PANSS. RESULTS: Of the 146 patients, 63.0% had no history of aggressive acts, 13.7% demonstrated severe aggression (defined as weapon use, sexual assault or victim injury) and 23.3% had lesser aggression (all other acts of aggression). Patients with aggression had a significantly longer duration of untreated psychosis (DUP) than those with no history of aggression (p = .01). The mean total PANSS scores did not differ significantly among the three groups. However, the General Psychopathology scores and the scores for 'hostility', 'poor impulse control', 'lack of insight and judgement' and 'somatic concern' were all significantly elevated in patients with aggression (p < .05). CONCLUSION: The significant association between aggression and longer DUP once again reiterates the need for early detection and effective management of first-episode psychosis.     

Untreated initial psychosis: relation to cognitive deficits and brain morphology in first-episode schizophrenia

OBJECTIVE: Studies of patients experiencing their first episode of psychosis have demonstrated that they typically remain undiagnosed and untreated for 1-2 years. It has been postulated that prolonged untreated psychosis may have serious effects: poor response to neuroleptic medications, poor clinical outcomes, and direct neurotoxicity. This study investigated the relationships between duration of untreated initial psychosis and neurocognitive functioning and high-resolution imaging brain measurements. METHOD: A total of 156 subjects with DSM-IV schizophrenia, schizophreniform disorder, or schizoaffective disorder were evaluated during their first episode of psychosis. Measurements included nine domains of neurocognitive functioning, volumetric measures of total brain tissue, gray and white matter, and CSF, and measures of brain surface anatomy. RESULTS: The mean duration of untreated initial psychosis was 74.3 weeks. Correlations between neurocognitive functioning, brain volumetric measurements, and surface anatomy measurements with duration of untreated initial psychosis were weak; none reached statistical significance. When the group was divided on the basis of median duration of untreated initial psychosis, there were again no significant differences between the groups with long and short duration of untreated initial psychosis except on two measures (verbal memory and cortical sulcal depth). CONCLUSIONS: The absence of strong correlations suggests that untreated initial psychosis has no direct toxic neural effects. These results suggest that large-scale initiatives designed to prevent neural injury through early intervention in the prepsychotic or early psychosis phase may be based on incorrect assumptions that neurotoxicity or cognitive deterioration may be avoided. Nevertheless, early treatment is justified because it reduces suffering.     

Assessment of posttraumatic symptoms in patients with first-episode psychosis

Posttraumatic stress disorder is common among patients with psychotic disorders. The present study examined the internal reliability and comparability of the Impact of Event Scale (IES) in a sample of 38 patients with first-episode psychosis and 47 controls exposed to severe physical and/or sexual abuse. The IES total score and both subscales showed high internal consistency in both groups (Cronbach's alpha coefficients of approximately 0.9 or higher). Given their equivalent trauma reporting, the lack of differences in IES scores between patients and controls seems to indicate that patients are likely to report accurately and neither exaggerate nor minimize their posttraumatic symptoms. Overall, the findings suggest that the IES can be used to assess symptoms of posttraumatic stress in patients with psychotic disorders as in other populations.     

'Social dysmetria' in first-episode psychosis patients

Waters F, Rock D, Dragovic M, Jablensky A. ‘Social dysmetria’ in first‐episode psychosis patients. Objective: The ‘embodied cognition’ hypothesis suggests a close relationship between internal self‐representations and the outward expression of social behaviours and emotions. Given self‐awareness disturbances in patients with first‐rank symptoms (FRS), we hypothesized that these patients would show abnormal social behaviours. In this study, we examined the social interactive skills of patients with first‐episode psychosis during an interview, together with changes in performance over time. Method: We analysed previously unreported data from 227 patients with first‐episode psychosis (90 with, and 137 without, FRS) who took part in the WHO multicentre study on the Determinants of Outcome of Severe Mental Disorders. They were assessed on the Psychological Impairment Rating Schedule (PIRS) and examined again after 2 years. Results: A principal component analysis on the Psychosocial Impairment Rating Schedule produced two factors (interactive skills; withdrawal from interactions). Patients with FRS showed greater impairments in the domain linked to ‘interactive skills’, which remained 2 years after the first experience of a psychotic illness. These findings were not explained by clinical characteristics, or presence of non‐FRS delusions. Conclusion: Self‐awareness deficits, as indexed by the FRS symptom cluster, are linked to deficits in social interactive behaviours. These abnormalities are indicative of ‘social dysmetria’ in this group, which involves difficulties conveying motor aspects of behaviours, volition and affect to facilitate mutual communication. These findings point to the utility of behavioural assessment scales in clinical and research settings.     

Structural brain abnormalities in early onset first-episode psychosis

Summary Background. Brain morphometry in children and adolescents with first-episode psychosis offer a unique opportunity for pathogenetic investigations. Methods. We compared high-resolution 3D T1-weighted magnetic resonance images of the brain in 29 patients (schizophrenia, schizotypal disorder, delusional disorder or other non-organic psychosis), aged 10–18 to those of 29 matched controls, using optimized voxel-based morphometry. Results. Psychotic patients had frontal white matter abnormalities, but expected (regional) gray matter reductions were not observed. Post hoc analyses revealed that schizophrenia patients (n = 15) had significantly larger lateral ventricles as compared to controls. Duration and dose of antipsychotics correlated negatively with global gray matter volume in minimally medicated patients (n = 18). Conclusion. Findings of white matter changes and enlarged lateral ventricles already at illness onset in young schizophrenia spectrum patients, suggests aberrant neurodevelopmental processes in the pathogenesis of these disorders. Gray matter volume changes, however, appear not to be a key feature in early onset first-episode psychosis.     

Spontaneous parkinsonism in antipsychotic-naive patients with first-episode psychosis.

OBJECTIVE: The purpose of this study was to establish rates of spontaneous parkinsonism (SP) among the different types of psychosis. We hypothesized that the rate would be higher among persons with affective symptoms. METHODS: We included in the study consecutive patients admitted to a first-episode psychosis intervention program. We recorded sociodemographic data from interviews with patients and caregivers and from medical records. We used the Simpson-Angus Rating Scale at baseline to assess parkinsonism and a diagnosis of SP was established if the Simpson-Angus score was > or = 0.3. RESULTS: A total of 174 patients were examined; of these, only 4 (2.3%; 2 Chinese women, 1 Chinese man, and 1 Malay man) had SP. There was a significant difference in the rates of SP in patients with affective psychosis and schizoaffective disorder, compared with those with nonaffective psychoses (15.4% vs 1.2%; chi2 = 10.7, P = 0.001). The 2 groups did not differ significantly in age, duration of untreated psychosis, or sex distribution. CONCLUSIONS: The rate of SP in Asian patients with first-episode psychosis was low, and it was significantly higher in those with affective symptoms.     

首发精神分裂症患者就诊途径调查

目的：调查首发精神分裂症患者在精神病医院和非精神病医院就诊途径。方法：完成对71例首发患者及家属调查,包括人口学资料、非精神病专科就诊情况、延迟至精神科求助原因、精神科就诊途径及原因、精神病未治疗期病程等。结果：非精神科主要求助方式为宗教迷信和非专科医生;精神科求助途径主要为家属意愿;精神病未治疗期病程（DUP）中位数为6个月,未发现DUP与其他调查因素相关;造成延迟至精神科求助主要原因是患者及家属对精神卫生知识缺乏。结论：加强社区精神卫生知识宣传普及对于缩短DUP非常必要。     

首发精神分裂症患者5年随访研究

目的：探讨首发精神分裂症患者5年预后,生活质量及其相关影响因素。方法：采用自制的一般情况调蠢衷,阳性和阴性症状量表（PANSS）。健康状况调查问卷（SF-36）,家庭负担量表（FIS）对86例患者及其家属进行问卷调查。结果：男性患者生活质量中的角色功能的分值高于女性,而躯体疼痛和社会功能的分值女性明显高于男性患者。患者的PANSS总分和各因子分与躯体功能呈显著负相关,PANSS总分、阴性症状分以及一般精神病理分与患者生活质量中的角色功能、社会功能以及角色情绪因子呈显著负相关。患者生活质量中的生理机能、生理职能和情感职能因子分与FIS中的经济负担、对家庭日常活动的扰乱、对家庭娱乐活动的影响以及对家庭关系的影响之间存在明显的负相关。结论：经济状况、精神症状等因素是影响患者生活质量的重要因素。     

Computed tomography and pattern reversal visual evoked potentials in chronic schizophrenic patients

Eighteen chronic schizophrenic subjects treated with a uniform dosage (4-6 mg/day p.o.) of haloperidol were submitted to computed tomography (CT) and to pattern reversal visual evoked potentials (VEPs). Compared to age-matched controls, schizophrenic patients showed lateral and third ventricular enlargement, greatly delayed VEP latencies and reduced amplitudes. These abnormalities were not related to diagnostic subgroups. Schizophrenic patients with a positive family history for major psychiatric disorders showed normal CT scan measures and greatly abnormal VEP measures, whereas patients with a negative family history showed CT scan signs of atrophy and less pronounced VEP abnormalities.     

Symptomatic and functional remission in patients with first-episode psychosis

Verma S, Subramaniam M, Abdin E, Poon LY, Chong SA. Symptomatic and functional remission in patients with first‐episode psychosis. Objective: For patients suffering from psychotic disorders and their caregivers, ‘recovery’ remains important. Our study aims to examine the rates of both symptomatic and functional remission in first‐episode psychosis (FEP) patients at 2 years and identify sociodemographic and clinical factors associated with recovery. Method: In this naturalistic study, all consecutive FEP patients presenting to an early psychosis intervention programme were recruited. Symptomatic remission was defined by the Schizophrenia Working Group’s criteria; functional remission was defined as a Global Assessment of Functioning (GAF) disability score of ≥61 with engagement in age‐appropriate vocation. Simple and multiple logistic regressions using stepwise method were used. Results: Out of 1175 patients, 636 (54.1%) met criteria for symptomatic remission, 686 (58.4%) for functional remission, while 345 (29.4%) met for both. Multiple logistic regression revealed female gender (OR 1.47; 95%CI, 1.12–1.93), those married (OR 1.49; 95%CI, 1.02–2.18), younger age (OR 0.98; 95%CI, 0.95–0.99), tertiary education (OR 1.56; 95%CI, 1.02–2.38), shorter DUP (OR 0.99; 95%CI, 0.98–0.99), lower baseline PANSS negative scores (OR 0.97; 95%CI, 0.95–0.99), and early response at month 3 (OR 1.78; 95%CI, 1.31–2.42), as significant predictors of recovery at year 2. Conclusion: Our results indicate that strategies to reduce DUP and achieve early response could improve remission rates in FEP patients.     

Features of structural brain abnormality detected in first-episode psychosis

OBJECTIVE: Structural magnetic resonance imaging (MRI) studies that focus on first-episode psychosis avoid some common confounds, such as chronicity of illness, treatment effects, and long-term substance abuse. However, such studies may select subjects with poor short-term treatment response or outcome. In this study, the authors focus on structural brain abnormalities in never or minimally treated patients who underwent MRI scanning early in their first episode of psychosis. METHOD: The authors examined 37 patients (13 medication naive, 24 previously treated) who were experiencing their first episode of psychosis; the mean duration of symptoms was short (31 weeks). These patients were comparable in age, gender, handedness, ethnicity, and parental socioeconomic status to a group of 25 healthy comparison subjects. A three-dimensional, inversion recovery prepared, fast spoiled gradient/recall in the steady state scan of the whole brain that used 1.5-mm contiguous sections was performed to acquire a T(1)-weighted data set. Human ratings of volumetric measurement of brain structures were performed with stereological techniques on three-dimensional reconstructed MRIs. RESULTS: The patient group had significant deficits in cortical gray matter, temporal lobe gray matter, and whole brain volume as well as significant enlargement of the lateral and third ventricles. Structural deviations were found in both treatment-naive and minimally treated subjects. No relationships were found between any brain matter volumes and positive or negative symptoms. CONCLUSIONS: Structural brain abnormalities were distributed throughout the cortex with particular decrement evident in gray matter. This feature is consistent with altered cell structure and disturbed neuronal connectivity, which accounts for the functional abnormality of psychosis.     

Homocysteine and cognition in first-episode psychosis patients

In the last years, there has been growing evidence linking elevated homocysteine levels with cognitive dysfunction in several neurological and neuropsychiatric diseases. The aim of the present study was to investigate the potential relationship between elevated homocysteine levels and cognitive deficits in first-episode psychosis patients. Plasma levels and cognitive performance of 139 patients and 99 healthy volunteers were compared. Patients were classified as elevated homocysteine (>90 percentile for controls) and normal and compared on 22 cognitive outcome measures grouped into cognitive domains known to be impaired in schizophrenia. Patients had a statistically significant increase in plasmatic homocysteine levels. In addition, they presented with significantly increased cognitive deficits. However, no relationship between homocysteine levels and cognitive impairment was detected. These results suggest the need for further studies to clarify the role of homocysteine in the etiology and prognosis of psychosis.     

Cortical excitability in neuroleptic-naive first-episode schizophrenic patients

Transcranial magnetic stimulation (TMS) provides an intriguing in vivo method to investigate motor cortex excitability in men. This offers new insights into the neurophysiological basis of neuropsychiatric diseases. Earlier TMS studies in patients with schizophrenia revealed inconsistent results, probably due to major confounding variables like state of medication and stage of illness. To control for these effects, we studied two TMS paradigms in 21 drug-naive first-episode schizophrenic patients and 21 age- and sex-matched healthy controls. The patient group demonstrated a significant lower resting motor threshold as compared with healthy controls, whereas TMS paradigms of intracortical inhibition and intracortical facilitation failed to show significant differences between patients and controls. This pattern of TMS parameters is similar to that obtained in healthy volunteers investigated under increasing doses of ketamine, a central acting drug known to produce psychosis-like effects. In agreement with recent results of functional imaging, our neurophysiological findings suggest that drug-induced and naturally occurring psychosis may share a common pathway, which may base on dysfunctional glutamatergic mechanisms.     

Shortening of the hippocampal formation in first-episode schizophrenic patients

Abstract Shortening of hippocampal formation (HF) in chronic schizophrenic patients have been demonstrated in our previous study. The purpose of the present study is to test if shortening of the HF occurs in schizophrenic patients suffering their initial psychotic episode. We performed contiguous, 1 mm thick, magnetic resonance imaging scans in 20 first-episode schizophrenic patients, 21 chronic schizophrenic patients, and 25 healthy subjects. Both groups of schizophrenic patients demonstrated significant shortening of the HF compared with normal controls (first-episode schizophrenia, 5.3%; chronic schizophrenia, 8.0%). However, the HF length was not significantly different between the first-episode and chronic schizophrenic patients. No significant correlation was seen between the HF length and the duration of illness in chronic schizophrenic patients. These results suggest that the HF shortening observed in schizophrenic patients may be genetic and/or developmental in origin.     

早期干预对首发精神分裂症患者的影响

目的：探讨早期干预对首发精神分裂症患者疗效和社会功能康复的影响。方法：干预组为50例首发精神分裂症患者,在药物治疗同时辅以心理和社会综合干预措施,50例与之匹配的对照患者单用药物治疗。采用阳性症状和阴性症状量表(PANSS)及社会功能缺陷筛选量表(SDSS)分别进行随访评定。结果：干预组随访时PANSS阴性量表分的改善明显优于对照组;SDSS的职业和工作、家庭外社会活动、家庭职能、个人生活自理、责任性和计划性5项因子分的改善明显优于对照组。结论：早期干预措施有助于提高精神分裂症患者的疗效和促进社会功能的康复。