Long-term follow-up of patients with a diagnosis of paranoid state and hospitalized, 1913 to 1940

From a sample of 239 patients diagnosed paranoid state and hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied a group of 60 patients without previous hospitalizations, consisting of 57 patients with follow-ups of 5 or more years, and 3 patients who killed themselves (the ultimate follow-up) less than 1 year after discharge. These 60 patients had been retrospectively diagnosed with delusional disorders by DSM-IV criteria. On follow-up, 27% were rated recovered, whereas 52% were rated unimproved. Long-term follow-up was correlated with discharge status. Poor follow-up was significantly correlated with seclusive personality, poor premorbid history, onset 6 months or more before admission, gradual onset, lack of insight, single marital status, and lack of precipitating events. A prognostic scale constructed from the first four of these variables was predictive of long-term outcome. More recent, better treatment results have been contrasted with these findings from an earlier non-drug-treatment era.     

精神分裂症的抑郁症状及其与疗效的关系

目的了解急性期住院精神分裂症患者伴发抑郁症状的影响因素以及抑郁症状与治疗结果间的关系。方法对符合CCMD-3诊断标准的精神分裂症患者75例,分别于入院3天内及每2周评定PANSS、HAMD、TESS量表,持续8周。结果偏执型精神分裂症、多次住院、年龄较小、受教育的时间较少者易出现抑郁症状。治疗后汉密顿抑郁量表总分与一般精神病理量表、抑郁症状群、TESS正相关。治疗前HAMD评分与治疗8周末PANSS总分减分率正相关。结论精神分裂症不同阶段抑郁症状的发生率不同,急性期精神症状与抑郁症状同时出现时,患者的治疗效果较好。偏执型精神分裂症、多次住院、年龄较小、受教育的时间较少是分裂症患者出现抑郁症状的危险因素。     

Validation of Danish case register diagnosis for schizophrenia

The ABC schizophrenia study aims at investigating sex differences in age of onset, symptoms and course of schizophrenic and paranoid disorders. For this purpose, we used case register data from Denmark and Mannheim and a directly examined sample of first admissions (ABC sample). The Danish case register sample included less clinical diagnoses of schizophrenia and more schizophrenia-related disorders (acute paranoid reaction, paranoid states and borderline schizophrenia) than the Mannheim data (case register and ABC sample). The problem therefore was whether the two datasets are comparable and the results are valid. For this reason a randomized, stratified sample of 116 patients was drawn from the Danish case register sample. The case notes of these 116 patients were requested from the hospitals where the patients had been treated and analyzed by means of a scoring sheet based on the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). The use of operationalized diagnoses of the CATEGO program, based on PSE items, which are integrated in IRAOS, demonstrated that the samples of the Danish and the Mannheim case registers and the directly investigated ABC sample have comparable diagnostic distributions. Possible explanations for the differences between the clinical and the CATEGO diagnoses in the Danish case register may be the frequent use of diagnoses of borderline schizophrenia and reactive psychoses (previously called psychogenic psychoses), and above all a more narrow concept of schizophrenia; in Denmark, schizophrenia is diagnosed relatively late, i.e., after the presence of enduring negative symptoms, and thus mostly after the appearance of residual state. These diagnostic preferences may help to explain the fall in first admission rates for schizophrenia – above all in women – in Denmark and the low incidence rates of schizophrenia by first contact within the WHO determinants of outcome study. The earlier hospitalization of men could be replicated as well as the course of treatment (readmissions and discharges) of schizophrenic men and women over 10 years after first admission.     

Schizophrenia and age

The association of age with time of onset, symptomatology and early course of schizophrenia was studied on a large, representative sample of first-admitted patients with a diagnosis of schizophrenia (nuclear and related diagnoses) from a total population of about 1.5 million by using a semi-structured interview (IRAOS) developed specifically for this purpose. As a result an age distribution differing between men and women was obtained when the appearance of the first sign of a mental disturbance was studied. 61.6% of the men and 47.4% of the women fell ill prior to the age of 25. Negative symptoms and the early course of the disease turned out to be relatively independent of age at onset. The few age differences observed with positive and unspecific symptoms seem to be accounted for by factors not specific for schizophrenia, such as slightly increased anxiety at young age, slightly increased depressiveness in early adulthood and slightly increased paranoid delusions later in adulthood. At young age delusional symptoms, probably as an expression of immature personality, are less stable, less differentiated and less systematized, whereas fully developed delusions of persecution become more frequent at higher age. An unexpected finding was a comparatively high proportion of lengthy phases characterized by negative symptoms prior to first admission in late-onset schizophrenia in females. Hence, beginning schizophrenia seems to be a fairly uniform pattern of response at all ages, female sex appearing to be the only factor independent of the disease that influences it to any significant extent by delaying onset.     

Manic-depressive patients with delusions. Clinical and diagnostic course

A study was made of the hospital records of 114 first admission patients under 60 years with a diagnosis of manic-depressive psychosis and coexisting paranoid symptoms. The male/female ratio was 1/1.4, and the females were significantly older. Symptomatology and treatment are presented. Seventy per cent disclosed delusions of reference and misinterpretation and 50% had synthymic delusions. During 11-15 years of admission 75% of the patients were re-admitted. The diagnostic concept was changed in 33%. Significantly more females were diagnosed unipolar manic-depressive. According to the general practitioners and hospital records psychotic traits were still present in 50% of the patients at follow-up. Significantly more patients diagnosed as unipolar manic-depressive had no relapse and no remaining psychotic traits. And significantly more patients with changed diagnosis had remaining psychotic traits. The need for prospective studies of patients with coexisting affective and paranoid symptomatology is stressed.     

Positive and negative subtypes in acute schizophrenia

This study examined the validity of the positive-negative dimension for the subtyping of young acute schizophrenics with under two years of illness. From a survey of 37 consecutively admitted acute schizophrenic inpatients with a mean age of 23.6 years, 9 were classified as having a positive syndrome and 8 a negative syndrome. They were compared on multiple psychopathological ratings, an affect scale, a test of attention and psychomotor rate, demographic, historic, and treatment variables, and drug side effects. A significant inverse relationship between positive and negative symptoms was found. The two groups were reliably distinguished on most criterion symptoms. The positive schizophrenics more commonly carried a paranoid subdiagnosis and also rated higher on symptoms associated with paranoid status. The negative patients showed an accurnulation of deficit symptoms that included impairments in affect, social relations, spontaneous thinking, attention, and motorium. Premorbidly they had less education and poorer work adjustment. Demographic variables, age and mode of onset of illness, duration since onset, global psychopathology, prevalence of extrapyramidal symptoms, and neuroleptic doses were essentially comparable in both groups. The data supported the presentation of a negative syndrome among young acute schizophrenics and its distinction from the positive subtype. The negative syndrome apparently was not secondary to progression of the disorder, prolonged institutionalization, severity of illness, neuroleptic dosage, or drug side effects. Processes accounting for the differentiation of these two syndromes early in the course of illness were discussed in the relation to developmental and biochemical hypotheses.     

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.     

Prediction of first episode of clinical depression in patients newly admitted to a medical long-term care facility: Findings from a prospective study

A cohort of 104 patients newly admitted to a medical long-term care facility was studied over 1 year for evolution of depression. Seven variables that were associated with level of depression were used in discriminant function analyses. Results showed that the variables had about 90% accuracy in predicting depressed versus non-depressed groups with good sensitivity and specificity. The variables measured: coping with admission; life satisfaction at admission; affective and non-affective symptoms at admission; clinical health status after admission; friends in hospital after admission; and changes in affective symptoms after admission before the onset of depression.     

Patterns of response to neuroleptic treatment: factors influencing the amelioration of individual symptoms in psychotic patients

Fifty-three patients with acute psychotic disorders (diagnosed according to DSM-III) were treated with thioridazine alone and observed during periods of up to 2 months. The amelioration of paranoid ideas and hallucinations (target symptoms) and of concentration difficulties, disorientation, reduced appetite, and reduced sleep (additional symptoms) was studied by repeated psychopathology ratings (CPRS). The patients were classified as "fast, slow or partial responders" according to the therapeutic effect registered on each target symptom. Paranoid ideas disappeared completely after less than 3 weeks of treatment in 28% of the patients (fast responders) and after more than 3 weeks in 32% (slow responders). Hallucinations disappeared significantly faster than paranoid ideas; 47% of the patients were completely free from hallucinations after less than 2 weeks of treatment (fast responders) and 38% after more than 2 weeks (slow responders). The following factors were significantly correlated to positive treatment effects of thioridazine: 1) diagnosis involving a brief history of psychotic symptoms before admission; 2) a low CPRS score for paranoid ideas on admission; 3) presence of disorientation on admission; 4) normal appetite on admission, and 5) rapidly reached optimal serum concentration of the drug.     

The relationship of demographic, clinical, and outcome variables to neuroleptic treatment requirements

A retrospective study of 61 acute schizophrenic patients examined whether any demographic, clinical, and outcome characteristics distinguished patients who improved with placebo or low dosages of antipsychotics (PLD patients) from patients who required high conventional dosages of antipsychotics (HCD patients). Patients in the PLD group (n = 30) and HCD group (n = 31) were similar in overall level of psychopathology at admission. Prominent excitement and certain somatic and auditory hallucinations were significantly more frequent in the HCD patients. PLD patients were more likely to be female, were hospitalized more rapidly after the onset of psychosis, and were more often first admissions. Although paranoid symptoms and premorbid schizoid personality did not differentiate the two groups, nonschizoid patients who were nonparanoid tended to be in the PLD group while nonschizoid patients who were paranoid tended to be in the HCD group. PLD patients were less psychotic at discharge, remained out of the hospital for longer periods, and had fewer rehospitalizations. These results confirm other reports of better outcome for patients successfully treated without medication. PLD patients were also functioning better as family members 1 year after discharge. Further research is indicated to improve the prediction of which acute psychotic patients will respond without medication or to low dose neuroleptic treatment and to determine if these predictions are generalizable to other treatment settings.     

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.     

Immunoglobulins,psychopathology and prognosis in schizophrenia

On admission, IgA, IgG and IgM concentrations were determined in 76 schizophrenics, and the correlations of these concentrations to the variables relating to psychopathology, background and prognosis were investigated in the present study, which is a part of a more extensive unpublished study. On the basis of factorization, the highest IgM concentrations were found in withdrawn schizophrenics and the lowest in paranoid schizophrenics. Of the background variables, the patient's present age had a positive correlation and his place of birth (rural-urban) a negative correlation to IgA concentrations, both being at a statistically significant level. IgA and IgM values higher than average at the beginning of treatment predicted a short hospital stay. Earlier, these patients had also needed little hospital care in relation to the duration of the disease. A hypothesis based on the results is presented, according to which a different way of reacting to stress may explain the differences in IgM concentrations in withdrawn and paranoid schizophrenics. The connection between prognosis and immunoglobulins was considered at least partially explainable on the grounds of age at the onset of the disease.     

Symptom patterns and subgrouping of schizophrenic patients: significance of negative symptoms assessed on admission

This study subgroups schizophrenic patients based on symptoms assessed on admission and examines the validity of the subgrouping using follow-up data and other clinical outcome variables. Schizophrenic patients (n=163) from consecutive admission received ratings on the positive and negative syndrome scale (PANSS) on admission and during a 1-year follow-up course. An exploratory graphic analysis on the admission PANSS derived four symptom dimensions: negative symptoms, disorganized thought, hostility/excitement and delusions/hallucinations. This yielded two subgroups of patients on admission, a group with marked negative (GWNEG) and a group without marked negative (GONEG) symptoms. Compared with the GONEG, the GWNEG had a poorer recovery rate, more impairment in attention, a slower response of the delusion/hallucination symptoms to neuroleptic treatment and a longer duration of index hospitalization. At a one-year follow-up, the GWNEG assessed on admission had persistently higher scores on the negative symptom and disorganized thought syndromes, less relapse rate, a shorter duration on job, as well as worse social functioning than the GONEG. Thus, the GONEG might comprise patients having a pure paranoid syndrome with quick and better treatment response, while the GWNEG comprises patients with the blunt-disorganization syndrome having a poorer outcome.     

Frequency of manic symptoms during a depressive episode and unipolar 'depressive mixed state' as bipolar spectrum

OBJECTIVE: To report the frequency of intra-episode manic symptoms in depressive episodes, and to evaluate unipolar depressive mixed state (DMS) as bipolar spectrum. METHOD: A total of 958 (863 unipolar, 25 bipolar II, and 70 bipolar I) depressive in-patients were assessed in terms of manic symptoms at admission, and several clinical variables using standardized methods. RESULTS: The frequency of manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility) was significantly higher in bipolar depressives than in unipolar depressives. Unipolar depressives with DMS - defined as having two or more manic symptoms - had more similarities to bipolar depressives than to other unipolar depressives in clinical variables such as onset age, family history of bipolar disorder, and possibly suicidality. CONCLUSION: Depressive mixed state is frequent, particular in bipolar depressives. Unipolar depressives with DMS may be better classified into bipolar spectrum.     

Acute paranoid psychotic symptoms after i.m. injection of nandrolone

Affective disorders and impulsivity are quite common when using anabolic substances, in this case-study one of the rather rare cases of a psychotic disorder following the abuse of androgenic steroids is described. A 30-year old formerly healthy white male was admitted as inpatient to psychiatric hospital showing symptoms of anxiety and paranoid ideation. In the last 1.5 years he had consumed androgenic steroids, directly before the onset of the first psychotic symptoms 8 weeks before admission he had received an i.m.-injection of nandrolone. Under therapy with neuroleptics the patient recovered completely within 2 months.     

Clinical correlates of first-episode polarity in bipolar disorder

OBJECTIVE: To determine the clinical and long-term implications of mood polarity at illness onset. METHODS: During a 10-year follow-up prospective study, systematic clinical and outcome data were collected from 300 bipolar I and II patients. The sample was split into 2 groups according to the polarity of the onset episode (depressive onset [DO] vs manic/hypomanic onset [MO]). Clinical features and social functioning were compared between the 2 groups of patients. RESULTS: In our sample, 67% of the patients experienced a depressive onset. Depressive onset patients were more chronic than MO patients, with a higher number of total episodes and a longer duration of illness. Depressive onset patients experienced a higher number of depressive episodes than MO patients, who in turn had more manic episodes. Depressive onset patients made more suicide attempts, had a later illness onset, were less often hospitalized, and were less likely to develop psychotic symptoms. Depressive onset was more prevalent among bipolar II patients. Bipolar I patients with DO had more axis II comorbidity and were more susceptible to have a history of psychotic symptoms than bipolar II patients with DO. CONCLUSION: The polarity at onset is a good predictor of the polarity of subsequent episodes over time. A depressive onset is twice as frequent as MO and carries more chronicity and cyclicity.     

强迫症与分裂型障碍共病的临床研究

目的调查强迫症患者的分裂型症状以及分裂型障碍共病发生比率并探讨伴有分裂型障碍的强迫症的临床特点。方法201例门诊强迫症患者,符合ICD-10与DSM-IV强迫症诊断标准,进行强迫症相关的一系列临床评定和ICD-10分裂型障碍症状评定,并分析分裂型症状与临床变量的关系,然后对伴有分裂型障碍的强迫症和单纯强迫症进行临床对照。结果31.3%(63/201)强迫症患者伴有3条或3条以上的分裂型障碍症状,28.4%(57/201)的强迫症患者同时存在ICD-10分裂型障碍。在9条ICD-10分裂型障碍症状中出现率比较高的依次是无内在阻力的强迫思维、古怪的信念或巫术性思想、不寻常的知觉体验、思维形式障碍(如赘述)等。有短暂的幻觉或妄想样信念者占9%。相关分析显示分裂型症状与强迫症状荒谬性(r=0.699,P<0.001)、抵抗力弱(r=0.5,P<0.001)、自知力不良(r=0.453,P<0.001)、残疾程度(r=0.328,P<0.001)等临床变量正相关。与单纯强迫症相比,伴有分裂型障碍者起病相对较急(P<0.05)、强迫症状比较荒谬、患者对症状顺从、自知力差、病情与社会功能障碍较重(P<0.001)。结论部分强迫症患者同时存在分裂型症状并符合分裂型障碍的诊断标准,分裂型症状与强迫症的某些临床特点相关,伴有分裂型障碍的强迫症倾向强迫症状荒谬、患者对症状抵抗较弱、自知力不良、病情较严重、社会功能损害较重。     

The association between social phobia, social anxiety cognitions and paranoid symptoms

Schutters SIJ, Dominguez M‐d‐G, Knappe S, Lieb R, van Os J, Schruers KRJ, Wittchen H‐U. The association between social phobia, social anxiety cognitions and paranoid symptoms. Objective: Previous research suggests high levels of comorbidity between social phobia and paranoid symptoms, although the nature of this association remains unclear. Method: Data were derived from the Early Developmental Stages of Psychopathology study, a 10‐year longitudinal study in a representative German community sample of 3021 participants aged 14–24 years at baseline. The Munich‐Composite International Diagnostic Interview was used to assess social phobia and paranoid symptoms, along with data on social phobia features. Cross‐sectional and longitudinal analyses were conducted. Differential associations with environmental risk factors and temperamental traits were investigated. Results: Lifetime social phobia and paranoid symptoms were associated with each other cross‐sectionally (OR = 1.80, 95% CI = 1.31–2.47). Lifetime paranoid symptoms were associated specifically with social anxiety cognitions. Lifetime cognitions of negative evaluation predicted later onset of paranoid symptoms, whereas onset of social phobia was predicted by cognitions of loss of control and fear/avoidance of social situations. Lifetime social phobia and paranoid symptoms shared temperamental traits of behavioural inhibition, but differed in environmental risks. Conclusions: The present study showed that paranoid symptoms and social phobia share similarities in cognitive profile and inhibited temperament. Avoidance appears to be important in the development of social phobia, whereas cannabis use and traumatic experiences may drive paranoid thinking in vulnerable individuals.     

Clinical features of illness in siblings with schizophrenia or schizoaffective disorder

Evidence implicating genetic or prenatal-perinatal environmental causes in the familial aggregation of schizophrenia led us to study 53 sets of siblings, two or more of whom had chronic psychosis, either schizophrenia or schizoaffective disorder. We looked for similarities in clinical features and concordance of diagnosis within sibships to test for shared familial causes. Clinical variables, including diagnosis, specific symptoms, age at onset, and nongenetic perinatal factors, were studied. Auditory hallucinations, paranoid delusions, thought disorder, negative symptoms, and poor premorbid social adjustment did not significantly correlate in siblings. Concordance was found for schizoaffective disorder and history of major depressive episodes, suggesting that schizophrenia with a depressive component and Research Diagnostic Criteria schizoaffective illness may represent a specific etiologic subtype(s) of the illness, whereas the other noted symptoms may represent the variable expression of the disorder. Age at onset and at first hospitalization were significantly correlated, consistent with genetic or other familial factors on time of onset. Birth complications were significantly more frequent among the schizophrenic compared with non-psychotic siblings, had a familial component, and tended to be associated with an earlier age at onset. Thus, nongenetic perinatal factors may increase the risk for schizophrenia in a familial form of the illness and contribute to the correlation of ages at onset in siblings.     

Non-cognitive psychiatric symptoms in vascular and Alzheimer brain disease

Psychiatric symptoms, other than dementia, are compared in two groups of mental hospital patients who came to autopsy and had complete brain examination. One group had Alzheimer brain changes with no cerebral infarction. The other group had cerebral infarction with no Alzheimer brain changes. Onset with a non-dementing paranoid illness after the age of 50 was commoner in the Alzheimer group. There was no predominance of affective symptoms in either group. Suddenness of onset of psychosis distinguished the infarct cases, even in cases where there was no neurologically evident stroke, and when there were long time intervals between onset and death. Those destined to suffer Alzheimer brain changes had a less sudden onset, fewer discharges and rehospitalizations and more frequent transition to dementia.§