First-episode schizophreniform disorder: comparisons with first-episode schizophrenia

BACKGROUND: Schizophreniform disorder remains poorly understood and has been reported probably to be a heterogeneous group of psychotic disorders. METHOD: This study compared first-episode schizophreniform disorder (N=12) and schizophrenia (N=18) patients. The authors propose that schizophreniform disorder has a different type of onset and outcome than schizophrenia. Patients were given extensive assessments at initial evaluation, 6 month follow-up, and 24 month follow-up. Comparisons between the two groups were made on type of onset, demographic, clinical ratings and outcome variables. RESULTS: Patients with schizophreniform disorder compared to patients with schizophrenia were more likely to have an acute onset (P=0.003), and have recovered by 6 months (P=0.03). However, there were no differences in outcome at 24 months. Furthermore, all schizophreniform cases except for two were re-diagnosed at 24 months as having schizophrenia. CONCLUSIONS: The findings suggest that the initial differences of schizophreniform disorder compared to schizophrenia were not apparent at 24 months follow-up. Schizophreniform disorder did not emerge as a highly distinctive and stable form of psychosis that merits a diagnostic classification separate from schizophrenia.     

分裂样精神病6年随访研究

目的：探讨分裂样精神病（简称ＳＦＰ）诊断归属及临床特征。方法：对经过６年随访仍维持ＳＦＰ诊断的４３例的临床资料进行分析,并与改诊为精神下（简称ＳＰ）６５例作比较。结果：１１５例患者中维持ＳＦＰ诊断４３例（３７．４％）,改诊为ＳＰ６５例（５６．５％）,改诊为情感性精神障碍７例（６．１％）。ＳＦＰ患者与改诊为ＳＰ患者比较,具有病前性格多外向,多社会心理因素诱发,检查合作程度高,阳性症状多,阴性症状少,     

Diagnostic stability 2 years after treatment initiation in the early psychosis intervention programme in Singapore

OBJECTIVE: To evaluate the diagnostic stability of psychotic disorders over a 2 year period in patients presenting with first-episode psychosis. METHODS: One hundred and fifty-four patients were recruited from an early psychosis intervention programme (EPIP). They were diagnosed by the attending psychiatrist using the Structured Clinical Interview for DSM-IV Axis I at first contact (baseline) and after 24 months. The diagnoses were classified into the following categories: schizophrenia spectrum disorders (schizophrenia, schizophreniform disorder and schizoaffective disorder), affective psychosis (bipolar and major depressive disorders with psychotic symptoms), and other non-affective psychosis (delusional disorder, psychosis not otherwise specified and brief psychotic disorder). Two measures of stability, the prospective and the retrospective consistency were determined for each diagnosis. RESULTS: The diagnoses with the best prospective consistency were schizophrenia (87.0%) and affective psychosis (54.5%). The shift into schizophrenia spectrum disorder was the most frequent diagnostic change. Duration of untreated psychosis was found to be the only significant predictor of shift. CONCLUSION: It is difficult to make a definitive diagnosis at first contact. The clinical need to review the diagnosis throughout the period of follow up is emphasized.     

Growth hormone response to apomorphine and diagnosis: a comparison of three diagnostic systems

Our study takes a further look at the apomorphine test in the psychoses and affective disorders, with special reference to the use of different diagnostic systems. Patients meeting Research Diagnostic Criteria (RDC) for schizophrenia, schizoaffective disorder, or manic disorder were included. In addition to the RDC, diagnosis was also made using the DSM-III and ICD-9. All patients underwent an evaluation of peak GH response to apomorphine administration. The results show that RDC and ICD-9 are similar, in that for both systems, a high GH response correlates with a schizoaffective disorder and distinguishes those patients significantly from manic patients. The DMS-III brings in some new dimensions, in that schizophreniform disorder (6-month cut-off) is distinguished from schizophrenia. In addition, patients with affective symptoms and mood-incongruent psychoses are more closely related to schizophreniform disorder than to classical manic disorder.     

Outcome after 40 years in DSM-III schizophreniform disorder

In an earlier report, we described the course of the index episode and the family history of patients with schizophreniform disorder, schizophrenia, or affective disorder. Those data indicated that DSM-III schizophreniform disorder defined a heterogeneous group that bore a closer relationship to schizophrenia than to affective disorder. The present report extends the study of these same patients to a 40-year field follow-up. As the earlier short-term and family history findings predicted, marital, occupational, mental, and residential status ratings for the schizophreniform group assumed intermediate positions between those for patients with affective disorder and those for schizophrenics but fell closer to the latter. Contrary to the short-term outcome findings, the present data show no relationship between illness duration at index admission and outcome status ratings after 40 years.     

Boundaries of schizophrenia.

The frontiers of schizophrenia are being increasingly challenged from several directions. In addition to ongoing debate as to divisions between schizophrenia and disorders of the schizophrenic spectrum, including schizotypal personality disorder and schizophreniform disorder, it has been suggested that obsessive-compulsive disorder might overlap phenomenologically with schizophrenia. There has been a long debate around the relationship of schizophrenia to affective disorders, particularly bipolar and schizoaffective disorder. The evidence suggests that although schizotypal personality and schizophreniform disorders are not homogeneous syndromes, they are related to or represent milder forms of schizophrenia. Obsessive-compulsive disorder seems to involve pathology in many of the same regions as observed in some patients with schizophrenia, which may account for the significant incidence of obsessive-compulsive symptoms in a subset of patients with schizophrenia. Despite similarities between schizophrenia and bipolar disorder, significant differences extend across suggested causes, phenomenology, and pathophysiology. These findings support the current conceptualization that the two disorders represent distinct disorders, probably with heterogeneous causes, rather than the ends of a spectrum of symptoms comprising a single syndrome. Schizoaffective disorder likely is made up of patients from the schizophrenic and bipolar cluster of illnesses. The long-standing debate as to the boundaries of schizophrenia is ultimately must await the eventual further elaboration of the underlying causes of schizophrenia and other psychotic disorders.     

A follow-up and family study of DSM-III-R schizophreniform disorder with good prognostic features

A follow-up and family study was carried out of 16 first episode, DSM-III-R schizophreniform disorder patients with good prognostic features. Mean length of follow-up was 52.3 months. It was found that 62.5% had affective episodes, 31.2% had schizophreniform episodes. No case of schizophrenia was observed. Outcome was good. Morbid risk for affective disorder among first degree relatives was 25%, morbid risk for schizophrenia was 0%. These findings suggest a link between DSM-III-R schizophreniform disorder with good prognostic features and affective disorder, and no relationship with schizophrenia.     

Nosological status of the intermediate area between schizophrenia and affective disorder]

Non-organic psychoses diagnosed with neither schizophrenia nor affective disorder are an aggregation of heterogeneous psychotic disorders including major groups such as acute polymorphic psychotic disorders and schizoaffective disorders. Historically, similar psychotic pictures have been reported in various cultures. However, their slightly different definition hindered comparative studies. Even after the establishment of an operational diagnostic guideline such as ICD-10, epidemiological studies on this intermediate area between schizophrenia and affective disorder have brought different findings, making the reliability of diagnosis of this area questionable. Moreover, the situation is further complicated that there exists not only cases which have repeated the same episode as the first, but also cases whereby the diagnosis has been changed to schizophrenia or affective disorder over a long-term course. K. Schneider, who suggested not differential diagnosis but differential typology in the area of endogenous psychoses, is right in thinking of the existence of this intermediate area. We should be satisfied with making a provisional diagnosis, should take a flexible attitude towards changes in diagnosis between episodes. And during diagnosis, we should not differentiate schizophrenia from affective disorders rigidly, nor define the intermediate area strictly.     

Diagnostic specificity of the insular cortex abnormalities in first-episode psychotic disorders

Volume reductions of the insular cortex have been described in schizophrenia, but it remains unclear whether other psychotic disorders such as affective psychosis also exhibit insular cortex abnormalities. In this study, we used magnetic resonance imaging to investigate the gray matter volume of the anterior (short) and posterior (long) insular cortices in 162 first-episode patients with various psychotic disorders (46 schizophrenia, 57 schizophreniform disorder, 34 affective psychosis, and 25 other psychoses) and 62 age- and gender-matched healthy comparison subjects. Patients with schizophrenia showed bilateral volume reduction of the anterior and posterior insular cortices compared with controls, but the remaining first-episode psychosis subgroups had normal insular volumes. The volumes of these insular subregions were significantly smaller in schizophrenia patients than in patients with schizophreniform disorder or affective psychoses. There was no association between the insular cortex volume and daily dosage or type of antipsychotic medication in any patient group. These findings suggest that the widespread volume reduction of the insular cortex is specific to established schizophrenia, implicating its role in the neurobiology of clinical characteristics associated with schizophrenia.     

Diagnostic stability 18 months after treatment initiation for first-episode psychosis

OBJECTIVES: (1) Assessment of diagnostic stability of psychotic disorders or psychotic mood disorders from 6 weeks to 18 months after initiation of treatment in a representative first-episode psychosis (FEP) sample. (2) Comparison between those patients who shifted from DSM-IV schizophreniform disorder to schizophrenia or schizo-affective disorder and those whose diagnosis of schizophreniform disorder remained stable. METHOD: The Early Psychosis Prevention and Intervention Centre (EPPIC) in Australia admitted 786 FEP patients from January 1998 to December 2000. Data were collected from patients' medical records (MRs) using a standardized questionnaire. Seven hundred four MRs were available, 36 of which were excluded owing to nonpsychotic diagnoses or a psychotic disorder due to a general medical condition. Of the remaining 668 patients, 176 (26.3%) were lost to follow-up. Four hundred ninety-two subjects were analyzed. Strategies to assure validity and reliability of diagnoses were applied. RESULTS: The same diagnosis was made at baseline (< or = 6 weeks after admission into EPPIC) and 18 months for 69.9% of the patients. Among the most consistent diagnoses were schizophrenia (97.3%), schizoaffective disorder (94.1%), and bipolar disorder (83.2%); the least stable, as expected, was schizophreniform disorder (40.0%). In subjects with schizophreniform disorder at baseline, the best predictors of a shift from schizophreniform disorder to schizophrenia or schizoaffective disorder were a higher baseline Clinical Global Impressions-Severity of Illness scale score and lower premorbid Global Assessment of Functioning score, although the variance accounted for was small (R2 = .07). CONCLUSIONS: A longitudinally based diagnostic process in FEP samples is needed, especially in schizophreniform disorder and bipolar disorder. However, a thorough initial assessment of patient and family by a specialized team of investigators regarding the kind and duration of patient symptoms may lead to high diagnostic stability, especially in schizophrenia and schizoaffective disorder, even in a FEP sample with a relatively short duration of untreated psychosis.     

Stability of olfactory identification deficits in neuroleptic-naive patients with first-episode psychosis

OBJECTIVE: Olfactory identification deficits and their relationship to negative symptoms in patients with schizophrenia were examined in patients with recent-onset psychosis, the majority of whom were neuroleptic naive. METHOD: Seventy-four inpatients with a first episode of psychosis (27 with schizophrenia or schizophreniform disorder, nine with schizoaffective disorder, 17 with affective psychoses, and 21 with other psychoses), 49 of whom had not received antipsychotic medication, were compared to 38 age- and gender-matched normal subjects. Olfactory identification ability was assessed with the University of Pennsylvania Smell Identification Test. Forty patients and 13 comparison subjects were reassessed at 6 months to examine whether olfactory deficits were specific to schizophrenia or schizophreniform disorder and were stable over time. RESULTS: At baseline, the patients had significant impairment in olfactory identification ability compared to the normal subjects. This difference persisted after controlling for gender, premorbid or current IQ, smoking history, cannabis use, or the effects of medication. Diagnostic subgroups did not differ in olfactory identification ability. The deficits remained stable at 6-month follow-up and were associated with negative symptoms at both time points. No relationship was found between olfactory identification ability and length of either untreated psychosis or illness prodrome. CONCLUSIONS: Impairment in olfactory identification ability was apparent from the outset of psychotic illness and was not specific to schizophrenia or schizophreniform disorder. No change in the degree of this deficit was found after patients were stabilized and had responded to medication. The deficit could not be explained by peripheral factors that might contribute to olfactory identification ability, suggesting that it reflects central mechanisms.     

Relationship of lateral ventricular size to psychophysiological measures and short-term outcome

To examine clinical and psychophysiological correlates of lateral ventricular size, computerized tomographic (CT) scans were obtained on a sample of 88 patients who had experienced their first psychotic episode. Patients met DSM-III criteria for schizophrenia, schizophreniform disorder, or affective disorder with psychotic features. For patients with schizophrenia, large lateral ventricles were associated with unfavorable outcome. No association between outcome and ventricular size was found in patients with affective or schizophreniform disorder. Patients with mood disorders who had large ventricles consumed significantly greater amounts of alcohol than those with small ventricles. No differences were found between patients with large or small ventricles in premorbid functioning, smooth pursuit eye tracking, or electrodermal activity.     

An MRI study of the superior temporal subregions in first-episode patients with various psychotic disorders

Morphologic abnormalities of the superior temporal gyrus (STG) have been reported in schizophrenia, but have not been extensively studied in other psychotic disorders such as affective psychosis. In the present study, magnetic resonance imaging was used to examine the volumes of the STG and its subregions [planum polare (PP), Heschl gyrus (HG), planum temporale (PT), rostral STG, and caudal STG] in 162 first-episode patients with various psychotic disorders [46 schizophrenia (31 schizophrenia and 15 schizoaffective disorder), 57 schizophreniform disorder, 34 affective psychosis, and 25 other psychoses] and 62 age- and sex-matched healthy controls. The first-episode schizophrenia patients had significantly less gray matter in HG, PT, and caudal STG bilaterally compared with all other groups, but there was no difference between the controls and affective psychosis, schizophreniform disorder, or other psychoses for any STG subregion. The STG white matter volume did not differ between groups. Our findings indicate that morphologic abnormalities of the STG gray matter are specific to schizophrenia among various psychotic disorders, implicating its role in the underlying pathophysiology of schizophrenia.     

The reliability of psychiatric diagnosis in Israel's Psychiatric Case Register

To determine the reliability of psychiatric diagnoses in the Israel Psychiatric Case Register, DSM-III criteria were applied to case record abstracts of first admissions to a large psychiatric hospital in Jerusalem. The DSM-III diagnoses were compared with ICD-8 records diagnoses. Between 40 and 50% of those originally diagnosed as schizophrenia were re-diagnosed into less severe categories. The proportion diagnosed as affective disorder doubled from 21% for ICD-8 diagnoses to 40% for DSM-III diagnoses. The unreliability concerned the diagnoses of schizophrenia and affective disorder. Findings suggest that the introduction of standardized diagnostic criteria in Israel will lead to a substantial increase in the number of cases diagnosed as affective disorder, although difficulties involved in differentiating schizophrenia from the major affective disorders remain. The DSM-III findings suggest a high prevalence of affective disorders among Jews.     

精神分裂症与心境障碍交替发作47例临床分析

目的:探讨精神分裂症和心境障碍交替发作这一特殊病例群体的演变规律和可能的诊断归属问题。方法:在15年间住院3次或以上,诊断为精神分裂症或心境障碍的638例病历中筛选出有精神分裂症和心境障碍诊断变更的81例,按中国精神障碍分类与诊断标准第3版分别再诊断,符合要求者作为研究组,共47例(7.4%)。结果:精神分裂症→心境障碍组36例,最后诊断为精神分裂症14例(38.9%),诊断为心境障碍22例(61.1%);心境障碍→精神分裂症组11例,最后诊断为心境障碍7例(63.6%),精神分裂症4例(36.4%);心境障碍→精神分裂症组的最后诊断与初次诊断的一致率显著高于精神分裂症→心境障碍组(P<0.05)。结论:本类型精神障碍在现象学层面是一个独立的疾病单元,其生物学特性以及临床特征可能与心境障碍存在更大关联,有待大样本前瞻性研究。建议在精神疾病分类方案与诊断标准中有其正式的归属。     

Schizophreniform disorder,delusional disorder and psychotic disorder not otherwise specified: clinical features,outcome and familial psychopathology

The relationship between DSM-III-R schizophreniform disorder, delusional disorder (DD) and psychotic disorder not otherwise specified (PD-NOS) and schizophrenia and affective illness (AI) remains uncertain. We explore this question in the Roscommon Family Study by examining symptoms, outcome and patterns of psychopathology in relatives. Probands were selected from a population-based case registry in the west of Ireland with an ICD-9 diagnosis of schizophrenia or AI. Personal interviews were conducted with 88% of traceable, living probands, a mean of 16 years after onset, and 86% of traceable, living first-degree relatives. Best-estimate diagnoses were made at follow-up. Schizophreniform disorder, DD and PD-NOS constituted 6.4%, 2.8% and 7.5%, respectively, of all probands with a registry diagnosis of schizophrenia. Probands with schizophreniform disorder had prominent positive psychotic symptoms, negligible negative symptoms and a good outcome, comparable to that seen in AI probands. Their relatives had an excess risk of schizophrenia spectrum illness but not AI. Probands with DD had prominent delusions but no other psychotic symptoms, few negative symptoms, fair to good outcome and an increased risk in relatives for alcoholism. Probands with PD-NOS had both moderate positive and negative psychotic symptoms, a poor to fair outcome and a substantially elevated risk in relatives of schizophrenia and schizophrenia spectrum disorders but not AI. These results suggest that i) DSM-III-R criteria for schizophreniform disorder define a good outcome disorder with prominent positive psychotic symptoms that probably has a familial relationship to schizophrenia, but not AI; ii) DD is a rare, monosymptomatic psychosis that may have a modest etiologic relationship with alcoholism, but probably not with schizophrenia or AI and iii) PD-NOS is probably heterogeneous but, of these 3 disorders, most closely resembles schizophrenia with respect to symptoms, outcome and familial psychopathology. These results should be seen as tentative given the small number of probands and relatives evaluated.     

Clinical characteristics, 4-year course, and DSM-IV classification of patients with nonaffective acute remitting psychosis

OBJECTIVE: The authors examined the clinical characteristics and 48-month illness course of cases of nonaffective acute remitting psychosis and described the classification of these cases in the DSM-IV system. METHOD: The data were derived from the Suffolk County (N.Y.) Mental Health Project, a study of first-admission patients with psychotic disorders admitted to psychiatric facilities between September 1989 and December 1995. The authors compared the demographic and clinical characteristics, 48-month course, and longitudinal research diagnoses of 16 patients with nonaffective acute remitting psychosis, defined by onset in 2 weeks or less and duration of less than 6 months, to those of 26 patients with other nonaffective remitting psychoses. RESULTS: Nonaffective acute remitting psychosis had a distinctly benign course-46% of the patients remained in full remission throughout the 48-month follow-up, compared with 14% of patients with other remitting psychoses. Nonaffective acute remitting psychosis was also associated with fewer negative symptoms than other remitting psychoses. By 24-month follow-up, only 6% of the patients with nonaffective acute remitting psychosis, compared with 77% of the patients with other remitting psychoses, received a research diagnosis of schizophrenia or schizoaffective disorder, whereas 44% of patients with nonaffective acute remitting psychosis, compared with 12% of patients with other remitting psychoses, were given the residual diagnosis of psychotic disorder not otherwise specified. CONCLUSIONS: Nonaffective acute remitting psychosis is a highly distinctive yet not adequately classified condition. Better delineation of nonaffective acute remitting psychosis in current diagnostic systems could lead to better understanding of this condition and improve the applicability of diagnostic systems in developing countries, where these conditions are more common than in industrialized countries.     

The role of psychotropic drugs in the insidious deconstruction of the Kraepelinian dichotomy

62 patients suffering from mood disorders or schizophrenia diagnosed retrospectively according to DSM-4 as 295.xx or 296.xx were followed up by the author personally for 20 years. The DSM-IV diagnosis of schizophrenia (295.xx) was changed to a diagnosis of a mood disorder in 13 patients (26%). If schizoaffective disorder is classified as a mood disorder to form a group of periodic disorders, 41% of patients diagnosed as "pure" schizophrenia (295.xx without 295.70) at the start of the observation period were re-diagnosed as periodic disorder over 20 years. This "retrogression" of schizophrenia is seen as a result of the treatment with psychotropic drugs. The Kraepelian dichotomy is based on the relationship between the symptomatic pattern (syndrome) and the course of the illness. This relationship is disrupted by long-term treatment with psychotropic drugs.     

Neuropsychological differences between first-admission schizophrenia and psychotic affective disorders

OBJECTIVE: The study compared the neuropsychological functioning of patients with first-admission schizophrenia with that of patients with first-admission psychotic affective disorders. METHOD: Data came from the Suffolk County Mental Health Project, an epidemiological study of first-admission psychotic disorders. Subjects with a diagnosis of schizophrenia (N=102) and psychotic affective disorders, including bipolar disorder with psychotic features (N=72) and major depressive disorder with psychotic features (N=49), were compared on a battery of neuropsychological tests administered 2 years after the index admission. RESULTS: Subjects with schizophrenia performed worse than those with the psychotic affective disorders, even after adjusting the results for differences in demographic characteristics and general intellectual functioning. The most consistent differences were on tests of attention, concentration, and mental tracking. The two psychotic affective disorder groups were indistinguishable in performance on the neuropsychological tests. CONCLUSIONS: Even early in its course, schizophrenia is distinguishable from psychotic affective disorders by global and specific neuropsychological deficits. These deficits might contribute to the disability and poor outcome associated with schizophrenia in the mid- and long-term course.     

Volumetric abnormalities predating the onset of schizophrenia and affective psychoses: an MRI study in subjects at ultrahigh risk of psychosis

It remains unclear whether brain structural abnormalities observed before the onset of psychosis are specific to schizophrenia or are common to all psychotic disorders. This study aimed to measure regional gray matter volume prior to the onset of schizophreniform and of affective psychoses. We investigated 102 subjects at ultrahigh risk (UHR) of developing psychosis recruited from the Personal Assessment and Crisis Evaluation Clinic in Melbourne, Australia. Twenty-eight of these subjects developed psychosis subsequent to scanning: 19 schizophrenia, 7 affective psychoses, and 2 other psychoses. We examined regional gray matter volume using 1.5 mm thick, coronal, 1.5 Tesla magnetic resonance imaging and voxel-based morphometry methods of image analysis. Subjects were scanned at presentation and were followed up clinically for a minimum of 12 months, to detect later transition to psychosis. We found that both groups of subjects who subsequently developed psychosis (schizophrenia and affective psychosis) showed reductions in the frontal cortex relative to UHR subjects who did not develop psychosis. The subgroup that subsequently developed schizophrenia also showed smaller volumes in the parietal cortex and, at trend level, in the temporal cortex, whereas those who developed an affective psychosis had significantly smaller subgenual cingulate volumes. These preliminary findings suggest that volumetric abnormalities in UHR individuals developing schizophrenia vs affective psychoses comprise a combination of features that predate both disorders and others that may be specific to the nature of the subsequent disorder.