Prognosis of periodic bipolar manic depressive and schizo-affective psychoses

Summary Aspects of the course of manic depressive and schizo-affective psychoses with high recurrence (the patient must have suffered from at least three episodes) are measured by length of episodes, intervals, and cycles. Differences between two patient samples from Switzerland and Poland, and differences between the two diagnostic groups are analyzed taking into account some independent variables such as sex, marital state, age at onset, precipitation, and symptomatology.Bipolar and schizo-affective psychoses show similar patterns of course: early onset, high relapse rate, high number of episodes, and short intervals. Compared to schizo-affective psychoses bipolar psychoses tend to have a higher frequency of episodes per year, shorter intervals, and the length of episodes is longer. Multivariate analysis shows very few correlations of independent variables with aspects of the course. On the whole the differences between the diagnostic groups are much smaller than between the two centers.The Polish and Swiss patient samples differ in course considerably. The patients from Zurich show longer episodes, intervals, and cycles, therefore, the frequency of episodes per year is lower in Zurich. Only a smaller part of the variance can be explained by differences in psychopathology (the Polish patients are more manic and more paranoid).There remain unexplained qualitative differences between the two centers which show how difficult it is to compare scientific results from different sources.From the Psycho-Neurological Institute in Warsaw, Poland, at present working at the Psychiatric University Hospital, Research Department (Scholarship holder of the Roche Research Foundation and Sandoz, Basel, Switzerland)     

Stability of diagnoses in affective,schizoaffective and schizophrenic disorders

Summary The present study investigated the syndrome shift during the course of disease in 355 patients with functional psychoses. The mean observation time was 25.2 years. Every episode was diagnosed cross-sectionally as schizophrenic, melancholic, manic, manic-depressive mixed, schizodepressive, schizomanic or schizomanic-depressive mixed. With regard to the whole course, 148 patients fulfilled the diagnostic criteria of schizophrenic, 106 of affective and 101 of schizoaffective disorders. Patients with a schizophrenic initial episode showed the greatest stability: 90% had no other type of episode. The majority of patients who suffered a melancholic initial episode remained unipolar melancholics or developed manic symptomatology, and only a few suffered schizoaffective or schizophrenic episodes. Patients with a manic symptomatology at the beginning had a very unstable and changeable course. The stability of patients with initial schizodepressive episodes lay between that of patients with melancholic initial episodes and that of those with manic initial episodes. The findings demonstrate the relevance of longitudinal considerations in making the final diagnosis.Supported by grants Ma 915-1/1, 915-1/2 and 915-2/1 from the German Research Association (Deutsche Forschungsgemeinschaft)     

Schizo-affective psychoses in childhood: A follow-up study

A follow-up study of 16 schizo-affectives (part of a group of 57 children originally diagnosed as schizophrenic) is reported. All 57 patients were under 14 years. They were reinvestigated after an average follow-up period of 16 years (range 6 to 40 years). Of the 57 psychoses 28% had a typical schizoaffective character. In contrast to purely schizophrenic psychoses, we found an overrepresentation in the schizo-affective psychoses of affective psychoses and suicides in the ancestry. Further, in the schizo-affective psychoses there were more premorbidly well adjusted, harmonious personalities. In contrast, maladjusted, dishormonious, introverted characters predominated in purely schizophrenic psychoses. The schizo-affective psychoses had mainly an acute-recurrent character and followed a favorable course. The schizoaffective and affective phases were of significantly shorter duration than the schizophrenic episodes.     

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.     

First admissions for psychosis in Turku. A time trend study.

Patients over 15 years of age from Turku hospitalized for psychosis for the first time during the years 1949-50, 1959-60 or 1969-70 were investigated. The incidence of hospitalized psychoses (per 100,000 inhabitants) was 115, 136 and 160, respectively. The increase in incidence was greater in women than in men. The incidence remained approximately the same in patients aged 30 to 59, but increased in the younger and older groups. The incidence of functional psychoses increased; in schizophrenia, however, it declined, while in paranoid and effective psychoses it increased. In organic psychoses, the admission frequency of psychoses of old age rose in the 1950's, but declined in some measure in the 1960's. The incidence of psychosis increased for single persons. The ratio of the incidence between single and married persons rose in men, whereas in women it fell. This was particularly pronounced in schizophrenics. The incidence of psychosis was highest in unskilled laborers. The overrepresentation of schizophrenia and paranoid psychoses seemed to have become more pronounced in this occupational group.     

The epidemiology of functional psychoses of late onset

For the functional psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services; and surveys of elderly persons sampled from the general population. A conspectus of published data from both sources leads to the following conclusions: States phenomenologically similar to those found in clinics do occur in the community in non-trivial numbers. There is no notable divergence in the information obtained from clinical series and from population-based surveys. These states are more common in women, they become more common with increasing age and are sometimes associated with decline in cognitive performance or with degenerative changes in the brain revealed by neuroimaging. Genetic factors appear to be less important than in early-onset psychoses but remain ill-defined, and the roles of social isolation and disorders of personality have not yet been sufficiently elucidated. Both clinical and community-based studies have found an association with sensory impairment. The community-based data suggest that paranoid symptoms may be detectable at subclinical level, and an association between them and cognitive impairment is demonstrable in individuals who are not diagnosable cases either of psychosis or of dementia. Differences exist between late-onset paranoid psychoses and affective psychoses in symptomatology and response to treatment. These observations confirm the importance of the late-onset psychoses for research directed towards uncovering the origins of psychotic symptoms in any age group.     

Course of schizoaffective psychoses: results of a followup study

The course of illness was investigated retrospectively and prospectively in a sample of 150 hospitalized schizoaffective patients and 95 hospitalized bipolar manic-depressive patients. The two disorders showed more similarities than differences in their course; this was true for the age of onset (31.8 versus 34.7 years) and the length of illness until the end of the observation period (22.5 versus 23.8 years). Schizoaffective disorders took a more benign course than bipolar disorders, as measured by the frequency of the episodes (median 7 versus 9 episodes). Accordingly, periods of remission between episodes were longer in schizoaffective patients. The length of the episodes themselves was about the same in both disorders (median 3 months). Although subjects had reached an average age of 60 years, 63% of schizoaffective and 82% of bipolar patients had experienced new episodes during the last 5 years of the observation period. Patients with schizoaffective psychoses were less likely to achieve a full remission than patients with bipolar disorders. A residual state was observed in 57% of schizoaffective and 24% of bipolar patients during the intervals between episodes. Because both schizoaffective and bipolar disorders showed a highly recurrent course, many patients received long-term treatment with neuroleptic drugs, antidepressants, or lithium.     

Major psychoses symptomatology: factor analysis of 2241 psychotic subjects

Current nosography classifies major psychoses as separate disorders, but their symptomatological presentation during illness episodes largely overlaps and diagnoses may change during a lifetime. Few analyses of major psychoses symptomatology have been performed so far because of the large number of subjects needed to obtain stable factors. The purpose of this study was, therefore, to identify the symptomatologic structure common to major psychoses based on lifetime symptoms. Two thousand and forty-one inpatients affected by schizophrenic (n=1008), bipolar (n=563), major depressive (n=352), delusional (n=108) and psychotic not otherwise specified disorder (n=210) were rated for lifetime symptoms using the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and included in a factorial analysis. Four factors were obtained, the first consisted of excitement symptoms, the second comprised psychotic features (delusions and hallucinations), the third comprised depression and the fourth disorganization. When scored by the OPCRIT checklist, major psychoses symptomatology is composed of excitement, depressive, delusion and disorganization symptoms.     

Bipolar I disorder with mood-incongruent psychotic symptoms

Objectives  The purpose of this paper is to demonstrate similarities and differences between bipolar I patients with and without mood-incongruent symptoms (MIS) over a long period of time, independently of longitudinal syndromatic constellations. Methods  The Halle bipolarity longitudinal study (HABILOS) prospectively investigates 182 patients meeting the DSM-IV criteria for bipolar I disorders over a long period of time (x;⁻ = 16.84 years). One thousand five hundred thirty-nine (1,539) episodes have been evaluated with standardized instruments. Patients and episodes were divided into two groups (with and without MIS) and were compared on various levels. Results  It was found: (1) The majority of the episodes of bipolar I patients during long-term course did not have MIS, but the majority of patients did. (2) Bipolar I patients with MIS differ from patients without MIS in the following features: (a) Bipolar I patients with MIS are more frequently males. (b) Bipolar I patients with MIS need treatment at a significantly younger age than those without MIS. (c) First manifestation of bipolar I disorder with MIS after the age of 50 is extremely seldom. (d) Bipolar I patients with MIS more frequently have relatives with schizophrenia. (e) Bipolar I patients with MIS more frequently become disabled and retire at a significantly younger age than patients without MIS and (f) Significantly fewer patients with MIS than those without MIS live in a stable partnership. Conclusions  It can be concluded that bipolar I disorders with MIS are more severe disorders than bipolar I disorders without MIS. This finding in combination with the above results, however, can give rise to the conclusion that bipolar I disorders with MIS are the epiphenomenon of the overlap, possibly genetic, of a “schizophrenic spectrum” and a “bipolar spectrum” and their antagonistic influence creating a “schizo-affective” area between them as a kind of psychotic continuum between prototypes. Supported by grants of the DFG German Research Association MA 915/11-1.     

The importance of the schizo-affective psychoses within the psychopathological and nosological systematics

Schizo-affective psychoses lead more often to reintegration of the paranoid-hallucinatory pattern than schizophrenic psychoses. The author interprets schizo-affective psychoses in the light of his systematic psychopathology and concludes that excitation is intensified in comparison with cyclothymia. Ego destruction is more serious, but paranoid manifestations decrease in the course and emotional syndromes become more pronounced. Prognosis depends on the intensity of therapeutic efforts in the sense of psychopharmacological and supportive therapies and is not prestabilized.     

Dysphoric mood in paranoid psychoses

Many authors have stressed the particular affective behavior in paranoid psychoses, mainly its dysphoric pattern. In 1983, Berner formulated the dysphoric axial syndrome as a third type of the endogenomorphous cyclothymic axial syndrome. In this paper two points are examined: (1) The interrelation between dysphoric and depressive and/or manic affective disorders in paranoid psychoses, cross-sectionally and longitudinally, in order to test the hypothesis of their independence, and (2) the relation of dysphoric mood disorders in paranoid psychoses to their course, again in comparison with other types of affective symptoms. The paper is based on an empirical study by Gabriel in 1978 on the phenomenology and the course of paranoid psychoses.     

Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: results from the STEP-BD study

Objective:  Symptoms of bipolar disorder are increasingly recognized among children and adolescents, but little is known about the course of bipolar disorder among adults who experience childhood onset of symptoms.
Methods:  We examined prospective outcomes during up to two years of naturalistic treatment among 3,658 adult bipolar I and II outpatients participating in a multicenter clinical effectiveness study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Age at illness onset was identified retrospectively by clinician assessment at study entry.
Results:  Compared to patients with onset of mood symptoms after age 18 years (n = 1,187), those with onset before age 13 years (n = 1,068) experienced earlier recurrence of mood episodes after initial remission, fewer days of euthymia, and greater impairment in functioning and quality of life over the two-year follow-up. Outcomes for those with onset between age 13 and 18 years (n = 1,403) were generally intermediate between these two groups.
Conclusion:  Consistent with previous reports in smaller cohorts, adults with retrospectively obtained early-onset bipolar disorder appear to be at greater risk for recurrence, chronicity of mood symptoms, and functional impairment during prospective observation.     

The genetics of delusional psychoses

In a genetic study of the first-degree relatives of 77 patients with delusional (paranoid) psychoses, the morbidity risks for schizophrenia, affective disorders, and atypical psychoses were evaluated using ICD-9 criteria. The prevalence of schizophrenia was 3.10 percent (4.12 percent with age correction to 40 years and 4.94 percent with age correction to age 60), which is higher than in investigations of paranoid psychoses, but lower than in studies of paranoid schizophrenia. The prevalence figure for affective disorders (age-corrected 3.04 percent for unipolar plus bipolar patients) is also intermediate to those for relatives of paranoid schizophrenics and paranoid psychotics. When the 77 index delusional patients were subdivided into axial syndromes (endogenomorphic-schizophrenic, endogenomorphic-cyclothymic, and organomorphic axial syndromes), two very homogeneous subgroups emerged. The endogenomorphic-schizophrenic subgroup showed high rates of schizophrenic secondary cases, whereas the endogenomorphic-cyclothymic subgroup showed high rates of affectively disordered secondary cases. The third organomorphic subgroup showed a high prevalence of atypical psychoses among first-degree relatives. Thirty-seven of the 77 index patients could not be assigned to any axial syndrome; their first-degree relatives had an increased prevalence of schizophrenia, but affective disorders were no more frequent than in the normal population. These data suggest that the heterogeneous group of paranoid psychoses can be meaningfully subdivided by use of axial syndromes which are viewed as representing "basic" disturbances underlying delusional symptomatology.     

A study of genetic factors, childhood bereavement, and premorbid personality traits in patients with anancastic endogenous depression.

From a sample of 1,005 patients admitted to the State Hospital in Aarhus for the first time during the period 1950-1959 and who had been diagnosed as suffering from manic-depressive psychosis or endogenous depression (affective psychoses), a subsample of 104 manic-depressive aptients with anancastic symptoms in the history were selected. The 104 probands were individually matched with 104 non-anancastic probands with affective psychoses. The anancastic probands and the controls who were still living were seen personally at the follow-up. Information concerning the psychiatric history of 945 first degree relatives of the anancastic probands and 1,000 first degree relatives of the controls were obtained. During the search for factors which could be used to distinguish affective psychoses with anancastic symptoms from affective psychoses without these traits, a positive correlation was found between the presence of anancasma and the following factors: (a) premorbid obsessive personality traits; (b) traumatic environmental factors in childhood; (c) a tendency to monopolarity; (d) a preponderance of monopolar depressions in the family; (e) the presence of secondary cases of anancastic endogenous depression. The findings are compatible with a theory which attributes a pathoplastic effect to the obsessive personality giving rise to anancastic symptomatology in the form of affective psychoses which tend to a unipolar course.     

Implications of the distinction between organic and functional psychoses

On the basis of their symptomatology, some psychoses are called organic. The remaining psychoses are called functional. It is generally supposed that symptomatically organic psychoses have organic causes and thus call for medical investigations, while the functional psychoses are not so caused, and call for a dynamic formulation rather than an organic one. The author examines the basis for this distinction, and argues that it is logically unsound. He gives examples of exceptions to the rule, both organic-seeming illnesses that are the consequence of psychological mechanisms, and symptomatologically functional psychoses with organic antecedents. The exceptions prove to be so numerous that a different approach to the investigation of the psychoses, an approach stressing antecedents rather than symptomatology, appears to be called for.     

Diagnostic subtypes of bipolar disorder in older versus younger adults

OBJECTIVE: To investigate differences in diagnostic subtypes of bipolar disorder as according to ICD-10 between patients whose first contact with psychiatric health care occurs late in life (over 50 years of age) and patients who have first contact earlier in life (50 years of age or below). METHODS: From 1994 to 2002 all patients who received a diagnosis of a manic episode or bipolar disorder at initial contact with the mental healthcare system, whether outpatient or inpatient, were identified in Denmark's nationwide register. RESULTS: A total of 852 (49.6%) patients, who were over age 50, and 867 patients, who were 50 or below, received a diagnosis of a manic episode or bipolar disorder at the first contact ever. Older inpatients presented with psychotic symptoms (35.4%) significantly less than younger inpatients (42.6%) due specifically to a lower prevalence of manic episodes with psychotic symptoms. Conversely, older inpatients more often presented with severe depressive episodes with psychotic symptoms than younger inpatients (32.0% versus 17.0%). Among outpatients, no significant differences were found between patients older than 50 years and patients 50 years of age or younger. However, a bimodal distribution of age at first outpatient contact was found with an intermode of 65 years and outpatients older than 65 years more often presented with severe depressive episodes with psychosis. CONCLUSIONS: Bipolar patients who are older at first psychiatric hospitalization (>50 years) present less with psychotic manic episodes and more with severe depressive episodes with psychosis than younger patients. The distribution of age at first outpatient contact is bimodal with an intermode of 65 years and outpatients older than 65 years more often present with severe depressive episodes with psychosis.     

Social and symptomatic outcomes of first-episode bipolar psychoses in an early intervention service

Aim: We aimed to establish the relative proportions of all diagnoses in people aged 14–35 years presenting to an early intervention in psychosis service, and to compare demographic variables, symptoms and outcomes between the bipolar psychoses and other psychoses at 3–6 months and 1 year post referral. Methods: Prospective 3‐ to 6‐month diagnostic and symptomatic assessments were carried out. Diagnoses were established using the Diagnostic Interview for Psychoses – Diagnostic Module. Symptoms and outcomes were assessed using standardized instruments at 3–6 months and 1 year. Bipolar diagnoses were grouped together in a bipolar group (n=16) and compared with all other diagnoses, in a non‐bipolar group (n=62). Parallel analysis was carried out using groups of lifetime elevated, expansive or irritable mood (n=32) and no lifetime elevated, expansive or irritable mood (n=46). Results: Bipolar disorders account for 20.5% of all new presentations to our service. Differences in outcomes over the range of psychotic diagnoses relate to early presence of negative symptoms. Psychoses with bipolar diagnoses or lifetime elevated, expansive or irritable mood showed lower rates of negative symptoms than other psychoses and had a higher quality of life and higher function at 3–6 months and 1 year. Conclusions: Planning for future early intervention services should take the high rate of affective psychoses and their need for diagnosis‐specific, evidence‐based treatments into account. Lifetime elevated, expansive or irritable mood may predict improved outcomes in early psychoses, possibly mediated by lower levels of negative symptoms.     

What can genetics contribute to reduce the problems of schizo-affective psychoses?

The biological base of psychoses is controlled by multifactorial genotype compounds using sometimes the same gene locus or DNA information section for diverse diseases, but always in different and repeatable combinations. These compounds can be formed by special regulatory or junction genes. With the help of inherited serum markers of the haptoglobin and the Gc system including quantitative studies of the ceruloplasmin and transferrin serum level, the combinations of diverse biological factors have been presented especially for cycloid psychoses, unsystematic schizophrenias, and paranoid psychoses with late onset and a cyclic axis syndrome. Considering the specifications of genetic control and clinical course no indefinite mixtures in the sense of schizo-affective psychoses should be discussed furthermore.