Seasonal influences on admissions for affective disorder and schizophrenia in Ireland: a comparison of first and readmissions.

Although genetic and environmental factors operating before or around the time of birth have been demonstrated to be relevant to the aetiology of the major psychoses, a seasonal variation in the rates of admission of such patients has long been recognised. Few studies have compared first and readmissions. This study examined for seasonal variation of admission in the major psychoses, and compared diagnostic categories by admission status. Patients admitted to Irish psychiatric inpatient facilities between 1989 and 1994 with an ICD-9/10 diagnosis of schizophrenia or affective disorder were identified from the National Psychiatric Inpatient Reporting System (NPIRS). The data were analysed using a hierarchical log linear model, the chi-square test, a Kolmogorov-Smirnov (KS) type statistic, and the method of Walter and Elwood. The hierarchical log linear model demonstrated significant interactions between the month of admission and admission order (change in scaled deviance 28.77, df = 11, P < 0.003). Both first admissions with mania, and readmissions with bipolar affective disorder exhibited significant seasonality. In contrast, only first admissions with schizophrenia showed significant seasonal effects. Although first admissions with mania and readmissions with bipolar disorder both show seasonality, seasonal influences appear to be more relevant to onset of schizophrenia than subsequent relapse.     

Gender differences in the incidence of definite schizophrenia and atypical psychosis--focus on negative symptoms of schizophrenia.

In a catchment area study of 101 first inceptions of schizophrenia, mania and atypical psychoses, women were significantly more likely to have atypical psychosis and men were more likely to have definite schizophrenia. Negative symptoms such as affective flattening and poverty of speech were already present in many cases, and were significantly increased in patients with definite schizophrenia (geometric mean 5.6) compared with those with atypical psychosis (geometric mean 3.2) and mania (geometric mean 1.5). Negative symptoms were also twice as severe in men (geometric mean 5.5) than women (geometric mean 2.6). There was a significant increase in negative symptom severity with longer illness and greater depression, but the diagnosis and the sex effects were not caused by these factors. We suggest that our findings are further support for the hypothesis that men have a greater biological vulnerability to negative symptoms and consequent social disability in the face of psychosis, particularly a schizophrenic psychosis, and that this may be one explanation for the apparently greater risk of definite schizophrenia and its poorer prognosis in men.     

Family history study of major psychiatric disorders and syndromes

The family history of major psychiatric disorders was examined among relatives of 193 in-patients fulfilling the Research Diagnostic Criteria (RDC) for Schizophrenia, Unspecified Functional Psychoses, Schizoaffective Disorder, Manic Disorder or Major Depressive Disorder. The morbid risk (MR) for schizophrenia was greater among the relatives of probands with non-affective psychoses whereas the MR for mania was greater among the relatives of probands with affective bipolar disorder. When major psychiatric syndromes were examined, only manic syndrome showed familial aggregation.     

Increased developmental deviance and premorbid dysfunction in early onset schizophrenia

Abnormal neurodevelopment and poor premorbid function have been described in schizophrenia. It is unclear whether abnormalities in these domains are increased in patients with early onset schizophrenia (EOS; onset before the 18th birthday) and whether they act to precipitate the earlier onset of the disorder. To address these questions, we collected information based on maternal interviews about the premorbid function of 40 adolescents with recent onset schizophrenia and an equal number of healthy controls using the Developmental Scale Score, the Premorbid Schizoid and Schizotypal Trait Scale (PSST) and Premorbid Adjustment Scale (PAS). Data on the PSST and PAS were also available in 54 patients with adult onset schizophrenia (AOS; onset after the 20th birthday). Compared to healthy controls, EOS patients had (a). delayed speech milestones, difficulties in reading and spelling and greater overall developmental deviance; (b). poor premorbid adjustment in childhood, which became even more deviant in adolescence particularly in boys and (c). more schizophrenia spectrum traits. Both premorbid adjustment and personality traits were more abnormal in patients with increased developmental deviance suggesting the possibility that they represent different manifestations of ongoing abnormalities in developmental processes. EOS patients had more impaired premorbid adjustment in adolescence and schizophrenia spectrum traits compared to AOS cases. Age of onset was related to developmental deviance, premorbid schizophrenia spectrum traits and childhood adjustment in EOS patients only.     

Personality and psychosis: use of the Standardized Assessment of Personality

The Standardized Assessment of Personality, a semistructured interview for use with an informant, was used with a relative or a close friend to determine the premorbid personality of 100 consecutive patients admitted with major psychiatric disorders - major affective disorders (18 manics, 35 depressives), schizophrenia (28) and other functional psychoses (19). Forty-four per cent of the entire sample had an abnormal personality as defined by the presence of one of 10 prominent traits to a marked degree. A further 6% had the same traits to a lesser degree. The proportion of patients with an abnormal personality (all types) was comparable across the four diagnostic groups (manics 39%, depressives 54%, schizophrenics 39%, other functional psychotics 37%). However, if one included all traits (marked and mild), patients with an affective disorder had more between them than did the non-affective groups. This difference was largely accounted for by cyclothymic, anxious and obsessional traits. The schizophrenics and other functional psychotics had surprisingly few prominent traits and, in particular, a schizoid personality rarely preceded a schizophrenic illness.     

Symptomatic presentation and initial treatment for schizophrenia in children and adolescents

Childhood-onset schizophrenia is a rare variant of adult-onset schizophrenia. Patients with early-onset schizophrenia typically have a more chronic course of illness, greater cognitive impairment, increased negative symptoms, and more severe social consequences than patients with adult-onset schizophrenia. Misdiagnosis of childhood-onset schizophrenia is common, but certain clinical features, such as predominant negative symptoms and premorbid developmental abnormalities, can help to differentiate the disorder from other psychiatric disorders in childhood. Treatment regimens that include both pharmacotherapy and psychosocial interventions are needed to comprehensively treat children and adolescents with schizophrenia.     

Predictors of clinical and social outcomes after hospitalization in schizophrenia

A prospective cohort study of schizophrenia was carried out in São Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level.     

Long-term outcome of major psychoses. I. Schizophrenia and affective disorders compared with psychiatrically symptom-free surgical conditions.

We conducted a 30- to 40-year field follow-up of 685 patients with schizophrenia, affective disorders, and nonpsychiatric conditions. Long-term outcome was analyzed in terms of the patients' marital, residential, occupational, and psychiatric status. On the whole, psychiatric patients showed a significantly poorer outcome than the surgical controls. On the basis of long-term outcome, schizophrenia, and affective disorders, selected according to the specified research criteria, were significantly different: schizophrenia definitely showed poorer outcome than affective disorders. However, no significant differences in all four outcome variables were found between mania and depression. We hope that the present data on long-term outcome of the typical cases can be used to compare outcome of other psychiatric disorders, such as undiagnosed psychoses, having mixtures of schizophrenic and affective features. In doing this, we hope to charify our understanding of undiagnosed psychoses and their relationship to schizophrenia and affective disorders.     

Premorbid performance IQ deficit in schizophrenia

OBJECTIVE: Performance IQ (PIQ) is often lower than verbal IQ (VIQ) in schizophrenic patients. Whether PIQ < VIQ precedes psychotic symptoms in schizophrenia remains uncertain. METHOD: We investigated premorbid IQ scores in 63 subjects assessed at a child and adolescent psychiatric unit (mean age 13.1 years, SD 3.2), who at follow-up in adulthood (mean age 30.9 years, SD 3.9) received a lifetime RDC diagnosis of schizophrenia-related psychosis, affective disorder, or no psychiatric disorder. RESULTS: Premorbid PIQ < VIQ significantly differentiated the groups with schizophrenia-related psychosis and no psychiatric disorder. Subjects with schizophrenia-related psychosis had a significantly lower mean value for premorbid PIQ, but not VIQ, compared to subjects who developed affective disorder or subjects without psychiatric disorder. CONCLUSION: Our results emphasize premorbid intellectual deficits in schizophrenia. Those deficits might largely be in consequence of an impairment on the PIQ scale.     

The persistence of developmental markers in childhood and adolescence and risk for schizophrenic psychoses in adult life. A 34-year follow-up of the Northern Finland 1966 birth cohort

Childhood precursors of schizophrenia include multiple abnormalities of development. Continuities between early and subsequent deviance are poorly characterised. We studied associations among premorbid developmental deviance using data at ages 1 year (learning to stand, walk, and speak, attainment of bladder and bowel control) and 16 years (success at school). Generalised linear modelling was used to examine differential linear associations and trends across adult psychiatric diagnoses. In babies who, as adults, suffered schizophrenia or any psychosis, those who learned to stand latest were also more likely to perform poorly at school in both motor and theoretical domains at age 16 when compared with earlier learners. The effect was independent of genetic and perinatal factors. We conclude that the early developmental deviation in the first year of life is associated with lower school performance at age 16. Developmental continuity among children who develop psychoses was stronger than among normal controls and those hospitalized for nonpsychotic psychiatric disorder. These findings are in line with the hypothesis that a neural diathesis is present during postnatal brain development before schizophrenia. This supports the longitudinal dimension and life span models of schizophrenia.     

The remitting atypical psychoses: clinical and nosologic considerations

There exists in the literature a group of nonorganic psychoses which appear to have no obvious relationship to either schizophrenia or affective illness. Diagnostic terminology to classify these atypical psychoses has been varied, although features in common can be identified. For example, they often are associated with antecedent personality problems, acute onset, florid and mixed symptomatology, brief duration, and full remission with a return to premorbid level of functioning. Case material reflecting these types of psychoses is presented here, and is discussed with reference to the nosologic status of these atypical psychoses.     

The relationship of premorbid functioning to illness course in schizophrenia and psychotic mood disorders during two years following first hospitalization

Studies suggest that better premorbid functioning is associated with better outcomes in chronic schizophrenia. Yet first admission studies, which are more appropriate to examine this, are less conclusive. Also, little attention has been given to whether these findings hold for other psychoses. We examined the relationship of premorbid functioning using the Premorbid Adjustment Scale and outcomes in first admission psychoses (schizophrenia, N = 177; bipolar disorder, N = 106; major depression, N = 68) in the Suffolk County-wide mental health project. Poor premorbid functioning was associated with worse outcomes in all three diagnostic groups. Specifically, it was associated with more negative symptoms early in the course of illness, less improvement in negative symptoms, poorer overall clinical functioning, and poorer social functioning. Consistent with new epidemiological research, early assessment of premorbid functioning could provide an avenue for targeted interventions that might improve outcomes.     

Five latent factors underlying schizophrenia: analysis and relationship to illnesses in relatives

Clinical signs and symptoms in a sample of 1,043 individuals with schizophrenia or schizoaffective disorder were subjected to latent class factor analysis. Positive, negative, disorganized, and affective factors were similar in content to factors described in a number of other studies, while a fifth factor representing early onset/developmental signs provided a new area for investigation. The five sets of factor scores were logistically regressed on psychiatric illness indicators in first and second degree relatives. Relatives of probands with higher positive or negative symptom factor scores had a lower risk of depressive illness. Higher affective factor scores in probands predicted more mania and depression in relatives. Both the disorganized and the early onset/developmental factors were related to increased risk of psychiatric hospitalization in relatives, as well as increased risk of psychosis (marginally so for the disorganization factor). Increased early onset/developmental signs in the proband were also associated with increased risk for depression in relatives. These findings suggest a possible endophenotypic role for the factor scores in future studies.     

Do women express and experience psychosis differently from men? Epidemiological evidence from the Australian National Study of Low Prevalence (Psychotic) Disorders

OBJECTIVE: To examine how women differ from men in their expression and experience of psychosis. METHOD: Using an epidemiological sampling frame, 1090 cases of psychosis (schizophrenia, schizoaffective disorder, affective psychoses, and other psychoses) were randomly selected from a catchment of 1.1 million people as part of the Australian Study of Low Prevalence (Psychotic) Disorders. Women and men were compared with respect to their premorbid functioning, onset and course of illness, symptomatology, levels of disability and service utilization. RESULTS: Results within diagnostic groupings confirm differences in how men and women experience and express their illness. Within each diagnostic group, women reported better premorbid functioning, a more benign illness course, lower levels of disability and better integration into the community than men. They were also less likely to have a chronic course of illness. There were no significant differences in age at onset. Differences between women across the diagnostic groups were more pronounced than differences between women and men within a diagnostic group. In particular, women with schizophrenia were severely disabled compared to other women. CONCLUSIONS: These comparisons across diagnostic groupings are among the most systematic and comprehensive in the literature. It is likely that several mechanisms are needed to explain the differences. Greater social integration and functioning in women across diagnostic groups may well reflect culturally and socially determined gender differences. In contrast, variability and attenuated findings with respect to symptom profiles beg the question of biological mechanisms with some degree of specificity.     

Differences between delusional disorder and schizophrenia: A mini narrative review

Psychotic syndromes are divided into affective and non-affective forms. Even among the non-affective forms, substantial differences exist. The aim of this relatively brief review is to synthesize what is known about the differences between two non-affective psychoses, schizophrenia and delusional disorder (DD), with respect to clinical, epidemiological, sociodemographic, and treatment response characteristics. A PubMed literature search revealed the following: in schizophrenia, hallucinations, negative symptoms and cognitive symptoms are prominent. They are rare in DD. Compared to schizophrenia patients, individuals with DD maintain relatively good function, and their delusions are believable; many are beliefs that are widely held in the general population. Treatments are generally similar in these two forms of psychosis, with the exception that antidepressants are used more frequently in DD and, for acute treatment, effective antipsychotic doses are lower in DD than in schizophrenia. It is with the hope that the contrasts between these two conditions will aid in the provision of safe and effective treatment for both that this review has been conducted.     

Increase in first admissions for schizophrenia and other major psychoses in Italy

Despite reports of falling first-admission rates for schizophrenia in some Western countries, methodological problems and bias preclude a definite conclusion about a genuine fall in the incidence of schizophrenia. This study set out to test the hypothesis that first admissions for schizophrenia in Italy have fallen in recent years. All admissions rated as 'first contact' in Italy from 1984 to 1994 for severe mental illnesses to general hospital psychiatric services, as reported in the Italian National Institute for Statistics Health-Care Yearbooks, were considered. Data were analyzed as rates per 100000 in the general population, and changes over time in incidence of schizophrenia, paranoia, affective psychoses and drug-induced psychoses (diagnosed according to ICD 9) were recorded. Changes in rates over time, with rates as the dependent variable and years as the independent variable, were the main outcome measure. First-admission rates for schizophrenia and paranoia increased progressively from 1984 to 1994, as did those for affective psychoses, mania and, to a lesser extent, major depression. In the same period, all admissions (both total and rated as 'first-contact') for mental disorders increased. Although linear regression tests for admission rates in most, but not all, cases indicate a significant ascending linear trend, quadratic model results show a significantly better fit than does the simple linear regression model for the majority of data. The change described by the quadratic model suggests an increase in admission rates more marked in the second half than in the first half of the period of the study. First-admission rates for schizophrenia and, to a lesser extent, paranoia seemed to increase concurrent to a decrease in first-admission rates for 'other' non-organic psychoses. Contrary to reports from other Western countries, hospital incidence in Italy for schizophrenia is on the increase, as is that for other severe psychoses. This increase is likely to be a reflection of changes in mental health-care organisation, in treatment and diagnostic patterns, and in cultural attitudes towards mental illness. Radical changes in the true incidence of psychoses, in particular of mood disorders, as described elsewhere, cannot be ruled out as contributing factors. Data bias and limitations preclude a generalisation of results, however.     

Changing trends in first admissions and readmissions for mania and schizophrenia in New Zealand, 1974 to 1984

From 1974 to 1984 in New Zealand there was a significant decline in first psychiatric admissions for the functional psychoses. This decline is due to decreasing first admission rates for schizophrenia and depressive psychoses, despite an increasing first admission rate for mania. Although a small part of the declining first admission rate for schizophrenia may be due to the increasing diagnosis of mania, this is insufficient to explain all the decline and suggests an actual decline in the incidence of schizophrenia. Over this same period readmissions for functional psychoses increased, with the most marked increase being in manic readmissions. Although a variety of factors influence readmission rates, the marked rise in manic readmissions suggests broadening diagnostic criteria for mania.     

Hippocampal volume in first-episode psychoses and chronic schizophrenia: a high-resolution magnetic resonance imaging study

BACKGROUND: It has been proposed that the hippocampus is a potential site for a neurodevelopmental lesion in schizophrenia. While smaller hippocampal volumes have been described in chronic schizophrenia, there have been few magnetic resonance imaging studies in first-episode psychosis. Furthermore, no studies have examined the specificity of this finding to first-episode schizophrenia, compared with first-episode affective psychosis. METHODS: Hippocampal and whole-brain volumes were estimated using high-resolution magnetic resonance imaging in 140 controls, 46 patients with chronic schizophrenia, and 32 patients with first-episode psychosis. RESULTS: Patients with chronic schizophrenia and first-episode psychosis had significantly smaller hippocampal volumes as compared with controls. Within the first-episode group, both patients with schizophrenia/schizophreniform psychosis and those with affective psychosis had smaller left hippocampal volumes as compared with controls. Smaller right hippocampal volumes were associated with age and illness duration in patients with chronic schizophrenia. Hippocampal volumes were not correlated with age of illness onset or medication dosage in either patient group. CONCLUSIONS: These data show that smaller hippocampal volumes are present from the onset of illness. While these findings would support the neurodevelopmental model of schizophrenia, the finding of smaller left hippocampal volume in patients with first-episode schizophrenia and affective psychosis does not support the prediction that smaller hippocampi are specific to schizophrenia. The association of smaller right hippocampal volumes with increased illness duration in chronic schizophrenia suggests either that there is further neurodegeneration after illness onset or that bilateral small hippocampi predict chronicity.     

Reactive psychoses and schizophrenia with good prognosis.

Cross-national studies have indicated that American psychiatrists diagnose schizophrenia more often than others. Clinical, genetic, and follow-up studies suggest that many patients diagnosed as having acute schizophrenia might be more appropriately diagnosed as having affective disorder. Forty probands diagnosed in Aarhus, Denmark, as having reactive psychoses are compared with 28 probands diagnosed in St Louis as having schizophrenia with good prognosis. Clinical differences largely reflect diagnostic criteria, with the patients from the St Louis group frequently having diagnosable affective disorder. A smaller proportion, 39% of the patients from St Louis, could be considered for the diagnosis of reactive psychosis. This is additional evidence supporting the use of the diagnostic category, reactive psychoses. Patients ordinarily given the diagnoses acute schizophrenic episode and/or schizo-affective schizophrenia may be more appropriately diagnosed as having (1) affective disorder and (2) reactive psychoses.