Tourette disorder and schizophrenia in children

In North Dakota children, the prevalence rate for DSM-III schizophrenia is 0.19 per 10,000 for both sexes; for males 0.35 per 10,000 and 0 per 10,000 for females. In this report we utilize case studies to convey the symptomatic courses of the 2 child patients with DSM-III-R defined schizophrenia. Both patients first developed Tourette Disorder (TD) and later developed schizophrenia by DSM-III and by DSM-III-R criteria. Among North Dakota children with TD the prevalence rate of schizophrenia is 8.7% for boys. The ramifications of concordance for the two disorders are explored.     

Diagnosing personality disorders in psychiatric inpatients

This study investigated assumptions made by DSM-III and DSM-III-R regarding Axis I-Axis II associations and sex differences for the 11 personality disorders (PD). A total of 112 patients formed 4 Axis I diagnostic groups: recent-onset schizophrenia (n = 35); recent-onset mania (n = 26); unipolar affective disorder (n = 30); and a mixed diagnostic group (n = 21). The prevalence of PD was determined using the Structured Interview for DSM-III Personality Disorders (SIDP). Schizophrenia was associated with antisocial PD and schizotypal PD; manic disorder was associated with histrionic PD; and unipolar affective disorder was associated with borderline, dependent and avoidant PD. Some of these results were consistent with DSM-III/DSM-III-R postulates. However, there was little support for the DSM-III/DSM-III-R statements on sex differences in the prevalence of PD, except for antisocial PD. The implications of the results for DSM-III/DSM-III-R assumptions are discussed.     

DSM-III and DSM-III-R: What are American psychiatrists using and why?

The purpose of this study was to determine whether American psychiatrists have switched from DSM-III to DSM-III-R as their primary diagnostic reference, and to examine what factors predicted the continued use of DSM-III. In 1989, we conducted a mail survey of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) regarding their training in, use of, and opinions about DSM-III and DSM-III-R. Approximately 30% of practitioners continued to use DSM-III as their primary diagnostic reference, although this was less frequently true of researchers and residents. In none of the four groups did a majority believe that DSM-III-R was needed, despite the fact that the majority of each group indicated that it was an improvement over DSM-III. The most commonly perceived reasons for publishing DSM-III-R were that it corrected problems with DSM-III and new research indicated changes were warranted. Compared with DSM-III-R users, DSM-III users more frequently believed that the 7-year interval between the two editions was too short, that DSM-III-R was not needed, and that the revised manual was little better than the original. Thus, 2 years after the publication of DSM-III-R 90% of psychiatrists were using DSM-III-R, at least in part, although a substantial minority continued to use DSM-III as their primary diagnostic manual. Even among DSM-III-R users, many believed that the revised manual was not needed. The perceived need for DSM-III-R was associated with the reasons ascribed to its publication; therefore, acceptance of DSM-IV may be partially a function of how its development is promoted and justified. That nearly one third of a random sample of practicing psychiatrists continued to use DSM-III supports concerns that the publication of DSM manuals every 6 or 7 years will divide the psychiatric community into subgroups using different diagnostic criteria.     

A family study of DSM-III-R schizoaffective disorder, depressive type, compared with schizophrenia and psychotic and nonpsychotic major depression

OBJECTIVE: To assess the validity of DSM-III-R schizoaffective disorder, the authors explored the morbid risks for schizophrenia and major affective disorders in the first-degree relatives of patients with schizoaffective disorder and relevant other diagnoses. METHOD: In addition to patients with DSM-III-R schizoaffective disorder, depressive type (N = 21), the probands included patients with mood-incongruent psychotic depression (N = 22), mood-congruent psychotic depression (N = 19), nonpsychotic depression (N = 27), or schizophrenia (N = 28) and normal subjects (N = 18). The patients were consecutively recruited from the outpatient facilities of a university psychiatry department; the normal subjects were students and nurses. All probands were directly interviewed, with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version (SADS-L), by a psychiatrist blind to information about relatives. Consenting relatives were directly interviewed, with the SADS-L, by two psychiatrists blind to the probands' diagnoses. The direct interview was supplemented--or replaced, when an interview was not possible (24%)--by family history data from all available sources. Morbid risks in relatives were calculated according to the Weinberg method. RESULTS: The relatives of the schizoaffective patients had almost the same risk for schizophrenia as the relatives of the schizophrenic patients. In the relatives of the patients mood-incongruent psychotic depression, the morbid risk for major affective disorders was about one-half that of the relatives of the patients with mood-congruent psychotic depression and one-third that of the relatives of the patients with nonpsychotic depression, but these differences did not reach statistical significance. CONCLUSIONS: These results suggest that DSM-III-R schizoaffective disorder is close to schizophrenia and largely corresponds to mainly schizophrenic schizoaffective disorder in the Research Diagnostic Criteria, whereas DSM-III-R mood-incongruent psychotic depression is probably quite heterogeneous and should be studied further.     

DSM-IV: a nosology sold before its time?

OBJECTIVE: The purpose of this study was to determine whether American psychiatrists believe that DSM-IV is being published too soon after DSM-III-R. METHOD: The authors conducted a mail survey of the attitudes of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) toward the scheduled publication of DSM-IV in the early 1990s. RESULTS: They found that the majority of all four groups believed that DSM-IV is being published prematurely. In contrast to respondents who believed that the timing of DSM-IV is appropriate, those who indicated that it is being published too soon had more recently completed their residency training and also believed that DSM-III-R was published prematurely. There was no association between the psychiatrists' responses and their theoretical orientation, Board certification status, ownership of the DSM manuals, the length of time they had used DSM-III, and the diagnostic manual (DSM-III or DSM-III-R) they were currently using. CONCLUSIONS: The belief that DSM-IV is being published too soon could contribute to underuse of DSM-IV by substantial numbers of psychiatrists. Thus, to foster compliance with it, APA must preserve in its efforts to demonstrate that the advantages of publishing it in 1993 outweigh the disadvantages of adopting yet another manual.     

Clozapine for treatment-refractory schizophrenia, schizoaffective disorder, and psychotic bipolar disorder: a 24-month naturalistic study

BACKGROUND: The aim of this study was to evaluate the 24-month response to clozapine in patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder. METHOD: Ninety-one psychotic patients with a principal DSM-III-R diagnosis of schizophrenia (N = 31), schizoaffective disorder (N = 26), or bipolar disorder with psychotic features (N = 34) were treated naturalistically with clozapine at flexible dosages over a 24-month period. Improvement was assessed by the 18-item Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity of Illness scale. RESULTS: All patients showed significant improvement 24 months from intake (p < .001). Such an improvement was significantly greater among patients with schizoaffective disorder or bipolar disorder than in patients with schizophrenia (p < .05). The presence of suicidal ideation at intake predicted greater improvement at endpoint. CONCLUSION: Clozapine appears to be effective and relatively well tolerated in acute and long-term treatment of patients with psychotic bipolar disorder or schizoaffective disorder who have not responded to conventional pharmacotherapies.     

Factor analysis of the DSM-III personality disorder clusters: a replication

The authors describe the replication of Kass et al.'s study where a factor analysis of scaled ratings of DSM-III personality disorders yielded groupings similar to those described in DSM-III. In this replication the authors used scaled ratings from a nationwide sample of psychiatrists on 358 patients. The authors conclude that this replication lends additional support for the DSM-III (now DSM-III-R) approach towards grouping personality disorders into three (or four) clusters.     

Hypochondriacal delusions in paranoid psychoses. Course and outcome compared with other types of delusions

From a large series of patients with delusional psychoses, first-time admitted to the Psychiatric Department, University of Oslo, hypochondriacal delusions were coded as the main delusion in 15 patients (0.4% of all admissions). These patients have been personally followed up by one of the authors (N.R.) after 5-18 years, and by the other author (S.O.) after 23-39 years (mean 30 years). The results are presented, also according to the newer diagnostic systems (DSM-III, DSM-III-R), and the course and outcome of hypochondriacal delusions are compared with those of other types of delusions. Course and outcome are mainly dependent on the diagnostic category, not the type of delusion. It is also demonstrated that the course and outcome in major affective disorders are more favourable than in paranoid disorders, with the latter being significantly different from schizophrenia.     

Is substance abuse in schizophrenia related to impulsivity, sensation seeking, or anhedonia?

OBJECTIVE: The authors compared impulsivity, sensation seeking, and anhedonia in a group of schizophrenic patients with and without lifetime substance abuse or dependence. METHOD: Patients (N=100) with schizophrenia or schizoaffective disorder (per DSM-III-R criteria) were assessed with the Composite International Diagnostic Interview's section on psychoactive substance use disorder, the Positive and Negative Syndrome Scale, the Barratt Impulsivity Scale, the Zuckerman Seeking Sensation Scale, and the Chapman Physical Anhedonia Scale. RESULTS: The mean scores for impulsivity and sensation seeking were higher in the group with substance abuse (N=41) than in the group without substance abuse (N=59). No significant difference between groups was found regarding physical anhedonia. CONCLUSIONS: As in the general population, high levels of impulsivity and sensation seeking are associated with substance abuse in patients with schizophrenia.     

Subtyping familial schizophrenia: reliability, concordance, and stability

This report examines the reliability, concordance, and long-term stability of the subtypes of schizophrenia defined by four major diagnostic systems (DSM-III, DSM-III-R, ICD-10, and Tsuang-Winokur criteria) and rated both for the first hospitalization and for a best estimate diagnosis reflecting lifetime evolution of symptomatology. Schizophrenics studied belonged to two samples of multiply affected families, namely a sample selected in France and a sample of non-metropolitan French identified in the island of La Réunion. ICD-10 and DSM-III-R show opposite stringency regarding subtyping of schizophrenia, with DSM-III-R having a narrow and ICD-10 a broader definition of specific subtypes. Long-term stability of each subtype was fairly good, stability being the highest for hebephrenics and only intermediate for paranoid and undifferentiated subtypes. Comparison of two different cultural and geographical regions reveals an overall similarity of subtype frequencies in familial schizophrenia. The implications of the results for the choice of diagnostic procedures in family studies of schizophrenia are discussed.     

A field trial of DSM-III-R psychoactive substance dependence disorders

The authors field-tested proposed criteria for diagnoses of psychoactive substance use disorders in the revision of DSM-III (DSM-III-R) and compared them with DSM-III criteria in a treated group of 83 patients. They found a high level of agreement between the diagnostic systems in rates of diagnosis and in the individuals receiving the diagnosis. The greatest cross-system agreement occurred when the minimum number of symptoms required to make the DSM-III-R diagnosis was set at three. Discrepant diagnoses between systems related to removal of social consequences as a requirement for the DSM-III-R diagnoses, less emphasis on physiological tolerance in DSM-III-R, and disagreement in subjects with mild symptoms.     

Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds.

OBJECTIVE: To examine the 1-year prevalence of psychotic symptoms and schizophrenia in nondemented 95-year-olds, and to examine the relation between psychotic symptoms and other psychiatric symptoms, sensory impairments, and cognitive functioning. PARTICIPANTS: The representative sample was 95-year-olds living in G?teborg, Sweden (N = 338). Individuals with dementia were excluded (N = 175), leaving 163 subjects for this study. DESIGN: This was a cross-sectional population study, including psychiatric and physical examinations, cognitive tests, and interviews with close informants. MEASUREMENTS: Diagnosis of schizophrenia, psychotic symptoms, paranoid ideation and dementia according to Diagnostic and Statistical Manual of Mental Disorders, Third Revision (DSM-III) were measured. Cognitive function was tested with the Mini-Mental State Exam. Other psychiatric symptoms were measured by the Comprehensive Psychopathological Rating Scale. RESULTS: The one-year prevalence of any psychotic symptom was 7.4% (95% confidence interval [CI] 3.8-12.5); including hallucinations 6.7% (95% CI 3.4-11.8) and delusions 0.6% (95% CI 0.0-3.4). Four (2.4%) individuals fulfilled DSM-III-R criteria for schizophrenia. Individuals with psychotic symptoms or paranoid ideation did not differ regarding cognitive functioning compared with individuals without these symptoms. Individuals with hallucinations and paranoid ideation had an increased frequency of previous paranoid personality traits compared with individuals without psychotic symptoms and paranoid ideation. No individuals with psychotic symptoms had a formal thought disorder, incoherence of speech, or flat affect. CONCLUSION: The authors found a high prevalence of psychotic symptoms, paranoid ideation, and schizophrenia in the very old. Most of the symptoms were elucidated by information from key informants, illustrating the importance of including relatives in the evaluation of elderly persons.     

Clinical subtypes and age at onset in schizophrenic siblings.

This study examines the concordance of clinical subtypes and age at onset of schizophrenia in 42 sibships of multiply affected schizophrenic patients. Subtypes were defined by four major diagnostic systems (DSM-III, DSM-III-R, ICD-10, and Tsuang-Winokur criteria) and rated both for the first hospitalization and long-term diagnosis. When a sibship method was used, no concordance for subtypes was found in siblings. Age at onset, analyzed as a continuous variable with the intraclass correlation method, was found to be correlated in siblings. This finding suggest that the search for continuous traits distributed in families of schizophrenic patients might constitute an alternative to discrete category-based family studies.     

Process-reactive dimension and outcome for narrow concepts of schizophrenia

The data presented by the authors suggest a more successful prediction of outcome by the process-reactive dimension when it is applied to schizophrenic patients defined according to broad concepts of schizophrenia (e.g., DSM-II) than to narrow concepts of schizophrenia (e.g., DSM-III). Research indicates that the DSM-III is more likely than the DSM-II diagnosis to be composed of "poor prognosis" schizophrenia, as defined by the classical prognostic indicators. In general, the overall results could support the views of Herron and others that the process-reactive dimension is more valuable as a predictor for a schizophrenia spectrum than for modern, narrow concepts of schizophrenia. However, while recent data of the authors indicate that DSM-III schizophrenic patients show poorer outcome than DSM-II schizophrenic patients, they also indicate that (1) DSM-III schizophrenic patients still show heterogeneity in prehospital functioning and outcome, and (2) other prognostic indexes, such as the Zigler-Phillips Scale and the Vaillant-Stephens Scale, have some efficacy in predicting course and outcome among DSM-III schizophrenic patients. Data on prehospital functioning and outcome are discussed in terms of two contrasting models--a developmental model and a natural history model of the course of schizophrenia.     

A prospective DSM-III study of 100 consecutive somatization patients

In this study the authors defined somatization and prospectively studied the prevalence of somatizing patients referred to a psychiatric consultation service. Included are the demographic characteristics and five-axis DSM-III diagnoses of 100 consecutive somatizing patients. A comparison of these patients was made to a control group (N = 161) of nonsomatizing patients also referred for consultation. There were significantly more patients with depression, panic disorder, personality disorders and psychophysiologic illness in the somatization patient sample and significantly more patients with schizophrenia, manic depressive illness, organic brain syndromes, adjustment disorder and serious medical illness in the non-somatization control group. Age, sex, and DSM-III axes IV and V did not significantly differentiate the two groups. The role of somatization as a process as distinguished from a DSM-III somatoform disorder is discsssed, and the importance of somatic symptoms as they relate to an underlying mental disorder is reviewed.     

Bizarre delusions and DSM-III-R schizophrenia.

OBJECTIVE: Bizarre delusions are assigned greater weight relative to other delusions in the DSM-III-R diagnosis of schizophrenia. The decision to emphasize bizarre delusions was based largely on historical tradition rather than empirical evidence. This study examined 1) the extent to which a history of bizarre delusions contributes to the diagnosis of schizophrenia and 2) whether schizophrenic patients with bizarre delusions constitute a clinically distinguishable subgroup. METHOD: Two hundred fourteen consecutively admitted psychotic inpatients were assessed for bizarre delusions according to the DSM-III-R criteria. Clinical and demographic correlates of bizarre delusions were examined in subsets of patients diagnosed as schizophrenic according to DSM-III-R who also received CT scans and neuropsychological testing. RESULTS: With the base prevalence rate for schizophrenia of 0.71, bizarre delusions had a sensitivity of 0.79, a specificity of 0.56, and a positive predictive power of 0.82 for the diagnosis of schizophrenia (N = 152) relative to other psychotic disorders (N = 62). Clinical, neurobehavioral, CT scan, and premorbid adjustment data on the schizophrenic patients indicated that beyond manifesting more severe positive symptoms, patients with bizarre delusions did not otherwise constitute a clinically distinguishable subgroup. CONCLUSIONS: The data suggest that criterion A for the diagnosis of schizophrenia in DSM-IV could be improved by removing the special emphasis that was placed on bizarre delusions in DSM-III-R.     

The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia

The authors present the findings from a long-term follow-up study of 118 patients from Vermont State Hospital who, when rediagnosed retrospectively, met DSM-III criteria for schizophrenia at their index hospitalization in the mid-1950s. The patients were studied with structured, reliable, multivariate instrument batteries by raters who were blind to information in their records. The rediagnostic process is described, and results of the follow-up are presented. Outcome varied widely, but one-half to two-thirds of the sample had achieved considerable improvement or recovered, in contrast to statements in DSM-III that predict a poor outcome for schizophrenic patients.     

Paranoid schizophrenia in adolescence

BACKGROUND: Paranoid schizophrenia is considered to be a rare condition in adolescence. Since this is contrary to the authors' clinical experience, they hypothesized that a controlled study would show that a significant number of adolescents would be diagnosed with paranoid schizophrenia and that scores from the childhood version of the Schedule for Affective Disorders and Schizophrenia (K-SADS) would differentiate between the paranoid schizophrenic adolescents and adolescents with other types of schizophrenia or with affective disorder. METHOD: The authors conducted a prospective study of 120 adolescents admitted consecutively to an adolescent psychiatric inpatient department. Patients were diagnosed on the basis of DSM-III after an 8-week period during which they were evaluated with a structured psychiatric history and psychiatric examination, the K-SADS, repeated nonstructured interviews, and extensive ward observations. RESULTS: Thirty-eight percent of the schizophrenic adolescents and 14% of the total hospitalized population met the DSM-III criteria for paranoid schizophrenia. The symptom profile of the paranoid schizophrenic adolescents clearly distinguished them from adolescents with other psychiatric disorders. CONCLUSIONS: Given the incidence of paranoid schizophrenia in an adolescent population, adolescent psychiatrists are likely to encounter this disorder. DSM-III-R should be used in future studies to further clarify the issue of the prevalence of paranoid schizophrenia in adolescents.     

The course of psychosis in early phases of schizophrenia

To study the course of psychosis in early schizophrenia, the authors assessed 111 patients at hospitalization and at one or two follow-ups. The course of psychosis was analyzed separately for broad (DSM-II) and narrow (DSM-III) concepts of schizophrenia. The patients diagnosed with DSM-II improved in psychosis between the first and second follow-ups. Those also diagnosed with DSM-III showed more persistent psychosis; 40% were psychotic at both follow-ups. A subgroup of patients showed improvement in psychosis even after several years of sustained symptoms. The authors discuss the implications of the data for views about the persistence of psychotic symptoms.     

The use of a self-report instrument for eating disorders diagnoses: how different are DSM-III-R vs. DSM-III?

In response to a 1982 magazine article 641 women completed self report instruments concerning their eating disorders. Simulated DSM-III and DSM-III-R diagnoses were generated from these responses. Rediagnosis of 397 DSM-III normal weight bulimics (NWB) yielded 93.7% with DSM-III-R bulimia nervosa (BN) and 6.3% with DSM-III-R anorexia nervosa with bulimic features (ANB). Rediagnosis of 30 DSM-III ANB, yielded 66.7% with DSM-III-R ANB, 13.3% with DSM-III-R BN and 20% with subdiagnostic eating disorders (SDED). Rediagnosis of 214 DSM-III SDEDs yielded 93.5% DSM-III-R SDEDs, and 6.5% DSM-III-R BNs a relatively small shift. No Eating Disorders Inventory Scale Score or eating disorders behavioral symptom differences were noted between DSM-III and DSM-III-R ANB, or between DSM-III NBW and DSM-III-R and BN in 1982 or 20 months later. Although DSM-III-R diagnostic criteria for eating disorders are more specific than those in DSM-III, our findings suggest they may ultimately make little difference clinically. Self report instruments may be useful in approximating clinical diagnoses in large surveys. They may be especially useful for syndromes such as eating disorders, in which measureable physical criteria and observable behaviors are prominent.