Magnetic resonance imaging findings in schizophrenia and atypical psychoses

The differences among MRI findings were studied in schizophrenic psychoses. The schizophrenics and atypical psychotics had significant reductions in bilateral hippocampal volumes compared to controls, but the two patient groups did not differ from each other. As for ventricle volume, the schizophrenics showed significantly larger temporal horns and third ventricle than normal controls, whereas atypical psychotics did not. Moreover, the left temporal horn in the schizophrenics was significantly larger than that seen in the atypical psychotics. By cluster analysis, schizophrenics and atypical psychotics were found to have a tendency to be distributed in different groups. These results might be considered to support the classification of schizophrenic psychoses into schizophrenia and atypical psychoses.     

Typological studies of psychotics' personality before their illness, with special reference to manic-depressives]

This article deals with the following problem: to what extent is it possible to draw conclusions about the type of psychosis involved--in a case of endogenous psychosis--when one only has indications about the family background and the development of the personality before the illness, excluding all data about cases in the family, former pathological episodes and the present illness of the patient? Only pure forms of endogenous psychoses have been taken into consideration. Our hypothesis was that schizophrenics show before their illness schizoid features, subjects with an endogenous depression show features of the melancholic type, whilst manic depressives do not correspond to any of these types. After having studied most of the literature on this subject, we have attempted to draw from case histories the most marked features of personality and to obtain an overall picture of the primary personality of schizophrenic, depressive and manic depressive patients. This material was used for a "blind diagnosis" from 40 case histories (20 schizophrenics, 10 depressives and 10 manic depressive patients treated at the Max Planck Institute of Psychiatry, Munich). The results of this evaluation were significantly superior to those of a random distribution. Furthermore, we have attempted to outline the principal elements of the personality of future manic depressives from three examples out of the ten case histories studied. We came to the conclusion that although it is impossible to clearly oppose the primary personality of manic depressives to that of depressive patients, we have found a series of differences that prevent us from outlining a real common denominator for patients with "affective psychoses'.     

Course and outcome of acute non-organic psychotic states in India

This paper presents an overview of the diagnoses and short-term course of acute psychotic illnesses—affective as well as nonaffective—in a developing country setting. In the Chandigarh Acute Psychosis Study (CAPS) in Northern India, a cohort of 91 cases of acute psychotic illness were assessed for symptoms, diagnosis, and course ratings at multiple intervals over a 12 month period; cases were drawn from a rural and an urban clinic, permitting comparison of patients in these two settings. Non-affective (mainly schizophrenic) patients were found to be the predominant group (51%), followed by manic (26%), and depressive (19%) patients. Overall the acute psychoses had an excellent shortterm course and outcome, a result which held across all diagnostic groups and both the rural and urban setting. Rural and urban patients were similar in diagnostic distribution and course of illness. Investigations of such cases can expand our view of the possible manifestations and course of psychotic disorders, and may have implications for diagnosis.     

Prognosis of the course of schizophrenic psychoses compared to other psychiatric illnesses

Summary In a prospectively designed study of the course of illness of 161 hospitalized psychiatric patients, data regarding outcome could be obtained for 93% 1 year after clinic discharge. It was possible to reexamine 67% of the patients by means of direct interviews. No significant differences appeared in the comparison of the course of illness outcomes (symptoms, rehospitalization, occupation and social contacts) of patients with schizophrenic psychoses, affective psychoses, neuroses or a group of mixed other diagnoses (predominantly alcohol dependency). For the group of neuroses there was a particularly striking discrepancy between the self- and the observer-ratings at the time of discharge from inpatient index-treatment. From this finding and from the comparatively more intense prominence of depressive symptoms at the time of follow-up, one can presume that there has been insufficient after-care treatment of this patient group considering the recorded treatment data. This seems to hold true for the group of alcohol dependents as well. In contrast, the after-care treatment of patients with affective and schizophrenic psychoses seems more likely to be ensured today. Despite this, however, for the latter the close link between the rate of relapse and the rate of rehospitalization can apparently scarcely be influenced.     

Single Photon Emission Computed Tomography (SPECT) Findings Using N-Isopropyl-p-[123I]iodoamphetamine (123I-IMP) in Schizophrenia and Atypical Psychosis

Abstract: As a basis for possible classification of schizophrenic psychoses into schizophrenia and atypical psychosis, we studied the brain functional differences among 16 schizophrenic patients, 16 atypical psychosis patients and 16 healthy volunteers by single photon emission computed tomography (SPECT) using N-isopropyl-p-[¹²³I]iodoamphetamine. As a result, schizophrenics showed hypofrontality. On the other hand, atypical psychotics had no such hypofrontality but showed a reduced uptake rate in the right thalamic region. No influence of sex, duration of illness and medication was confirmed by the findings. The results suggest that schizophrenics might have some lesions in the frontal regions, whereas atypical psychotics might have no such lesions, but dysfunction in the right thalamic region. Consequently, the SPECT findings at least indicate possibly different etiologies for schizophrenia and atypical psychosis.     

伴抑郁症状的精神分裂症的临床特征分析

目的了解伴抑郁症状的精神分裂症的临床特症。方法对８１例伴抑郁症状的精神分裂症、１００例不伴抑郁症状的精神分裂症及６０例抑郁症患者进行临床对照研究。结果伴抑郁症状的精神分裂症具有每次发病时间长、易复发的特点，临床表现以罪恶妄想、疑病妄想、虚无妄想、贫穷妄想多见，抑郁症状以无助、无望感及精神运动性迟滞突出；加用与不加用抗抑郁剂比较，在治疗起效时间、症状改善时间方面的差异均有非常显著性（Ｐ＜０．０１）。结论对伴抑郁症状的精神分裂症患者给予适当的社会支持、治疗上加用抗抑郁剂是缩短疗程的有效途径之一     

Single-Photon Emission Computed Tomography of the Brain in Acute Mania and Schizophrenia

Single-photon emission computed tomography (SPECT) imaging with n-isopropyl1odoamphetamine (IMP) was performed on 11 patients with bipolar mania, 21 acute schizophrenics, and 15 healthy control subjects. Subjects were evaluated with neuropsychological tests and psychiatnc rating scales. SPECT bram studies were blindly evaluated to assess the degree of radiopharmaceutical uptake in three neuroanatomical regions of interest in each hemisphere. All the control subjects, 1 manic patient and 1 schizophrenic patient had normal brain SPECT uptake patterns. The scans of all others were read as abnormal. Hypofrontality was noted in some schizophrenics and maniacs. A significant increase in tracer uptake in temporal lobes was observed in both patient groups, more prominently in the manic patients. Increased and decreased basal ganglia uptake was also observed in patients. Both manic and schizophrenic patients showed cortical tracer heterogeneity of varying degree. The patterns of cerebral SPECT uptake seen in these acute psychoses were not specific for a diagnosis, but may be associated with dimensions of psychopathology. Because the patterns are different from those seen in cerebrovascular disease and the dementias, they may prove to be helpful in differential diagnosis.     

A long-term follow-up study of schizophrenia: psychiatric course of illness and prognosis.

A systematic psychiatric follow-up study of 502 schizophrenics was carried out using the same well-defined criteria to evaluate the patients throughout the investigation. After an average course of disease of 22.4 years, 22.1% of the patients showed complete psychopathological remission, 43.2% had non-characteristic types of remission and 34.7% suffered from characteristic schizophrenic deficiency syndromes. At the time of the last follow-up investigation, 86.7% of the patients were living at home, while 13.3% were permanently hospitalized. Of the entire sample, 55.9% were found to be "socially recovered". Higher education, psychoreactive provocation, depressive traits, perception of delusions, catatonic agitation, non-characteristic thought disorders and symptoms of depersonalization at the onset of the illness tended to carry with them a favorable prognosis. On the other hand, low intelligence, abnormal primary personality, premorbid disturbances in social behavior, broken homes, prolonged prodromal stages, pneumoence-phalographically measurable atrophic or dysplastic changes in the brain ventricles as well as somatic and auditory hallucinations and predominance of hebephrenic symptoms at the onset of the illness tended to lead to an unfavorable prognosis. The principle of the basic reversibility of typical schizophrenic symptoms and the extensive irreversibility of the non-characteristic defect is important for the psychopathological and social long-term prognosis.     

Classification and prognosis of schizophrenic disorders in light of the Bonn follow-up studies

In the Bonn Schizophrenia Study (Huber et al., Monogr. Gesamtgebiete Psychiat., vol. 21, Springer, Berlin 1979) 113 cases fulfilled the criteria for four types of schizo-affective and/or cycloid psychoses. Each of these subgroups had a significantly more favorable long-term prognosis than that of the Bonn sample as a whole. Several prognostically favorable factors found in the Bonn Study are identical to criteria used to classify schizo-affective, schizophreniform and cycloid psychoses, e.g., acute onset, endogenomorph-depressive symptoms, and psychoreactivity. In the Bonn main sample of 502 schizophrenics, 22% demonstrated complete recovery and 40% more or less noncharacteristic types of remission (pure asthenic defect); 56% were socially recovered, two thirds reaching their premorbid level and one third remaining below it. The 12 different types of course are described. There are four course type groups, the prognostically favorable (types I-III), the relatively favorable (types IV-VI), the relatively unfavorable (types VII-IX), and the unfavorable group (types X-XII), each embracing about one quarter of all schizophrenics. The long-term prognosis is dependent on factors such as primary personality, school success, precipitating factors and certain psychopathological initial symptoms and syndromes. The results support the assumption that early treatment, including that of the prodromes, improves the long-term prognosis or at least the chance of complete remission of the subgroup with peracute and acute onset. In spite of the more favorable long-term outcome of the schizo-affective psychoses the results cannot justify the nosological differentiation and classification of these and related psychoses as an independent disease entity but only as different prognostically favorable types of endogenous psychoses. In this respect it is possible to make a distinction between a nuclear group of schizophrenia and a different group with a better prognosis, variously termed schizophreniform, schizo-affective or psychogenic psychoses, which with respect to prognosis is an intermediate group.     

A prognostic study of clinical dimensions in adolescent-onset psychoses

Adolescent-onset psychoses often raise diagnostic difficulties because of the mixture of schizophrenic and affective features. This study examined prospectively which clinical dimensions contribute to difficulty in initial diagnosis and which clinical features have predictive value for outcomes of schizophrenia or affective disorders, and for eventual psychosocial functioning. Thirty-six adolescents consecutively admitted for a psychotic episode were followed up for 1 to 4 years. Symptoms were assessed at admission, at discharge, and once a year. DSM-III-R (APA 1989) diagnoses were assessed at admission and once a year. Comparisons were performed across initial and followup diagnostic groups. Positive symptoms did not differentiate the initial clinical pictures, while negative symptoms, manic symptoms, and disorganization differentiated the manic and depressive episodes in the acute phase. When initial positive symptoms (mainly delusions) were severe, they predicted a final diagnosis in the schizophrenia spectrum. Poor outcome was associated with more anhedonia-associality and lower functioning scores at admission. Results suggest (1) a higher vulnerability to positive symptoms in adolescents who will further develop schizophrenia and (2) the low specificity of affective symptoms at this age.     

Genetic investigations of atypical psychoses. I. Morbidity in parents and siblings.

In the literature a number of terms have been applied to psychoses that seem to be neither manic-depressive nor schizophrenic. In this report we have chosen the term atypical psychoses as being the most neutral. Whether these psychoses represent a separate psychosis or simply present atypical features of manic-depressive psychosis or schizophrenia is an unresolved issue. Family studies are one way of resolving such questions. Seven family studies of atypical psychoses were found that report age-corrected risks for psychoses in family members. Data from the studies were combined. The results do not support claims that atypical psychoses may be categorized as strictly manic-depressive or schizophrenic. There is some evidence that investigator bias may have skewed results away from finding an increased morbidity risk for atypical psychosis. The most striking finding is that the modal illness in parents and siblings is remitting. The genetic evidence would suggest that the relationship of atypical psychoses to schizophrenia is minor. The question now centers on the relationship between atypical psychoses and the affective disorders.     

Evidence for heterogeneity in a group of good-prognosis schizophrenics

Twenty-eight good-prognosis schizophrenics were selected on the basis of factors known from previous studies to predict recovery. These probands received a detailed mental-status exam in addition to providing extensive historical information. First-degree family members were contacted and interviewed wherever possible to establish psychiatric diagnoses in relatives.The 28 probands were divided into two subgroups: (1) unipolar, those who exhibited depressive symptoms only (N = 11), and (2) bipolar, those with previous or current history or findings of manic symptoms (N = 16). Bipolars showed a trend toward earlier age of onset of illness and had more episodes and larger numbers of “schizophrenic” symptoms than did unipolars. There was a trend for ill relatives in the families of bipolars to be manic and to have schizophrenic symptoms.The conclusion of the study is that this sample of good-prognosis schizophrenics is heterogeneous and is composed of at least two subgroups similar in some clinical features to patients with unipolar and bipolar affective disorder.     

Pseudoneurotic and pseudopsychopathic schizophrenia: a follow-up

A series of 67 pseudoneurotic and pseudopsychopathic schizophrenics were followed up. The prognosis was good insofar as these psychoses do not develop schizophrenic deterioration. Complete recoveries are rare, as borderline characteristics tend to persist. We only considered 5 cases as completely recovered. The hospital diagnosis was predominantly reactive psychoses, and the largest group of close relatives also had reactive psychoses. The distinction between pseudoneurotic and pseudopsychopathic schizophrenia is fairly reliable. By independent coding of 64 cases, the authors agreed on about 58 cases and disagreed on about 6 cases.     

Influence of personality disorder on the course of manic-depressive illness

In these past years, comorbidity of manic-depressive illness with personality disorders were the subject of many studies. In order to study the influence of personality disorder on the course of the disease, the authors have compared a group of manic depressive patients with personality disorders to an other group of manic depressive patients without personality disorders. The comparison between the outcome and prognosis of each group has leaded to the conclusion that manic depressive patients with personality disorders evaluate worse than those without personality disorders: they are more often hospitalized and have more suicide attempts, they are more vulnerable to stress factors and finally they have low scores on the Global Assessment of Functioning scale (GAF).     

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)     

Horizontal and vertical pursuit eye movements,the oculocephalic reflex,and the functional psychoses

Sixteen schizophrenic patients, 16 manic-depressive patients, and 14 nonpatient control subjects were tested for horizontal and vertical smooth pursuit eye movements (SPEM) and the oculocephalic reflex. All patients with impaired horizontal pursuit also displayed disrupted vertical pursuit, suggesting that a common mechanism underlies these abnormalities. The oculocephalic reflex was intact in 96% of the subjects whether or not pursuit was disrupted, suggesting that the locus of the eye movement disorder in psychosis may be cortical. For horizontal pursuit, there were significant differences between schizophrenics and nonpatient controls, and between manic depressives and nonpatient controls, but not between schizophrenics and manic depressives, suggesting that the SPEM disruption occurs with significant prevalence in major functional psychoses and not only in schizophrenia.     

Quality of affective symptomatology and its importance for the definition of schizoaffective disorders

169 patients with schizophrenic symptomatology at least once and a mean follow-up period of 20 years were divided in three groups regarding the presence and type of accompanying affective symptomatology. The groups were compared regarding sociodemographic and other premorbid features and long-term outcome. The results show that not every depressive or euphoric symptom but only melancholic or manic symptomatology qualifies the schizophrenic syndrome as schizoaffective.     

Discriminating symptoms in schizophrenia. A report from the international pilot study of schizophrenia.

Schizophrenia is recognized by the presence of one or more clinical syndromes, but there is disagreement as to how far the boundaries of the concept should be extended. During the course of a World Health Organization study, using the Present State Examination and a computerized classification program, a nuclear schizophrenic syndrome was nearly always (95.1%) associated with a diagnosis of schizophrenic or paranoid psychosis. The only substantial exception was that 13 out of 79 patients diagnosed as manic were said to show the nuclear syndrome. The computer classification was concordant with a clinical diagnosis of schizophrenic or paranoid psychosis, manic psychosis, or depressive disorder, in 90% of cases. If appropriate precautions are taken, many of the sources of noncomparability in epidemiological, therapeutic, and prognostic studies can be brought under control.     

Frontal dysfunction in schizophrenia – a new electrophysiological classifier for research and clinical applications

We determined whether schizophrenic patients can be reliably classified with electrophysiological tools. We developed a fully computerized classifier based on 5 minutes of EEG recording during an acoustical choice reaction time task (AMDP-module IV). We included factorized variables from the frequency domain and evoked potentials (N100/P200-complex) from central and frontal electrodes, which were preprocessed in a sample of 150 normal subjects prior to classification. We applied discriminant analyses to the electrophysiological data from depressive, schizophrenic and schizotypal subjects, most of them being unmedicated or drug-naive. The classifier was developed on a training set (33 schizophrenics, 49 normals) and tested on an independent sample (32 schizophrenics, 49 normals). A simple three-variable classifier was found to classify schizophrenics and normals in 77% of those tested correctly. Diagnostic specificity of the classifier proved to be low as the inclusion of depressive patients (n= 60) significantly decreased classification power. It was demonstrated that atypical but not typical neuroleptic drugs may influence the classification results. Correctly classified schizophrenics showed significantly more negative symptoms and slower reaction times than those schizophrenics who were misclassified as normals. In contrast, these misclassified schizophrenics showed a non-significant trend for more positive symptoms and shorter reaction times. As the correctly classified schizophrenics showed increased frontally pronounced delta-activity and decreased signal power of the N100/P200 amplitude, it was concluded that these schizophrenics show dysfunction of the frontal lobe. It is proposed that this new classifier can be useful for clinical and research applications when subtyping of schizophrenics with detection of frontal dysfunction as the aim.