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.     

Illness appraisals and self-esteem as correlates of anxiety and affective comorbid disorders in schizophrenia

Comorbidity of anxiety and affective disorders in people with a diagnosis of schizophrenia is common. This study investigated the hypothesis that greater negative beliefs about illness and lower self-esteem will be significantly associated with the presence of anxiety or affective comorbidity in a sample of persons (n = 138) diagnosed with schizophrenia. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Positive and Negative Syndrome Scale; the Global Assessment of Functioning Scale; the Personal Beliefs about Illness Questionnaire; and the Rosenberg Self-Esteem Scale were all completed for each participant. Of the total sample, 62 (44.9%) had a comorbid anxiety or affective disorder. Logistic regression revealed that those with a comorbid anxiety or affective disorder had significantly lower levels of functioning (Global Assessment of Functioning), more negative appraisals of entrapment in psychosis (Personal Beliefs about Illness Questionnaire), and lower levels of self-esteem (Rosenberg Self-Esteem Scale). Although further research is required, the strong association between personal beliefs about self and illness and comorbidity suggests that negative beliefs about psychotic experiences and self-esteem may be linked to the development and maintenance of anxiety and affective comorbid conditions among people with a diagnosis of schizophrenia or the like.     

The diagnostic value in assessing mood congruence in delusions and hallucinations and their relationship to the affective state

Summary An examination was carried out on 140 schizophrenics, 34 schizoaffective manics, 6 schizoaffective depressives, 59 unipolars, and 30 bipolars to determine the variables of affective states and mood-congruent and mood-incongruent psychotic symptoms. These patients had been admitted to a hospital in Zürich and were systematically diagnosed, using both clinical and computer-derived systems. Forty-eight patients (18%) had both mood-congruent and incongruent psychotic symptoms. However, the affective disorders usually showed mood-congruent symptoms and the schizophrenics the mood-incongruent types. The schizoaffectives were likely to show both types. There was a marked dissociation between affective states and mood congruence in the schizophrenics. Though the majority of these patients showed depressive syndromes, they were quite unlikely to have mood-congruent symptoms. Likewise, 25% of the schizophrenics had manic-like syndromes, which contrasted with the fact that they rarely had mood-congruent psychotic delusions and hallucinations.     

Longitudinal outcome and medication noncompliance among manic patients with and without mood-incongruent psychotic features.

The prognostic utility of mood-incongruent psychotic features was examined in a sample of 23 hospitalized manic patients. Patients were initially subdivided according to whether they met Research Diagnostic Criteria (RDC) for schizoaffective, mainly affective (mood-incongruent) manic disorder (SAM; N = 11) or RDC primary manic (mood-congruent or nonpsychotic) manic disorder (PM; N = 12). Patients were then followed over a 9-month posthospitalization period and rated every 3 months for relapse status, symptom severity, social adjustment, and medication noncompliance. Patients with SAM and PM did not differ at follow-up on rates or timing of manic or depressive relapses or on cycling of symptoms of mood disorder. However, at follow-up, SAM patients had more severe positive and negative psychotic symptoms and poorer social adjustment, and were less medically compliant than PM patients. Results are consistent with the view that mania with mood-incongruent psychotic features is a poor-prognosis subtype of bipolar disorder.     

Adult quality of life and associated factors in adolescent onset schizophrenia and affective psychotic disorders

BACKGROUND: Subjects in treatment for affective disorders are usually less satisfied with life compared to subjects with schizophrenia. AIMS: The aims of this study were to compare subjective quality of life (QoL) at adult age of adolescent onset psychotic disorders and analyse associated factors. METHOD: Fifty-three patients with adolescent onset psychotic disorders were followed up at age 25, diagnostically re-evaluated according to the DSM-IV and assessed with the Positive and Negative Symptoms Scale, the Strauss-Carpenter Scale and the Lancashire Quality of Life Profile. RESULTS: Subjects diagnosed with schizophrenia or schizoaffective disorder (n = 27) experienced significantly lower overall QoL than subjects with psychotic mood disorders (n = 26). Overall QoL was strongly associated to depressed mood (R2 = 0.49) in the schizophrenia group and to degree of employment (R2 = 0.39) in the mood disordered group. CONCLUSION: Depression is a major concern in the evaluation and treatment of patients with schizophrenia, while vocational support seems particularly important after an episode of psychotic mood disorder.     

Major depression with mood-congruent or mood-incongruent psychotic features: outcome after 40 years

Using cross-sectional evaluations 40 years after index admissions, the authors compared depressed patients with mood-congruent and those with mood-incongruent psychotic features. These patients were then compared with patients with nonpsychotic major depression, schizophreniform disorder, or schizophrenia. Outcome in the mood-congruent group resembled that in the nonpsychotic group and was significantly better than that in the mood-incongruent group. Patients in this latter group, however, had significantly better follow-up scores than did schizophrenic patients. These findings are consistent with a short-term outcome and family history study and suggest that patients with major depression and mood-incongruent psychotic features constitute a more diagnostically heterogeneous group than do those with mood-congruent psychotic features.     

Neuropsychological differences between first-admission schizophrenia and psychotic affective disorders

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

Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features.

BACKGROUND: The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions. AIMS OF THE STUDY: To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania. METHODS: One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD). RESULTS: There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania. CONCLUSION: Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.     

Psychosis in bipolar disorder: phenomenology and impact on morbidity and course of illness

Although psychosis is common in bipolar disorder, few studies have examined the prognostic significance of psychotic features. In addition, some studies suggest that the presence of mood-incongruent psychosis, in particular, is associated with poorer outcome compared with mood-congruent psychosis. We assesses the phenomenology and prevalence of mood-congruent and mood-incongruent psychotic symptoms in 352 patients with bipolar I disorder participating in the Stanley Foundation Bipolar Treatment Network. We compared the demographic and clinical features, and measures of psychosocial and vocational functioning in patients with and without a history of psychosis. The phenomenology of psychosis in this cohort of patients with bipolar disorder was similar to that reported in earlier studies and supported the lack of diagnostic specificity of any one type of psychotic symptom. There were no significant differences between patients with and without a history of psychosis on any demographic, psychosocial, vocational, or course of illness variables. Only family history of bipolar disorder was significantly more common in patients with nonpsychotic bipolar disorder compared to patients with a history of psychosis. Among bipolar patients with a history of psychosis, only the proportion of women and lifetime prevalence rates of anxiety disorders occurred significantly more in patients with mood-incongruent delusions. In this large cohort of outpatients with bipolar I disorder, neither a history of psychosis nor of mood-incongruent psychosis had prognostic significance at entry into the Network. The lack of observable prognostic impact may have been, in part, due to the relatively high morbidity and poor functional outcome of a substantial portion of the total cohort.     

Diagnostic specificity of poor premorbid adjustment: Comparison of schizophrenia, schizoaffective disorder, and mood disorder with psychotic features

Individuals with schizophrenia have significant deficits in premorbid social and academic adjustment compared to individuals with non-psychotic diagnoses. However, it is unclear how severity and developmental trajectory of premorbid maladjustment compare across psychotic disorders. This study examined the association between premorbid functioning (in childhood, early adolescence, and late adolescence) and psychotic disorder diagnosis in a first-episode sample of 105 individuals: schizophrenia (n=68), schizoaffective disorder (n=22), and mood disorder with psychotic features (n=15). Social and academic maladjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. Worse social functioning in late adolescence was associated with higher odds of schizophrenia compared to odds of either schizoaffective disorder or mood disorder with psychotic features, independently of child and early adolescent maladjustment. Greater social dysfunction in childhood was associated with higher odds of schizoaffective disorder compared to odds of schizophrenia. Premorbid decline in academic adjustment was observed for all groups, but did not predict diagnosis at any stage of development. Results suggest that social functioning is disrupted in the premorbid phase of both schizophrenia and schizoaffective disorder, but remains fairly stable in mood disorders with psychotic features. Disparities in the onset and time course of social dysfunction suggest important developmental differences between schizophrenia and schizoaffective disorder.     

Profile and Determinants of Disability in Psychotic Disorders in Nigeria

We compared profile and predictors of disability among 210 patients with schizophrenia, schizoaffective disorder, bipolar I disorder with psychosis and depression with psychosis, respectively in a Nigerian clinical population, using the WHO Disability Assessment Schedule, (2.0). Severity of psychosis was determined with Positive and Negative Symptoms Scale, functioning was assessed using the Global Assessment of Functioning Scale, medication adherence with the Medication Adherence Questionnaire. Analyses were by SPSS 20.0. There were remarkable differences in the predictors of disability across these psychotic disorders. The findings strengthens the significance of psychosocial rehabilitation in patients with psychosis as clinical remission and medication adherence did not equate functional recovery.     

Do maternal psychotic symptoms predict offspring's psychotic disorder? Findings from the Helsinki High-Risk Study

The Helsinki High-Risk (HR) Study is a follow-up study of 179 offspring born to mothers with DSM-IV-TR diagnoses of schizophrenia, schizoaffective disorder, other schizophrenia spectrum disorders, and affective psychoses. Mothers comprised all female patients born between 1916 and 1948 who had been treated with hospital diagnoses of schizophrenia, schizophreniform, or schizoaffective psychoses in any mental hospital in the city of Helsinki up to 1974, and who had given birth in Helsinki between 1960 and 1964. In this report we conducted a principal factor analysis of maternal symptoms using 12 items of the Major Symptoms of Schizophrenia Scale (MSSS), the global ratings of anhedonia-asociality and avolition-apathy from the Scale for the Assessment of Negative Symptoms (SANS), and the global rating of bizarre behavior from the Scale for the Assessment of Positive symptoms (SAPS), and examined whether the factor scores predicted the offspring's morbidity from psychotic disorders. We found a four-factor solution (negative, positive, catatonic, and affective symptom factors). High maternal positive symptom factor score significantly predicted decreased morbidity from schizophrenia among offspring (P=0.0098). Our result suggests that maternal positive symptoms are less harmful to the child than other maternal psychotic symptoms, and supports the view that positive symptoms are non-specific symptoms of psychosis rather than core features of schizophrenia.     

Symptom factors in early-onset psychotic disorders

OBJECTIVE: To examine the factor structure of symptom ratings in early-onset psychotic illnesses. METHOD: Subjects were drawn from a 2-year prospective study of early onset psychotic disorders. Principal components analysis with orthogonal (varimax) rotation was used to create factors from baseline ratings on the Schedule for Positive Symptoms, the Schedule for Negative Symptoms, and the Brief Psychiatric Rating Scale for Children. RESULTS: Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (n = 20) were included. Four symptom factors were identified: negative symptoms, positive symptoms, behavioral problems, and dysphoria. Negative symptoms were predictive of the diagnosis of schizophrenia and treatment with antipsychotic medications. Neither behavior problems nor dysphoria were predictive of diagnosis. In subjects who completed follow-up assessments at year 1 (n = 49) and year 2 (n = 39), negative symptoms and behavioral problems predicted poorer functioning. CONCLUSIONS: The four factors are clinically relevant, with both treatment planning and prognostic implications. Negative symptoms best differentiated schizophrenia from the other disorders. Behavior problems and dysphoria were nonspecific problems that occurred in all three disorders, which likely leads to misdiagnosis in community settings.     

Influence of gender on social outcome in schizophrenia

OBJECTIVE: To study the relevance of gender on social functioning in schizophrenia. METHOD: A sample of 200 schizophrenic (DSM-IV criteria) out-patients were followed-up during 2 years and were administered the following instruments: Positive and Negative Symptom Scale (PANSS), Disability Assessment Scale (DAS-sv), and Global Assessment of Functioning (GAF) Scale. A regression model was created with DAS and GAF as dependent variables, and gender, PANSS, age of onset, duration of illness and marital status as independent variables. Separate regression models were then generated for females and males. RESULTS: Gender influenced significantly on DAS and GAF, with men showing worse functioning. In gender specific analyses, we found a significant influence of illness duration and Positive and Negative PANSS on social functioning in men, and of age at onset and Negative PANSS in women. CONCLUSION: Gender had a significant influence on social functioning in schizophrenia, even after adjusting for the other independent variables.     

Long-term course of adolescent schizophrenia

Our study investigated premorbid functioning, course, and outcome in early-onset schizophrenia. All inpatients with DSM-III-R diagnoses of schizophrenia (n = 101) consecutively admitted between 1983 and 1988 to the Department of Child and Adolescent Psychiatry at the University of Marburg in Germany were included. To assess premorbid adaptation and precursor symptoms, we administered the Instrument for the Retrospective Assessment of the Onset of Schizophrenia, which we modified to assess children and adolescents. Symptomatology was measured by the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, and the Brief Psychiatric Rating Scale. In addition, the Global Assessment of Functioning was applied. Followup data for 81 patients (80.2%) were available. The mean duration of schizophrenia at followup was 9.5 +/- 2.2 years. Assessment of the highest level of adaptive functioning revealed very good or good outcome in 19.8 percent of the patients, fair or poor outcome in 38.2 percent, and very poor outcome and gross impairment in 42.0 percent. Premorbid adjustment was the best predictor of outcome in our schizophrenia sample. A poor prognosis was found in patients with premorbid developmental delays and those who were introverted and withdrawn before their psychotic state.     

Is there an association between duration of untreated psychosis and 24-month clinical outcome in a first-admission series?

OBJECTIVE: The authors examined the duration of untreated psychosis, defined as the interval from first psychotic symptom to first psychiatric hospitalization, in a county-wide sample of first-admission inpatients who had received no previous antipsychotic medication. Differences between diagnostic groups in 24-month illness course and clinical outcomes as well as relationships between outcomes and duration of untreated psychosis were evaluated. METHOD: The data were derived from subjects in the Suffolk County Psychosis Project who were diagnosed at 24-month follow-up according to DSM-IV as having schizophrenia or schizoaffective disorder (N=155), bipolar disorder with psychotic features (N=119), or major depressive disorder with psychotic features (N=75). Duration of untreated psychosis was derived from the Structured Clinical Interview for DSM-III-R, medical records, and information from significant others. Measures at 24-month follow-up included consensus ratings of illness course, Global Assessment of Functioning Scale scores for the worst week in the month before interview, and current affective and psychotic symptoms. RESULTS: The median duration of untreated psychosis was 98 days for schizophrenia, 9 days for psychotic bipolar disorder, and 22 days for psychotic depression. Duration of untreated psychosis was not significantly associated with 24-month illness course or clinical outcomes in any of the diagnostic subgroups. CONCLUSIONS: Although these findings require replication in other epidemiologically based first-admission samples, at face value they do not support the suggestion of a psychotoxic effect of prolonged exposure to untreated psychosis.     

Psychotic features in chronic posttraumatic stress disorder and schizophrenia: comparative severity

Psychotic features are frequent in combat veterans with chronic posttraumatic stress disorder (PTSD), may correlate with severity of PTSD symptoms, and may reflect a distinct subtype of the disorder. These psychotic features include auditory and visual hallucinations and delusional thinking that is usually paranoid in nature. Psychotic features may be under-recognized in chronic PTSD because patients are reluctant to report these symptoms and because they may not have overt changes in affect or bizarre delusions characteristic of other psychoses, e.g., schizophrenia. To further assess these phenomena, we compared clinical ratings on the Positive and Negative Syndrome Scale (PANSS) and other assessments, including the Clinical Global Impression Scale and the Structured Clinical Interview with Psychotic Screen, in veterans meeting DSM-IV criteria for chronic PTSD with well-defined comorbid psychotic features (N = 40) or chronic schizophrenia (N = 40). The patients with schizophrenia had modestly higher composite PANSS scores and positive symptom scores although average scores in both groups were moderate to severe in intensity. Negative symptom and general psychopathology subscale scores were comparable in both groups. Regarding specific positive symptoms, hallucinations were comparable between groups in severity; however, schizophrenia patients had slightly more intense delusions and conceptual disorganization. These data further validate the occurrence of positive as well as negative symptoms of psychosis in chronic PTSD in a range of severity that may approach that of patients with schizophrenia. Although meeting DSM-IV criteria for two different major psychiatric disorders, these two patient populations were remarkably similar with respect to not only positive but also negative symptoms.     

Mood-incongruent versus mood-congruent psychosis: differential antipsychotic response to lithium therapy

The authors previously reported that a subgroup of schizophrenic-like patients respond favorably to lithium (Li) therapy, as do patients with a classical manic illness. In the present study, the time course of psychotic and affective symptom remission after Li therapy was examined in these two groups of patients. Li responsive patients with a mood-incongruent psychosis (schizophrenic-like illness) demonstrated a rapid antipsychotic response to Li therapy, showing a 50% improvement during the first 7 days, while no improvement in affective symptoms was seen until week 2 or 3 of treatment. Alternatively, patients with a mood-congruent psychosis (where mania is the primary diagnosis) demonstrated no antipsychotic response to Li therapy during the first 2 weeks of treatment, while some improvement in manic symptoms occurred during treatment week 2. The present study demonstrates that Li therapy differentially affects psychotic symptoms in mood-incongruent as opposed to mood-congruent psychosis. Further, the growth hormone (GH) response to apomorphine administration differentiated these two groups of Li responsive patients. Patients with a Li responsive mood-incongruent psychosis demonstrated over a seven-fold greater GH response than mood-congruent psychotic patients. The present data suggest that mood-incongruent and mood-congruent psychoses may represent two biologically distinct psychotic processes separable by both medication response and central dopamine function.     

Competence to give informed consent in acute psychosis is associated with symptoms rather than diagnosis

To investigate the association between competence to give informed consent to treatment, specific symptomology and diagnostic category, 110 inpatients diagnosed with DSM-IV acute schizophrenia (n = 64), schizoaffective disorder (n = 25) and bipolar affective disorder (n = 21) were interviewed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Positive and Negative Syndrome Scale (PANSS). Results indicated no significant difference in competence between the three disorders. Elevated positive, cognitive and excitement PANSS factor scores had lower MacCAT-T scores. Further analyses indicated symptoms that impair cognition; particularly, conceptual disorganisation and poor attention were most consistently related to poor performance on competence tests.     

Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder

Background

Psychotic disorders are associated with significant social dysfunction. Anomalous self-experiences (ASE) present in psychotic disorders could contribute to social dysfunction.

Aim

To investigate if ASE contribute to social dysfunction in the early phases of psychotic disorders after controlling for factors related to social functioning including diagnoses.

Methods

ASE were assessed by means of the EASE (Examination of Anomalous Self-Experience) in 76 patients referred to their first adequate treatment for schizophrenia or psychotic bipolar disorder. Diagnoses, symptom severity, and functioning were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Premorbid Adjustment Scale, Global Assessment of Functioning—Split Version, and Social Functioning Scale. Neurocognitive assessments included measures of psychomotor speed, working memory, executive and memory functions. Duration of untreated psychosis was also assessed.

Results

High levels of ASE were significantly associated with poorer social functioning in the early phases of schizophrenia and psychotic bipolar disorder also after correcting for diagnosis.

Conclusion

This study demonstrates the significance of ASE for social dysfunction in patients with psychotic disorders, and contributes to the understanding of the complexity of illness-related factors that affect social functioning.