Premorbid functioning in early-onset psychotic disorders

OBJECTIVE: To examine the premorbid characteristics of youths with early-onset psychotic disorders. METHOD: Subjects with early-onset psychotic disorders received an extensive diagnostic evaluation upon entry into the study, including a historic review of premorbid functioning using the Premorbid Adjustment Scale. RESULTS: Youths with schizophrenia (n = 27), bipolar disorder (n = 22), and psychosis not otherwise specified (NOS) (n = 20) were included. High rates of premorbid behavioral problems and academic difficulties were noted across all subjects. Youths with schizophrenia had higher rates of premorbid social withdrawal and global impairment. They also tended to have fewer friends. The psychosis NOS group had significantly higher rates of abuse histories and posttraumatic stress disorder. CONCLUSIONS: Premorbid abnormalities are common features of early-onset psychotic disorders. The social withdrawal and peer problems specific to youths with schizophrenia likely represent early manifestations of negative symptoms. The abuse histories in the psychosis NOS group may explain the atypical nature of their reported psychotic symptoms, which in many cases are likely posttraumatic phenomena.     

Efficacy of atypical antipsychotics in early-onset schizophrenia and other psychotic disorders

Early-onset psychotic illnesses in children and adolescents are not as rare as is commonly believed. These disorders, which include schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, and major depression with psychotic features, often have a chronic and severe course and poor long-term outcome. Many patients with early-onset schizophrenia have greater functional impairments than most patients with adult-onset schizophrenia. Magnetic resonance imaging studies show that patients with early-onset schizophrenia experience substantial gray matter loss during adolescence, which is not observed in studies of patients with adult-onset schizophrenia. The chronic course, severe functional impairments, and poor prognosis of early-onset psychosis create a great need to identify effective and safe treatments for youth with psychosis. Although atypical anti-psychotics have been considered superior to traditional antipsychotics, there has been little controlled information to inform clinical decisions until recently. Over the past 5 years, several studies have been initiated to address these questions. The results of the studies completed to date are reviewed.     

Risk factors for homelessness among people with psychotic disorders

  Background: Although it is widely accepted that rates of severe mental illness amongst single homeless people are high, little is known about the reasons these individuals become homeless. This study aimed to identify risk factors for homelessness among people with psychotic disorders. Methods: A matched case-control study of homeless and never homeless people with psychotic disorders was carried out, with respondents recruited from mental health services (N = 39 pairs). Data were collected by semi-structured interviews and from medical records. Results: A number of social and behavioural risk factors were identified; key factors being loss of contact with childhood carers, and substance use. Clinical and service use factors appeared less important as predictors of homelessness. Conclusions: Mental health services have a limited role in circumventing homelessness among people with psychotic disorders. An integrated approach involving other key agencies is required. Accepted: 23 May 2000     

Self-control in psychotic disorders

Our follow-up study of 20 psychiatric patients and a review of the relevant literature support the idea that some persons may be able to exert control over their own psychiatric symptoms. This self-regulation process consists of three phases: In the first phase, persons become aware of the existence of psychotic or prepsychotic behavior by self-monitoring. In the second phase, self-evaluation, the person recognizes the implications of these behaviors as a signal of disorder. In these phases, detecting early affective signals that may herald the onset of psychotic symptoms and noting the sequences of events often followed by symptoms are particularly important. Once these symptoms or their precursors are detected, phase 3 occurs in which mechanisms of self-control are employed. Three such mechanisms are particularly common: self-instruction, reduced involvement in activity, and increased involvement in activity.     

Neuroprotection in emerging psychotic disorders

Aim: The emerging phase of psychotic disorders is pleomorphic and fluctuates in presentation. Hence, from a clinical perspective, treatment modalities are often unclear. This paper investigates the rational and potential use of neuroprotective agents in emerging psychotic disorders. Methods: Medline databases were searched from 1966 to 2006 followed by the cross‐checking of references using following keywords: neuroprotection, apoptosis, natural cell death, neurodevelopment, plasticity, neurogenesis, combined with brain and schizophrenia. Results: Agents such as atypical antipsychotics, antidepressants, omega‐3 fatty acids, modulators of glutamateric neurotransmission (e.g. ampakines, glycine, memantine), erythropoietin, N‐acetylcysteine, COX‐2 inhibitors or antioxidants have neuroprotective (anti‐apoptotic) properties and may therefore be able to protect brain maturational processes disturbed in emerging psychotic disorders. Clinical trials suggest that atypical antipsychotics, antidepressants, omega‐3 fatty acids and low‐dose lithium as sole treatments were able to improve symptoms and functioning, and delay or in some cases even prevent the onset of frank psychosis. Initially these substances have been chosen because they have been used either as sole or augmentation treatments in established psychotic disorders. However, chronicity and already effective treatments may overshadow their potential clinical use in emerging (prodromal) psychosis. Conclusion: Neuroprotection as a new treatment paradigm for at‐risk mental states seems to be promising and pilot data are suggestive that more benign interventions may already be sufficient to delay or even prevent the onset of frank psychosis. A coordinated research effort will be necessary to address the question which agents should be used under which circumstances.     

Estradiol levels in psychotic disorders

Estradiol has been postulated to constitute a protective factor for schizophrenia, which could provide women at risk to experience a psychotic episode with a relative protection in phases of high estradiol levels, i.e. before menopause and during the peri- and postovulatory phases of their cycle. Women suffering from schizophrenia have been reported to show significantly lower estradiol levels than the normal population and to experience first onset or recurrence of a psychotic episode significantly more often in low estrogen phases of the cycle with low estradiol levels. We examined estradiol levels in an open prospective study in 43 women admitted with a diagnosis of an acute psychotic episode and could confirm these findings for schizophrenia as well as other psychotic disorders. Only 28% of the women exhibited estradiol and progesterone levels indicating a peri- or postovulatory phase and all of the estradiol levels on admission were either within the lower part of the cycle-dependent normal range or below normal; comparison with a control group of healthy volunteers and patients admitted with different psychiatric diagnoses confirmed their estradiol levels to be significantly higher. However, when splitting this control group, the statistical difference would only hold between the study group of psychotic patients and the healthy control group. The group of patients with other diagnoses than a psychotic episode fell in between of the other two groups and did not differ significantly from either. Thus, an unspecific effect, i.e. a hypothalamic downregulation due to the stress of acute hospitalization must be born in mind when assessing hormone levels in acutely psychotic women.     

Genetic consultation in psychotic disorders

The author gives an account of the problem of psychotic diseases in the practice of a genetic department. She mentions the specificity of decision taking on the reproduction in psychotic subjects, where in addition to the empirical risk of affection of the offspring and the possible teratogenic effect of medication, the load associated with the disease from the medical and socio-economical aspect must be considered. These factors are subject to the subjective interpretation by the family. The task of the geneticist is to help a rational solution of the situation in close cooperation with the psychiatrist.     

Interactive risk factors for treatment adherence in a chronic psychotic disorders population

This study identified the unique and primary contributions of several concurrent risk factors for poor adherence to treatment recommendations in a clinic population of individuals with chronic psychotic disorders, i.e. 48% had DSM-IV diagnoses of schizoaffective disorder, 38% had schizophrenia, paranoid type, 12% had schizophrenia, undifferentiated type, and 2% had affective disorder with psychotic features. The target cohort consisted of 87 consecutive admissions to a continuing day treatment program. As part of a services-oriented quality assurance program, clinical staff completed rating scales for all patients. These included the BASIS-32 rating scale, which consisted of the following five subscales: psychosis; depression/anxiety; impulsive/addictive behavior; relation to self and others; and daily living and role functioning, and the Working Alliance Inventory-short form (therapist version), which consisted of the following three subscales: goal; task; and bond. These data were used to identify risk factors that weaken a patient's adherence to medication and non-medication treatment during the first 2 weeks of treatment in the clinic. Medication treatment consisted of both typical and atypical neuroleptic medications, with most patients being on multiple medications. Correlational analyses suggested that many of the risk factor variables were significantly associated with poor treatment adherence. Regression analyses suggested that the degree of psychoticism was most strongly associated with poor adherence to medication treatment and that difficulties relating to self and others were the strongest predictor of poor adherence to non-medication treatment. A large-sample services research design such as this can begin to determine patterns of associations between previous identified risk factors and poor treatment adherence in individuals with chronic psychotic disorders.     

Migration and psychotic disorders

The incidence of psychotic disorders is extremely high in several immigrant groups in Europe. This article describes the epidemiological evidence for increased incidence rates among immigrants compared with nonimmigrant populations and explores possible explanations for this excess risk. Potential causes not only involve factors acting at the level of the individual, but encompass the broader social context of neighborhoods and ethnic groups. Growing up and living in a disadvantaged ethnic minority position, characterized by a low social status, high degree of discrimination against the group and low neighborhood ethnic density, may lead to an increased risk of psychotic disorders, especially when individuals reject their minority status and when their social resources are insufficient to buffer the impact of adverse social experiences. Future research should refine measures of the social context, adopt a life-course perspective and should integrate social and neurobiological pathways.     

Future classification of psychotic disorders

Reclassifying psychotic disorders in the upcoming revisions of the mental disorders section of ICD-10 and DSM-IV will first necessitate the development of a unified and operationalized definition of the term “psychosis”. Ideally, such a definition would be harmonized between both groups of diagnostic classification systems and become part of a glossary of terms. Conceptually and based on epidemiological and some genetic work, incorporating dimensional criteria and criteria for prodromal high-risk symptoms may become feasible. Considering the currently available evidence from genetic, neuroimaging and neurophysiological studies, none seems yet sufficiently validated to warrant major changes. However, further research in these areas promises to yield important new insights which may become relevant for the classification of psychotic disorders in the near future. Given the rapid progress in these fields, regular updates of the classification criteria at shorter intervals than in the past may become necessary.

     

Schooling students with psychotic disorders

The term psychosis is generally used to describe the abnormal behaviors of children and adolescents with grossly impaired reality testing. This article discusses evaluation of psychotic symptoms in students and psychosocial school interventions for students with psychosis, including the roles of teachers and school administrators. Psychoeducation provided by clinicians and school staff to enhance coping and cognitive strategies is described.