首发精神分裂症病人的抑郁症状

目的探讨首发精神分裂症病人抑郁症状的发生率、特征及相关因素。方法于入院、治疗3、6、9、12月时用汉密尔顿抑郁量表(HAMD)、简明精神病评定量表(BPRS)、阴性症状量表中文版(SANS-CV)、临床总体印象量表(CGI)及功能总体评定量表(GAF)对164例首发精神分裂症患者进行评定。结果急性期首发精神分裂症病人轻度或以上程度抑郁症状的发生率为71%,但在缓解期降至12%。急性期突出的抑郁表现为认知障碍与迟缓(因子分各占HAMD总分的35%和29%)。抑郁症状随着精神病性症状的缓解而减轻,与性别、发病年龄、受教育时间、病程及前驱期长短无关。HAMD总分在急性期仅与BPRS的焦虑抑郁因子分有关,但在缓解期与阴阳性症状、临床总体印象以及总体功能均有密切的相关性;急性期以及治疗3个月时的抑郁症状与随后的阴阳性症状、总体功能的变化无关。结论首发精神分裂症急性期的抑郁症状可能是一个独立的症状群,抑郁程度不能作为预测首发精神分裂症病人预后的指标。     

Substance abuse and suicidality in schizophrenia: a common risk factor linked to impulsivity

Lifetime substance abuse comorbidity is frequent in schizophrenic patients, but the clinical correlates remain unclear. We have explored the chronological relations between substance abuse and course of schizophrenia, and compared several clinical characteristics and personality dimensions in 50 schizophrenic patients with or without lifetime substance abuse or dependence. Abuse occurred mainly after the first prodromal symptoms and just before the first psychotic episode. Substance-abusing patients were not different from non-substance-abusing patients on the Chapman Physical Anhedonia Scale, PANSS total score, negative subscore or depression item, CGI, treatment response and demographic variables. In contrast, substance-abusing patients had higher scores on the Barratt Impulsivity Scale (total, cognitive and non-planning scores) and had attempted suicide more often. In patients with schizophrenia, as in the general population, substance abuse or dependence appears associated with higher impulsivity and suicidality. High impulsivity could facilitate substance abuse as a maladaptive behavior in response to prodromal symptoms, precipitating the onset of a characterized psychosis.     

Prodromal symptoms to relapse in bipolar disorder

In a cyclical and recurring illness such as bipolar disorder, prodrome detection is of vital importance. This paper describes manic and depressive prodromal symptoms to relapse, methods used in their detection, problems inherent in their assessment, and patients' coping strategies. A review of the literature on the issue was performed using MEDLINE and EMBASE databases (1965-May 2006). 'Bipolar disorder', 'prodromes', 'early symptoms', 'coping', 'manic' and 'depression' were entered as key words. A hand search was conducted simultaneously and the references of the articles found were used to locate additional articles. The most common depressive prodromes are mood changes, psychomotor symptoms and increased anxiety; the most frequent manic prodromes are sleep disturbances, psychotic symptoms and mood changes. The manic prodromes also last longer. Certain psychological interventions, both at the individual and psychoeducational group level, have proven effective, especially in preventing manic episodes. Bipolar patients are highly capable of detecting prodromal symptoms to relapse, although they do find the depressive ones harder to identify. Learning detection, coping strategies and idiosyncratic prodromes are elements that should be incorporated into daily clinical practice with bipolar patients.     

Depressive symptoms in schizophrenia: comprehensive differential diagnosis

Depression is a common complication of schizophrenia and is associated with increased morbidity and mortality. Contrary to traditional clinical wisdom, depressive symptoms occur during all phases of schizophrenia and are not restricted to the postpsychotic period. In this review, the authors summarize current empirical research and offer a practical approach to the identification of depressive subtypes in schizophrenia. The following subtypes are considered: (1) depressive symptoms occurring secondary to organic factors (caused by medications, substance abuse, or underlying medical problems); (2) nonorganic depressive symptoms occurring with acute psychotic symptoms (intrinsic to the acute psychotic episode or schizoaffective disorder); and (3) nonorganic depressive symptoms occurring without acute psychotic symptoms (prodromal symptoms, negative symptoms, acute dysphoria, secondary depressive syndrome, or chronic demoralization). The authors discuss each of these entities and offer guidelines for diagnosis.     

精神分裂症伴发抑郁症状及其临床特征

目的 了解急性期住院精神分裂症患者伴发抑郁症状的发生率、临床特征及其相关因素。方法 对符合CCMD-3诊断标准的精神分裂症患者75例，分别于入院3天内评定PA．NSS、HAMD、TESS量表。结果 急性期抑郁发生率为30．7％，抑郁组与非抑郁组性别、婚姻、文化、年龄无显著性差异，抑郁组平均住院次数、偏执型精神分裂症所占比例多于非抑郁组。治疗前汉密顿抑郁量表总分与阴性量表、思维障碍症状群、反应缺乏症状群负相关，与一般精神病理量表、抑郁症状群正相关。结论 精神分裂症抑郁症状急性期较常见、较严重，偏执型精神分裂症更易出现抑郁症状。     

Depressive episodes in stable schizophrenia: critical evaluation of the DSM-IV and ICD-10 diagnostic criteria

Depressive episodes are a common and potentially severe occurrence in schizophrenia but are poorly recognised by psychiatrists. Coherent diagnostic criteria are necessary to improve diagnosis and treatment of these conditions. To evaluate the usefulness of the ICD-10 category of post-schizophrenic depression (PSD) and the DSM-IV category of postpsychotic depressive disorder of schizophrenia (PDDS), 80 clinically stable schizophrenic outpatients were evaluated with two independent measures of depression, a dimensional measure and a categorical measure. One rater applied the DSM-IV criteria for major depressive episodes (MDE), and the other applied the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Extrapyramidal Symptoms Rating Scale. Thirteen patients (16.3%) met criteria for MDE. All of them met the DSM-IV PDDS research criteria, but only two patients matched the ICD-10 PSD criteria, which require that the episode occurred in the 12 months after the last psychotic episode. There was no significant difference in the incidence of depressive episodes within 12 months after an acute psychotic episode and outside this time period. The data suggest that depressive episodes in schizophrenia are not restricted to the first year following the psychotic episode. Useful criteria for depressive episodes in schizophrenia should avoid a temporal relation with the psychotic episode.     

Prodromal symptoms of relapse in a sample of Egyptian schizophrenic patients

BACKGROUND: Schizophrenic patients and family members often retrospectively report having observed a number of nonpsychotic symptoms and/or certain alterations in behavior that they believe preceded any psychotic symptoms and behavior. The identification of possible relapse before its actual occurrence and the timely intervention in management are expected to spare both patient and family the suffering and pain of a full schizophrenic episode. The aim of this study was to determine if prodromal symptoms could be used as valid predictors of relapse in schizophrenic disorders and the relative diagnostic values of these symptoms in a sample of Egyptian schizophrenic patients. METHOD: One hundred Egyptian patients with schizophrenic disorders (DSM-III-R criteria) that had recently relapsed were retrospectively assessed for prodromal symptoms in the month preceding relapse. They were compared with 2 control groups, 50 Egyptian nonrelapsing schizophrenic patients and 50 healthy Egyptian individuals. RESULTS: Nonpsychotic symptoms were the most common prodromal symptoms occurring in relapsing patients. A significant difference in frequency of prodromal symptoms was found for relapsing patients versus nonrelapsing patients (p < .001) and healthy controls (p < .05). Prodromal symptoms appear to have a relatively specific value for predicting subsequent psychotic symptoms in those subjects who previously experienced such symptoms. CONCLUSION: Clusters of nonspecific prodromal symptoms exist that significantly differentiate between relapsing, nonrelapsing, and healthy controls. Fine-tuning of the identification of these symptoms could be a plausible clinical tool to be used by psychiatrists and general practitioners alike to predict a possibility of an impending relapse.     

Is there a primary prevention of schizophrenic psychiasis?

At first, this article comprises the innovative programme of the international "Early Detection and Intervention" research and then shows results of the "Cologne/Bonn Early Recognition - CER" project on schizophrenia, the first longterm prospective study on patients in potentially initial prodromal stages prior to the first psychotic manifestation. At re-examination at an average of 9.6 years later, 79 of 160 patients had subsequently developed a schizophrenic psychosis according to DSM-IV criteria. Prediction values for the complete range of prodromal symptoms, for 5 subsyndromes and for individual symptoms were assessed. Best prediction values with a high positive predictive power (71 - 91 %) and a low rate of false-positive predictions (7.5 - 1.9 %) were achieved for 10 symptoms and symptom complexes mainly out of the group of thought, speech and perception disturbances. As only unsatisfactory prediction values for other prodromal symptom definitions were reported, e.g. the commonly used DSM-III-R definition, empirical evidence for the possibility of diagnosing schizophrenia as early as in the initial prodromal stage, has been found for the first time. In the following, this article considers essential initiatives for the development, performance and evaluation of a promising early intervention programme based on the results found. In Germany, within the project unit "Early Recognition and Intervention" of the competence network "Schizophrenia", such a programme has been initiated. Late prodromal stages are defined by attenuated or transient psychotic symptoms and early prodromal stages by the presence of at least one of the highly predictive prodromal symptoms from the CER-study or decline in psychic functions in combination with other risk factors. Intervention strategies are a multimodal psychological programme for the intervention in early prodromal stages and a combination of psychotherapy with atypical neuroleptic drugs in the late prodromal stages. If such strategies were able to suppress the progress to first psychotic episodes, this prevention could be classified as a primary prevention, not with regard to the prodromal symptoms but to frank/manifest schizophrenia.     

Subjective experiences in schizophrenia and bipolar disorders

Studies comparing 'subjective experiences' in schizophrenic and affective disorders have reached inconclusive results. We investigated the pattern of 'subjective perceived cognitive disturbances' in a group of 55 schizophrenic patients and 39 bipolar patients hospitalized for an index psychotic episode. The assessment of the subjective experiences was made using the Frankfurter Beschwerde-Fragebogen (FBF). Comparing the two groups on the four FBF factors, schizophrenic patients showed significantly higher scores in the areas of 'central cognitive disturbances', 'perception and motility' other than a significantly higher FBF total score. Our results suggest that cognitive, perception and motility disturbances are the most characteristic subjective experiences of schizophrenic patients in comparison with bipolar patients. This finding need to be further explored in light of the issue of cognitive dysfunction in schizophrenia.     

The epidemiology of onset and course of schizophrenia

Traditionally the heterogeneity of schizophrenia was dealt with by subdividing the syndrome into different subtypes. However, due to lacking standards, the result was an immense variety of subtypes partly based on cross-sectional assessments, partly taken the whole course between onset, resp. first admission and outcome after many years into account. Some solutions were based on symptomatology only, other also relied on social characteristics as the ability to fulfil different roles in family and the world of employment. So it is not surprising that the number of subtypes ranges from two up to more than 70. As one possible solution Carpenter and Kirkpatrick (1988) suggest that attempts to subdivide the schizophrenic syndrome should concentrate on few significant parts of the course thought of to represent specific disease processes. Based on two epidemiological studies finding about the onset, middle course and late course of schizophrenia are presented. In three quarter of the cases the onset of the first psychotic episode in schizophrenia is preceded by a prodromal phase with a mean length of about five years. The earliest signs of the disorder are depressive and negative symptoms. Early depressive symptoms predict higher overall symptom scores in the first illness episode and lower scores for affective flattening in the medium-term course. There is no decrease in the number of patients with acute symptomatology over fifteen years after first hospital admission, rather there is a tendency of an increase. With respect to social abilities we found a significant increase of disability over time. But the change already takes place during the first five years. Approx. 60% of those falling ill with schizophrenia become chronic and approx. 25% will recover during the first five to six years. Received: 10 April 2000 / Accepted: 25 April 2000     

The early course of schizophrenia and depression*

OBJECTIVE: Risk factors, emergence and accumulation of symptoms in the untreated early course were studied as a basis for understanding the relationship between schizophrenia and depression. MATERIALS AND METHODS: 130 representative first admissions for schizophrenia were compared retrospectively with 130 individually matched first admissions for depressive episodes and with 130 healthy controls. RESULTS: Onsets of schizophrenia and severe depression were marked by depressive symptoms, followed by negative symptoms and functional impairment. This prodromal core syndrome became more prevalent as the disorders progressed, and it reappeared in psychotic relapses. Psychotic symptoms emerged late, indicating a different and more severe "disease pattern". CONCLUSION: The prevalence of depressive symptoms in the general population and at the prodromal stage of numerous mental disorders precipitated by various psychological and biological factors suggests that depression might be an expression of an inborn mild reaction pattern of the human brain. With progressing brain dysfunction more severe patterns like psychosis are expressed.     

Depression in the long-term course of schizophrenia

Abstract Depressive symptoms are quantitatively and qualitatively among the most important characteristics of schizophrenia. The following contribution reports on the prevalence of depression in 107 patients of the ABC schizophrenia study over 12 years after first hospital admission, looks into a preponderance of depression at certain stages of the illness and the predictive value of depressive symptoms for course and outcome. All but one of the 107 patients experienced one to 10 episodes of depressed mood between index assessment and long-term follow-up. In any month of the observation period about 30–35% of the patients presented at least one symptom of the depressive core syndrome (depressive mood, loss of pleasure, loss of interests, loss of self-confidence, feelings of guilt, suicidal thoughts/suicide attempt). Depressive symptoms are particularly frequent during a psychotic episode at a rate of approximately 50%. There were moderate but statistically significant correlations between the amount of depressive symptoms during a psychotic episode and the frequency of relapses, defined by hospital admissions as well as the total length of inpatient treatment. Depression occurring in the interval was not associated with an increased need for inpatient treatment.     

Transition to schizophrenia and related disorders: toward a taxonomy of risk

The early detection and prevention of schizophrenia and other psychotic disorders are receiving rapidly growing attention subsequent to the suggestion that poorer outcome is associated with delayed onset of treatment among patients in their first psychotic episode. Although the first generation of so-called "prodromal" research programs has produced encouraging preliminary results, more information is necessary on the conversion rates from prodromal states to schizophrenia in specific samples. Early recognition and prevention strategies require a new taxonomy that classifies subjects by their status of risk of imminent onset of psychosis. Without additional knowledge of the mechanisms through which particular constellations of vulnerability factors, precursors, and prodromal symptoms predict the onset of schizophrenia, it is difficult to judge the effects of existing programs. In this paper, we discuss three sets of issues that will need to be resolved before these preventive programs can be implemented into routine care: (1) optimization of predicting the onset of psychotic disorders; (2) development and evaluation of alternative treatment strategies depending on the presenting risk status; and (3) evaluation of costs and benefits of identifying subjects at risk of psychosis/schizophrenia and receiving a specific preventive treatment.     

White matter abnormalities in subjects at ultra high-risk for schizophrenia and first-episode schizophrenic patients

Schizophrenia is associated with neuroanatomical abnormalities. Gray matter decrease seems to predate first schizophrenic episode. Whether white matter abnormalities predate the onset of psychotic symptoms is unclear. We investigated this issue using voxel-based morphometry (VBM) of structural magnetic resonance images to examine individuals with prodromal symptoms who were at ultra high-risk (UHR) of developing schizophrenia and compared them to first-episode schizophrenic patients and healthy controls. White matter volume maps from high-resolution magnetic resonance T1 weighted whole brain images were analyzed in a cross-sectional study using SPM2 in 30 UHR patients, 23 first-episode schizophrenic patients and 29 healthy controls. UHR patients showed significant lower white matter volume in the right superior temporal lobe compared to healthy controls. First-episode patients with schizophrenia showed widespread smaller white matter volume bilaterally compared to UHR patients. This study provides first evidence for smaller white matter volume in the right temporal lobe of UHR patients, one of the key structures in the pathophysiology of schizophrenia. Furthermore, white matter abnormalities seem to progress after transition into schizophrenia.     

Differences of cerebral lateralization among schizophrenic and depressed patients.

Conjugate lateral eye movements (LEMs) have been used as a measure of contralateral frontal hemisphere activation when individuals carry out reflective tasks. In a previous study, schizophrenics were noted to produce significantly more R-LEMs than controls suggesting that they use the left hemisphere in general more often than controls when initiating thought. More specifically, schizophrenics initiated thought on spatial emotional material in their left hemisphere more often than normals. In an effort to replicate these findings, the present study contrasted a new sample of 13 schizophrenics first with the original schizophrenic sample, and then with 13 psychotic depressives, and the original controls. In addition, other group comparisons are reported. The data obtained replicate the original findings of increased R-LEM (i.e., increased left hemisphere activity) and the excessive processing of spatial and to a lesser extent emotional material in the left hemisphere of schizophrenics. Psychotic depressives were found to initiate reflective tasks more often in their right hemisphere than either schizophrenic or the original sample of normal controls. Significant group differences among schizophrenics, normal controls, and psychotically depressed patients were obtained. The data are consistent with emerging concepts of a left hemisphere locus of disturbance in schizophrenia and right hemisphere disturbances in affective disorders.     

Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review

OBJECTIVE: To review the available literature on depressive symptomatology in schizophrenia in order to establish a diagnostic algorithm of depressive syndromes in schizophrenia. METHOD: A literature search was performed using PubMed and Medline. Additional information was gained by cross-referencing from papers found in the database. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. Depressive symptoms were classified with respect to their temporal relationship to acute psychotic symptoms before the background of nosological entities as operationalized by Diagnostic Statistical Manual IV (DSM IV). RESULTS: Depression is a common and devastating comorbid syndrome in patients suffering from schizophrenic disorder. The paper summarizes the relevant diagnostic steps to guide the clinician towards therapeutic interventions, which differ depending on the nature of the depressive syndrome. CONCLUSION: Differentiating depressives states in schizophrenia has consequences in terms of choosing therapeutic strategies. An algorithm which leads the practitioner to a reliable diagnosis and in consequence to a valid therapy is presented.     

Prospective diagnosis of the initial prodrome for schizophrenia based on the Structured Interview for Prodromal Syndromes: preliminary evidence of interrater reliability and predictive validity

OBJECTIVE: This study was conducted to determine the interrater reliability and predictive validity of a set of diagnostic criteria for the prodrome of the first episode of schizophrenic psychosis when based on the Structured Interview for Prodromal Syndromes. METHOD: The subjects were patients referred for evaluation because of a suspected schizophrenia prodromal syndrome. For the reliability study, two to four raters independently diagnosed 18 patients on the basis of face-to-face or videotaped interviews. For the validity study, 6- and 12-month outcome data were collected for 29 patients. RESULTS: Agreement in differentiating prodromal from nonprodromal patients was 93%. The prodromal features had converted to schizophrenic psychosis for 46% of the prodromal patients at 6 months and for 54% at 12 months. CONCLUSIONS: In small groups of subjects, these diagnostic criteria for the schizophrenic prodrome and the Structured Interview for Prodromal Syndromes showed promising interrater reliability and predictive validity.     

Stress et transition psychotique : revue de la littérature

BackgroundPsychiatric disorders are consistent with the gene x environment model, and non-specific environmental factors such as childhood trauma, urbanity, and migration have been implicated. All of these factors have in common to dysregulate the biological pathways involved in response to stress. Stress is a well-known precipitating factor implicated in psychiatric disorders such as depression, bipolar disorder, anxiety, and possibly schizophrenia. More precisely, psychosocial stress induces dysregulation of the hypothalamic-pituitary-adrenal axis (HPA) and could modify neurotransmission, which raises the question of the involvement of stress-related biological changes in psychotic disorders. Indeed, the literature reveals dysregulation of the HPA axis in schizophrenia. This dysregulation seems to be present in the prodromal phases (UHR subjects for ultra-high risk) and early schizophrenia (FEP for first episode psychosis). Thus, and following the stress–vulnerability model, stress could act directly on psychotic onset and precipitate the transition of vulnerable subjects to a full-blown psychosis.ObjectiveThe present paper reviews the literature on stress and onset of schizophrenia, with consideration for the causal role vs. associated role of HPA axis dysregulation in schizophrenia and the factors that influence it, in particular during prodromal and earlier phases. We also discuss different methods developed to measure stress in humans.MethodologyWe performed a bibliographic search using the keywords ‘cortisol’, ‘glucocorticoid’, ‘HPA’ with ‘UHR’, ‘CHR’, ‘at-risk mental state’, ‘first episode psychosis’, ‘schizotypal’, ‘prodromal schizophrenia’ in Medline, Web of Knowledge (WOS), and EBSCO completed by a screening of the references of the selected articles.ResultsStress has been studied for many years in schizophrenia, either by subjective methods (questionnaires), or objective methods (standardized experimental protocols) with biological sampling and/or brain imaging methods. These methods have suggested a link between dysregulation of the HPA axis and psychotic symptoms both through abnormal basal levels of cortisol and flattened reactivity to social stress. Imaging results suggest indirect modifications, including abnormal pituitary or hippocampal volume. Several factors dysregulating the HPA axis have also been highlighted, such as consumption of drugs (i.e. cannabis), childhood trauma or genetic factors (such as COMT, or MTHFR variants). Psychological stress induces subcortical dopaminergic activation attributable to hypothalamic-pituitary-adrenal (HPA) axis dysregulation. This dysregulation is present in the prodromal phase (UHR) in patients who have experienced a first psychotic episode (FEP) and in siblings of schizophrenic patients. Stress dysregulation is a plausible hypothesis to understand the psychosis onset.DiscussionThe effect of stress on brain pathways could participate to the mechanisms underlying the onset of psychotic symptoms, both as a precipitating factor and as a marker of a predisposing vulnerability. This dysregulation fits into the gene x environment model: in subjects with genetic predispositions, stressful environmental factors can modify biological pathways implicated in psychiatric disorders, promoting the emergence of symptoms. However, many confounding factors obscure the literature, and further studies are needed in schizophrenic patients, UHR and FEP patients to clarify the precise role of stress in psychotic transition. Identification of stress biomarkers could help diagnosis and prognosis, and pave the way for specific care strategies based on stress-targeted therapies.