Search

We present three cases of travel-induced psychosis in an elderly population. The clinical presentations are described with a review of the literature., (Copyright 2000 John Wiley & Sons, Ltd.)

Background: It is unclear whether outcome in schizoaffective disorders is more similar to schizophrenia or affective disorders., Aims: To provide longitudinal data on clinical course and outcome in schizoaffective disorders versus schizophrenia and affective disorders, and determine whether mood-incongruent psychotic symptoms have negative prognostic implications., Method: A total of 210 patients with schizoaffective disorders, schizophrenia, bipolar manic disorders and depression were assessed at hospitalisation and then followed up four times over 10 years., Results: At all four follow-ups, fewer patients with schizoaffective disorders than with schizophrenia showed uniformly poor outcome. Patients with mood-incongruent psychotic symptoms during index hospitalisation showed significantly poorer subsequent outcome (P < 0.05)., Conclusions: Schizoaffective outcome was better than schizophrenic outcome and poorer than outcome for psychotic affective disorders. Mood-incongruent psychotic symptoms have negative prognostic implications. The results could fit a symptom dimension view of schizoaffective course.

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.

Objective: Electrophysiological recording of the electrically elicited blink reflex is the most reliable method of investigating habituation of the startle reflex. The purpose of this study was to compare the habituation and the late R3-component of the blink reflex between control subjects (N=19) and first-episode patients with schizophrenia (N=17), psychotic depression (N=23), and severe non-psychotic depression (N=25)., Methods: The blink reflex was evoked by electrical stimulation of the supraorbital nerve, and the deficient habituation of the R2i-component was measured with a computer-assisted integral area measurement. Prefrontal executive function of the patients was assessed with the Wisconsin Card Sorting Test. Current psychiatric symptoms were assessed with the Brief Psychiatric Rating Scale, the Hamilton Depression Scale, the Positive and Negative Syndrome Scale, and the Calgary Depression Scale., Results: Deficient habituation of the blink reflex and occurrence of the late R3 component were associated both with a previous diagnosis of psychotic disorder and with the presence of current psychosis. The sensitivity and specificity of the abnormal habituation of the blink reflex in detecting psychotic disorder were 0.50 and 0.80, respectively. The abnormalities of the blink reflex were not associated with psychotropic medication. In schizophrenic patients, defective habituation of the blink reflex was associated with negative and cognitive symptoms, and in depressive patients with the presence of delusions., Conclusions: The deficient habituation of the blink reflex and occurrence of the late R3 component seem to be both trait and state markers of a psychotic disorder. The results suggest that schizophrenia and psychotic depression share some common neurobiological mechanisms involved in the modulation of the startle reflex.

The article is a literature review of psychosis in children and adolescents. Earlier studies point to psychosis in children and adolescence being of the same types as the ones seen in adults. Schizophrenia has an early onset in boys, there are more premorbid dysfunctions, a gradual onset of disease, a number of unspecific symptoms and a poorer prognosis than for adults. For the children with bipolar affective disorder the prognosis is similar to that of adults, and it is better than for the schizophrenics. The relationships between developmental disorders and schizophrenia, and between hyperactivity syndromes and manic-depressive disorders need to be further clarified, as does the validity of the follow-up investigations.

Background: In controlled studies of patients with schizophrenia, the atypical antipsychotic quetiapine, 300 mg/day, has been shown to be as effective in the treatment of positive and negative symptoms as haloperidol. However, little is known about the efficacy of quetiapine in patients with psychotic mood disorders. The purpose of this study was to assess the efficacy of quetiapine in the treatment of psychotic mood disorders in comparison with nonaffective psychotic disorders and identify clinical factors associated with quetiapine response., Method: In a naturalistic setting, by reviewing medical records, we assessed response to quetiapine and factors associated with response to quetiapine in 145 consecutive patients newly treated with the drug at a nonprofit academic psychiatric hospital. These patients had received a discharge diagnosis of bipolar disorder (manic, mixed, or depressive type), major depression with psychotic features, schizophrenia, schizoaffective disorder (bipolar or depressive type), delusional disorder, or psychosis not otherwise specified (NOS) according to DSM-IV criteria., Results: Patients with a diagnosis of bipolar disorder, manic, mixed, or depressed and schizoaffective disorder, bipolar type displayed higher response rates (> 74%) compared with patients with schizophrenia. However, this finding did not achieve statistical significance. A diagnosis of major depression with psychotic features (p = .02) and longer duration of illness (p = .03) were associated with less chance of responding., Conclusion: Quetiapine may be a useful alternative or adjunctive treatment for patients with bipolar and schizoaffective disorders.

The military setting offers unique opportunities for the study of the epidemiology of first psychotic episodes among Israeli youth. The aim of the present study was to describe characteristics of first psychotic episodes among a cohort of Israeli soldiers. Ninety soldiers, 67 males and 23 females, who were hospitalized for a first psychotic episode were studied and compared with 90 soldiers hospitalized in psychiatric units during the same year who were not psychotic. The results include a high rate of schizophreniform psychoses and schizophrenia; no gender difference in the occurrence of psychoses; within-average mean ratings on the preinduction psychometric intelligence test; no history of substance abuse; and a remarkable occurrence of psychiatric hospitalizations, including first psychotic episodes, during the stressful beginning of military service, supporting the hypothesis that psychotic symptoms are likely to occur in a stressful situation among vulnerable individuals. Follow-up studies will indicate whether early detection and treatment may improve the outcome of the psychoses.

Objective: Psychotic affective disorders are the most prevalent idiopathic psychoses, but their outcome from onset has rarely been studied. In this study, the authors determined the rate and latency of syndromal recovery and rates of functional recovery after first lifetime hospitalization in patients with first-episode psychotic affective disorders., Method: From first lifetime hospitalization in 1989-1996, 219 patients with a DSM-IV psychotic affective illness were assessed at intervals over 24 months. Time to syndromal recovery (no longer meeting DSM-IV episode criteria) was assessed by survival analysis, and functional recovery (regaining baseline vocational and residential status) was rated. Factors associated with recovery were identified by bivariate and multivariate methods., Results: By 3, 6, 12, and 24 months after first hospitalization, syndromal recovery was attained by 65.1%, 83.7%, 91.1%, and 97.5%, respectively, of subjects. Time to syndromal recovery (6.1 weeks to 50% of subjects recovered) was shorter for patients who had bipolar disorder, were married, were age 30 or older at onset, lacked comorbidity, required relatively brief hospitalization, and received fewer medicines. Functional recovery by 6 (30.4%) and 24 months (37. 6% of patients) was 2.6-2.7 times less likely than syndromal recovery; 63.1% of those recovering syndromally did not recover functionally by 2 years. Functional recovery was associated with older age at onset and shorter hospitalization. Annual recovery rates remained stable as mean hospital length of stay decreased 3. 6-fold over the 8-year study period., Conclusions: Syndromal recovery was attained by most psychotic affective disorder patients soon after hospitalization, but only one-third recovered functionally by 24 months. The findings suggest that these very common psychotic illnesses can carry a grave functional prognosis from the initial episode and first hospitalization.

Psychotic depression is reported and requires different pharmacological treatment from other mood disorders, however, sufficient studies to guide us in selecting successful treatment strategies have not been performed. In this study, algorithm for the treatment of psychotic depression was developed by the Japan Psychopharmacology Algorithm Project. The following three issues are emphasized: (1) risk of suicide; (2) agitation; and (3) oral intake ability. When patients show a high risk of suicide and/or agitation, prompt treatment strategies, such as tricyclic antidepressant (TCA)/neuroleptics therapy or electroconvulsive therapy (ECT), are necessary. If patients show no suicidal risk without agitation, TCA therapy is recommended. ECT is recommended as the first choice when the symptoms are severe or when there is an inability of oral intake.

The present study evaluated clinical and demographic features of subjects with delusional versus nondelusional major depressive disorder. Two hundred eighty-eight subjects with mood disorder (bipolar disorder, n = 94; major depressive disorder, n = 194) were included in the study. No differences were observed for gender, polarity of mood disorder, age of onset, duration of index episode, number of episodes, number of previous hospital admissions, frequency of illness episodes, and number of suicide attempts. On the other hand, delusional subjects showed a higher rate of cluster A personality disorder and a lower level of education. We also detected a larger number of cluster B personality disorders among nondelusionals. Our data suggest that subjects with delusional mood disorder do not differ substantially from nondelusionals in terms of the clinical and demographic variables considered in this study except for personality disorders.

Background: The relationship between bipolar and unipolar psychotic depression has not been well studied. Therefore, the aim of the present study was to compare bipolar with unipolar psychotic outpatient depression., Methods: Seventy consecutive unipolar (n = 40) and bipolar (n = 30) psychotic depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, the Global Assessment of Functioning Scale, and the Brief Psychiatric Rating Scale., Results: Of the variables studied (age, duration of illness, severity, recurrences, atypical features, chronicity, gender, comorbidity, hallucinations, delusions), none was significantly different between unipolar and bipolar psychotic patients., Conclusions: Bipolar psychotic depression was similar to unipolar psychotic depression on variables reported in the literature to distinguish bipolar from unipolar disorder., Clinical Implications: The findings might suggest, but do not necessarily imply, that psychotic depression might be a distinct clinical entity., Limitations: Single interviewer, nonblind cross-sectional assessment, outpatient sample, sample size.

Objective: Gray matter volume and glucose utilization have been reported to be reduced in the left subgenual cingulate of subjects with familial bipolar or unipolar depression. It is unclear whether these findings are secondary to recurrent illness or are part of a familial/genetic syndrome. The authors' goal was to clarify these findings., Method: Volumetric analyses were performed by using magnetic resonance imaging in 41 patients experiencing their first episode of affective disorder or schizophrenia and in 20 normal comparison subjects., Results: The left subgenual cingulate volume of the patients with affective disorder who had a family history of affective disorder was smaller than that of patients with affective disorder with no family history of the illness and the normal comparison subjects. Patients with schizophrenia did not differ from comparison subjects in left subgenual cingulate volume., Conclusions: Left subgenual cingulate abnormalities are present at first hospitalization for psychotic affective disorder in patients who have a family history of affective disorder.

Background: Many studies have established that a large percentage of patients with posttraumatic stress disorder (PTSD) have comorbid major depressive disorder. Other studies have found that patients with PTSD or a history of childhood trauma have an increased rate of psychotic symptoms. In the present report from the Rhode Island Methods to Improve Diagnosis and Services project, we examine whether an association exists between psychotic subtyping of major depressive disorder and PTSD., Method: Five hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV., Results: Almost half of the 500 patients had nonbipolar major depressive disorder (N = 235, 47.0%), 45 (19.1%) of whom had PTSD. Nineteen patients had psychotic depression, 216 had nonpsychotic depression. Compared with patients with nonpsychotic depression, the patients with psychotic depression were nearly 4 times more likely to have PTSD (57.9% vs. 15.7%, Fisher exact test, p = .0001)., Conclusion: The results of the present study suggest that the presence of psychosis in psychiatric outpatients with major depressive disorder is associated with concurrent PTSD. It is hypothesized that the poorer longitudinal course of psychotic versus nonpsychotic depression may be due to the underrecognition of PTSD in psychotically depressed patients.

Objective: The authors investigated frequencies and clinical correlates of multiple associations of panic disorder, obsessive-compulsive disorder (OCD), and social phobia in patients with severe mood disorders., Method: Subjects were 77 consecutively hospitalized adults with psychotic symptoms and with a diagnosis of bipolar I disorder, major depression, or schizoaffective disorder, bipolar type. Principal diagnosis and comorbidity were assessed by the Structured Clinical Interview for DSM-III-R-Patient Version., Results: Of the entire cohort, 33.8% had a single anxiety disorder and 14.3% had two or three comorbid diagnoses. Patients with multiple comorbidity had significantly higher scores on the Brief Psychiatric Rating Scale and SCL-90 and abused stimulants more frequently than did those without anxiety disorders., Conclusions: Multiple associations of panic disorder, OCD, and social phobia are not rare among patients with affective psychoses and are likely to be associated with more severe psychopathology than is found in patients without anxiety disorders.

Background: Regular assessment of mood is often important for treatment but traditional measures can be time-consuming. A quick'litmus test' is needed., Aims: To test the reliability and validity of a single-item scale for mood., Method: Mood was measured repeatedly in 812 patients (258 in-patients, 554 out-patient) being treated in an anxiety disorders unit. Patients had self- and clinician ratings of a single-item depression scale and also rated the 21-item Beck Depression Inventory (BDI-21). Their single-item scores were compared with BDI-21 scores and with outcome measures., Results: The single-item depression scores correlated 0.71 to 0.78 with the BDI-21 scores. Clinically useful cut-off points were identified. Depression scores at discharge, but not pre-treatment, correlated significantly with improvement in the main problem., Conclusions: The quick single-item depression scale, whether rated by patient or by clinician, is a reasonable rough guide to mood in anxiety disorders and saves time for the patient and the clinician compared to longer measures.

Diagnoses obtained from the hospital computer system were compared at two consecutive visits in 286 psychiatric emergency room patients within a 7-month period. Diagnostic agreement of schizophrenia and changes from and to schizophrenia were examined. There was moderate stability for a schizophrenic diagnosis in patients at two consecutive visits (kappa 0.5). schizophrenia was a more stable diagnosis in males (kappa 0.6) than females (0.4). Underdiagnosis of schizophrenia in females may be due to initial diagnostic confusion with affective illnesses. Further studies are needed in other settings to assess if underdiagnosis is associated with undertreatment of schizophrenia in females.

Clinical practice, training and evaluation of treatment in the functional psychoses continues to be carried out mostly along the traditional line of separation by diagnostic entity. However, the combined evidence from research on risk factors for onset and for persistence of psychotic illness indicates quantitative, but not qualitative, differences between categories of schizophrenia and affective psychosis. "Developmental" factors, such as childhood dysfunction, increased cerebral ventricle size and familial morbid risk of schizophrenia operate preferentially, though not specifically, at that end of the psychopathological spectrum characterised by a preponderance of negative features. On the other hand, "social" factors, such as ethnic group, adverse life events and familial morbid risk of affective disorder have a larger impact at the end associated with predominance of affective features. Heterogeneity in the functional psychoses may thus be best conceived as two discrete effects operating at different ends of a continuous psychopathological spectrum. The use of highly reliable but arbitrary diagnostic categories may introduce serious bias in aetiological and treatment research. Evidence supporting the validity of a model of shared risk factors for continuous characteristics needs to be further elaborated and incorporated into our concepts of psychotic illness.

Objective: Magnetic resonance imaging (MRI) studies of schizophrenic patients have revealed structural brain abnormalities, with low volumes of gray matter in the left posterior superior temporal gyrus and in medial temporal lobe structures. However, the specificity to schizophrenia and the roles of chronic morbidity and neuroleptic treatment in these abnormalities remain unclear., Method: Magnetic resonance (1.5-T) scans were obtained from 33 patients with first-episode psychosis and 18 age-matched normal comparison subjects, all right-handed. Sixteen of the patients were diagnosed with affective disorder and 17 with schizophrenia., Results: Quantitative volumetric analysis showed that the patients with first-episode schizophrenia had significantly smaller gray matter volume in the left posterior superior temporal gyrus than did the patients with first-episode affective psychosis or the comparison subjects, with a significant left-less-than-right asymmetry. The schizophrenic patients also showed a smaller gray matter volume of the left posterior amygdala-hippocampal complex than the comparison subjects. Both the patients with schizophrenia and those with affective psychosis had significant left-less-than-right asymmetry of the posterior amygdala-hippocampal complex., Conclusions: These findings suggest that temporal lobe abnormalities are present at the first hospitalization for schizophrenia and that low volume of the left posterior superior temporal gyrus gray matter is specific to schizophrenia compared with affective disorder.

Several studies have shown an increased mortality rate among psychiatric patients. Morbidity, however, has been studied less often. In this study, the authors examined the number of hospitalizations with somatic diagnoses in 722 patients with affective psychoses and 472 with a paranoid disorder. Every patient had an age- and sex-matched control subject who did not have a psychiatric illness. Both groups of patients exhibited an increased number of somatic diagnoses compared with their control subjects, and this was true for the majority of the 14 different groups classified according to the International Classification of Diseases the authors studied. The pattern of somatic diagnoses was similar to that presented in one of the authors' prior studies of schizophrenic patients.

This report on the Chandigarh Acute Psychosis Study examines the early course of affective disorders of acute onset in a developing country setting. Forty-one cases of acute onset affective disorder (17 depressive and 24 manic subjects) were assessed at intake and evaluated at selected intervals up to 1 year. The rates of recovery and relapse and episode duration were determined for both the depressive and manic groups, and the relationship between possible predictors of outcome and the duration of the index episode was examined. All subjects experienced full recovery within the 1-year period. At 1-year follow-up, 71% of depressive patients and 75% of manic patients demonstrated no symptoms or social impairment. For depression and mania, respectively, the mean episode duration was 14.2 and 10.2 weeks, and the rate of relapse was 18% and 21%. Overall, these outcomes are considerably more favorable than in comparable studies of affective disorders in developed settings. Our findings suggest that acuteness of onset may be a major prognostic factor in predicting the course of affective disorders.

Objective: The effectiveness of clozapine treatment in a treatment-refractory sample of older adult veterans with primary psychosis was examined., Methods: Data were collected over a five-year period for patients age 55 and older who were given clozapine because of a history of treatment-refractory or treatment-intolerant psychosis. At initiation of clozapine therapy, baseline demographic, clinical, and psychopathology data were collected. At baseline and quarterly, patients' psychopathology was rated with the Brief Psychiatric Rating Scale (BPRS), and involuntary movements were rated with the Abnormal Involuntary Movement Scale (AIMS)., Results: The 329 patients age 55 or older who received clozapine during the study period represented 10 percent of all patients on clozapine therapy in the VA system. Of the 312 patients for whom demographic information was available, 294 were men and 18 were women. Overall, patients improved on clozapine therapy, although wide variation in drug response was observed. Complete BPRS and AIMS data were available for 97 patients. The 55- to 64-year-old group had a mean improvement in total BPRS score of 19.8 percent, with 42.6 percent showing more than a 20 percent improvement; those age 65 and older had a mean improvement of 5.7 percent, with 17.2 percent showing an improvement greater than 20 percent. The 97 patients with complete AIMS data showed a mean improvement of 16.6 percent in total score., Conclusions: Clozapine is an important therapeutic agent for older adults with treatment-refractory psychosis. Patients between the ages of 55 and 64 may have a better response than those age 65 and older.

Objective: To determine the outcome of DSM-III-R schizophreniform disorder with good prognostic features., Method: A 6-year follow-up of 20 cases was conducted with structured interviews (comprehensive assessment of symptoms and history) and assessments of functioning scales (global assessment of functioning, Strauss-Carpenter Scale)., Results: Thirty-five percent of the cases had major affective disorders, 35% had schizophreniform episodes and major affective disorders, 5% had schizophreniform episodes only, 10% developed schizophrenia, and 15% had no disorders., Conclusion: The findings suggest an association between schizophreniform disorder with good prognostic features and affective illness.

Background: Schizophrenia is associated with central (sagittal) midline reductions of the P300 cognitive event-related potential and topographic asymmetry of P300, with reduced left temporal voltage. This P300 asymmetry is, in turn, linked to tissue volume asymmetry in the posterior superior temporal gyrus. However, it is unknown whether P300 asymmetry is specific to schizophrenia and whether central and lateral P300 abnormalities are due to chronic morbidity, neuroleptic medication, and/or hospitalization, or whether they are present at the onset of illness., Methods: P300 was recorded in first-episode schizophrenia, first-episode affective psychosis, and control subjects (n = 14 per group). Subjects silently counted rare (15%) target tones (1.5 kHz) among trains of standard tones (1.0 kHz). Averages were constructed from brain responses to target tones., Results: Peak amplitude of P300 and integrated voltage over 300 to 400 milliseconds were significantly different between first-episode schizophrenics and controls over the posterior sagittal midline of the head. First-episode schizophrenics displayed smaller amplitudes over the left temporal lobe than first-episode affective psychotics and controls, but the groups showed no differences over the right temporal lobe., Conclusions: Left-sided P300 abnormality in first-episode schizophrenia relative to first-episode affective psychosis and controls suggests that P300 asymmetry is specific to schizophrenic psychosis and present at initial hospitalization. This P300 asymmetry suggests left temporal lobe dysfunction at the onset of schizophrenia.

Background: The aim of this study was to explore patterns and clinical correlates of psychiatric comorbidity in patients with schizophrenia spectrum disorders and mood spectrum disorders with psychotic features., Method: Ninety-six consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Psychopathology was assessed by the SCID-P, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, and Hopkins Symptom Checklist. Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders., Results: The total lifetime prevalence of psychiatric comorbidity in the entire cohort was 57.3% (58.1% in schizophrenia spectrum disorders and 56.9% in mood spectrum psychoses). Overall, panic disorder (24%), obsessive-compulsive disorder (24%), social phobia (17.7%), substance abuse (11.5%), alcohol abuse (10.4%), and simple phobia (7.3%) were the most frequent comorbidities. Within the group of mood spectrum disorders, negative symptoms were found to be more frequent among patients with psychiatric comorbidity than among those without comorbidity, while such a difference was not detected within the group of schizophrenia spectrum disorders. Social phobia, substance abuse disorder, and panic disorder comorbidity showed the greatest association with psychotic features. An association between earlier age at first hospitalization and comorbidity was found only in patients with unipolar psychotic depression. Patient self-reported psychopathology was more severe in schizophrenia spectrum patients with comorbidity than in those without, while such a difference was less pronounced in mood spectrum psychoses., Conclusion: These findings suggest that psychiatric comorbidity is a relevant phenomenon in psychoses and is likely to negatively affect the phenomenology of psychotic illness. Further studies in larger psychotic populations are needed to gain more insight into the clinical and therapeutic implications of psychiatric comorbidity in psychoses.

Background: We studied the 12-month course of illness after a first hospitalization for affective psychosis to identify potential outcome predictors in this rarely studied patient population., Methods: For this study, 109 patients consecutively admitted for their first psychiatric hospitalization for treatment of affective psychosis were recruited. Diagnostic, symptomatic, and functional evaluations were obtained at the index hospitalization and at 2, 6, and 12 months after discharge to assess syndromic, symptomatic, and functional outcome predictors. Factors associated with outcome were identified by means of multivariate analyses., Results: Fifty-six percent of the patients achieved syndromic recovery during the 12-month follow-up. Full treatment compliance was associated with more frequent and rapid syndromic recovery. Full compliance was more common in white patients and in patients without substance abuse. Only 35% of these patients achieved symptomatic recovery during this same 12-month interval, and, similarly, only 35% achieved functional recovery. Symptomatic recovery was delayed in patients with substance abuse and was associated with higher socioeconomic status. Higher socioeconomic status was also associated with functional recovery, as was good premorbid function., Conclusions: Few patients achieved a favorable outcome in the year after a first hospitalization for an affective psychosis. Low socioeconomic status, poor premorbid function, treatment noncompliance, and substance abuse were associated with lower rates or delayed onset of recovery.

Objective: The authors developed and evaluated the reliability and validity of the Brown Assessment of Beliefs Scale, a clinician-administered seven-item scale designed to assess delusions across a wide range of psychiatric disorders., Method: The authors developed the scale after reviewing the literature on the assessment of delusions. Four raters administered the scale to 20 patients with obsessive-compulsive disorder (OCD), 20 patients with body dysmorphic disorder, and 10 patients with mood disorder with psychotic features. Audiotaped interviews of scale administration conducted by one rater were independently scored by the other raters to evaluate interrater reliability. The scale was administered to 27 patients twice to determine test-retest reliability. Other insight instruments as well as scales that assess symptom severity were administered to assess convergent and discriminant validity. Sensitivity to change was assessed in a multicenter treatment study of sertraline for OCD., Results: Interrater and test-retest reliability for the total score and individual item scores was excellent, with a high degree of internal consistency. One factor was obtained that accounted for 56% of the variance. Scores on the Brown Assessment of Beliefs Scale were not correlated with symptom severity but were correlated with other measures of insight. The scale was sensitive to change in insight in OCD but was not identical to improvement in severity., Conclusions: The Brown Assessment of Beliefs Scale is a reliable and valid instrument for assessing delusionality in a number of psychiatric disorders. This scale may help clarify whether delusional and nondelusional variants of disorders constitute the same disorder as well as whether delusionality affects treatment outcome and prognosis.

Prolactin (PRL) and Cortisol (CORT) responses to d,l-fenfluramine (FEN) challenge (60 mg) were examined in patients with affective disorders on two occasions under euthymic conditions: drug-free before admission to prophylactic treatment and after about 9 months of medication with lithium or carbamazepine. Response to treatment was assessed by a complex algorithm using continuous ratings in outpatient clinic over a period of 2 years. In general, treatment resulted in a delayed and diminished CORT release (n.s.); subgroup analysis revealed an attenuated CORT response (P < 0.05) in responders, whereas nonresponders showed no change in CORT secretion pattern except an enhanced CORT baseline value (P < 0.05). Cross-sectional comparison of responders with nonresponders under medication yielded a trend for greater CORT stimulation in nonresponders. This result was not affected by FEN/NorFEN or lithium/carbamazepine serum levels, baseline CORT values, age, sex, diagnostic distribution, number of appointments to the outpatient clinic or duration of medication at the time of FEN test session. Before onset of prophylactic medication responders and nonresponders could not be discriminated significantly regarding stimulated hormone release, probably due to the small sample size (n = 17). CORT response to FEN was increased in drugfree unipolar patients compared to bipolar (P < 0.05) and to schizoaffective patients (P < 0.1). In accordance with its well-documented presynaptic 5-HT-agonistic action lithium medication resulted in a significantly greater increase in CORT release than carbamazepine (P < 0.05). Evaluation of PRL stimulation showed patterns of secretion quite similar to those of CORT, without reaching statistical significance in most cases. Perhaps due to methodological differences in assessing treatment response, these data do not confirm former results, which supposed an enhanced 5-HT net activity in long-term prophylactic lithium treatment. Because of high interindividual variances of hormone parameters, the FEN-test procedure is not a useful tool for the prediction of therapeutical outcome in terms of clinical routine use. Relations of stimulated hormone response as a marker of central serotoninergic activity and clinical outcome are discussed.

Global ratings from the Scale for the Assessment of Positive Symptoms and Scale for the Assessment of Negative Symptoms were subjected to principal-component analysis (PCA) in 80 schizophrenia patients, 76 patients with schizophreniform disorder, 80 patients with schizoaffective and mood disorders, and 78 patients with delusional, brief reactive, and atypical psychoses. The resulting factors were correlated with depressive, manic, and catatonic syndromes, and subjected to a multivariate analysis of variance across DSM-III-R diagnoses. PCAs revealed that psychosis, disorganization, and negative factors were also present in each of the nonschizophrenic groups. The disorganization factor tended to be related to the manic syndrome, and the negative factor to depressive and catatonic syndromes. Overall, the three factors had little diagnostic relevance in functional psychoses, although the negative factor was relatively more characteristic of schizophrenia. The data suggest that positive, negative, and disorganization factors are not specific to schizophrenia; this is consistent with a dimensional view of psychopathology in functional psychoses.

Psychoses in late life are a diagnostic challenge because of disagreement over how these entities should be classified. The main diagnostic categories of late-life psychoses include dementia with psychotic symptoms, late-onset schizophrenia, delusional disorder, early-onset psychotic disorders extending through late life, late-onset mood disorders, psychotic disorders caused by medical conditions or medications, and delirium. First onset of psychotic symptoms in late life is commonly associated with identifiable structural brain abnormalities and reflects underlying brain pathology. We reviewed the available literature on late-life psychotic manifestations, focusing on diagnostic classification and treatment approaches. Antipsychotics are the mainstay of treatment for these conditions, but should be used cautiously in elderly patients because of their increased sensitivity to side effects. Overall, appropriate research data on the effectiveness of various antipsychotic agents for late-life psychotic conditions are lacking. Non-antipsychotic psychotropic medications may be of value in managing some of these conditions.

Objective: The authors compared the clinical characteristics and family history of patients with early-onset (before age 18), typical-onset (at 20-25 years), and late-onset (after age 35) affective psychosis at the time of first hospitalization., Method: Diagnostic, symptom, and family history information was obtained from 88 consecutively hospitalized patients., Results: Major depression was more common in the late-onset group, and a family history of affective and substance abuse disorders was more common among the early-onset patients. Affective symptoms differed significantly among groups; specifically, early-onset patients had more energy, minimal sleep disruption, and greater suicidality, while typical-onset patients had more severe abnormal thought content., Conclusions: Among patients with affective psychosis, there may be heterogeneity of symptoms and family history associated with age at first hospitalization.

Mood disorders are common in women. A prepregnancy personal history of mood disorder (bipolar or major depression), premenstrual syndrome, or (possibly) postpartum blues places a woman at high risk for a postpartum exacerbation of symptoms. Untreated or unrecognized postpartum mood disorders can lead to serious psychologic and social consequences, in some cases even leading to suicide or infanticide. Women at risk for postpartum mood disorders need to be referred for psychiatric consultation before pregnancy and parturition. Informed, professional collaboration offers the best opportunities for prevention, as well as the earliest recognition and treatment of emergent symptoms.

Kahlbaum described catatonia as a disorder in which mood syndromes were the primary features and characteristic symptoms were the motor ones. However, after Kahlbaum this concept has not been taken into account and catatonia has been identified with motor features alone. In the present study, we assessed the clinical validity of Kahlbaum's concept of catatonia, its nosological position in relation to DSM-III-R, DSM-IV, and Leonhard's diagnostic criteria, and its relationships with schizophrenia and mood disorder. Of 567 patients consecutively admitted due to a functional psychotic disorder, 45 met criteria for catatonia according to Kahlbaum's concept (the Kahlbaum syndrome [KS]). Patients with the KS were differentiated from those with schizophrenia and mood disorders across a number of demographic and clinical variables, the differences being greater with the former than with the latter group. KS does not appear to fit any particular nosologic category, although this issue largely depends on whether schizophrenia and mood disorder are broadly or restrictively defined. When definitions of both disorders are most restrictive, as in the case of the Leonhard system, KS seems better accommodated as a "third psychosis". Overall, the data raise the possibility that KS is either a variant of mood disorder, or a distinct clinical entity.

Numerous studies in stroke patients suggest that the left frontal anterior region may be strategic for depression. However, these findings could not always be replicated. Some authors even deny any etiological contribution of lesion location to depression. The predominant role of the right hemisphere in secondary mania is well recognized. In disorders such as apathy, anxiety, catastrophe reactions and pathological laughing and crying, further studies are needed to determine the potential clinico-topographic correlations. Affective disorders are important to consider in stroke patients, since they may influence neurological recovery and may be responsive to treatment. Remarkable features of emotional behavior, such as disinhibition, denial, indifference, overt sadness and aggressiveness, are not rare during the acute phase of stroke and might be overlooked if not searched for systematically with appropriately designed scales. Some of these early behaviors, such as denial, may relate to the late development of depression, anxiety and other disorders. Systematic studies on large samples of patients may allow to establish which of these acute emotional behavioral changes are markers for the delayed development of mood disorders.

45 patients with endogenous mental disorders were observed: 11 with manic-depressive psychosis and 34 with shift-like progredient schizophrenia. The peculiarity of the cases observed was the presence of paroxysmal-like disorders (PD) in clinical picture of the disease. 8 variants of PD were established: 1) with vegetative disorders, 2) with affective disturbances, 3) with obsessions, 4) with sensopathies and depersonalization, 5) with impulsive drives, 6) with alterations of consciousness (similar hysteric twilight type), 7) with hallucinations, 8) with development of manifestations of Kandinskiĭ-Clérambault's syndrome. The duration of PD varied from several seldom till a few hours, while their frequency from 1-2 in a year till several in twenty four hours. Paroxysmal-like states were accompanied by anxiety, fear or by low- differentiated sense of discomfort and "suppression", but second subjective affective feeling was neutral or even pleasant. The phenomenon which might be called as the anxious waiting for the fit was also marked. The observations of combinations of different variations of PD in one person as well as the cases of including of elements one variant in the picture of the other one permitted one to suggest the presence of a single pathobiological basis for PD rise.

The origins of schizophrenia are obscure. One suggestion is that it represents a component of the genetic variation associated with the establishment of dominance in one or other cerebral hemisphere, a mechanism that has been crucial in the evolution of language. Indices of cerebral hemispheric dominance (hand, foot and eye preference, speed of checking squares) recorded on the 16,980 children in the UK National Child Development Study cohort were examined in relation to psychiatric admission by the age of 28 years. Diagnoses were established by the application of Present State Examination criteria to case notes. Pre-schizophrenic children (n = 34-36) were more likely (p < 0.0003) to be rated by their mothers as ambidextrous at the age of 7 years, and at 11 years were less (p < 0.01) strongly right-handed than their peers in the cohort population on a test of relative hand skill: children who later developed affective psychosis (n = 25) or neurosis (n = 60) did not differ significantly from controls. Delay in establishing dominance in one hemisphere could be the critical factor that predisposes to schizophrenia.

Background: It has been reported that real ECT is more effective than simulated treatment among depressed patients with delusions and/or retardation, and that ECT is not effective among depressed patients who lack these features., Method: In two randomised, double-blind studies, 143 patients with major depression were subtyped regarding psychosis, retardation and agitation. In both studies, low dosage, right unilateral ECT was ineffective compared with other forms of ECT. This report examined whether the depressive subtypes differed in clinical response to the ineffective and effective forms of ECT., Results: The therapeutic advantage of effective forms of ECT was similar across the depression subtypes. Patients who lacked both psychosis and retardation showed this pattern., Conclusions: The findings cast doubt on the utility of these depression subtypes in predicting ECT response. ECT is a viable treatment option for patients with major depression regardless of the presence or absence of psychosis, retardation and/or agitation.

We examined the relationship of smooth pursuit eye tracking to the course of first-episode psychosis. Various measures of social, occupational, and psychological functioning were obtained for 134 persons with diagnoses of schizophrenia, schizophreniform disorder, or psychotic mood disorder at the time of their psychosis and 9 and 18 months later. Poor eye-tracking performance was associated with generally impaired functioning over the 18-month course of disorder for patients with schizophrenia. A similar association between smooth pursuit and adaptive functioning was not found in patients with schizophreniform or affective disorder. The results suggest that patients with schizophrenia who are characterized by poor eye tracking have a more severe disorder, indications of which are present at the onset of their psychosis.

Objective: To determine whether there is a difference in length of stay for patients with affective disorders between private and public psychiatric hospitals., Method: The casemix Australian national diagnosis-related group (AN-DRG) diagnoses of all inpatient separations from private and public psychiatric hospitals in South Australia for 1 year were abstracted from records. The average length of stay for patients with affective disorders was calculated., Results: There was no significant difference in the average length of stay for patients with affective disorders treated in private and public psychiatric hospitals., Conclusions: These results should allay fears that the treatment of patients with affective disorders in any particular treatment setting will be compromised by the introduction of casemix.

Since little is known of the dynamics of the rehabilitation process, this pilot study aims to explore (1) the work performance and personal and social functioning of patients attending a vocational reintegration program; (2) any significant differences in course between successful and unsuccessful patients; and (3) whether these subgroups differed at entrance assessment. Using the 30-item Nurses' Observation Scale for inpatient Evaluation (NOSIE) and a global work performance scale, the sample (N = 31) showed a significant decrease in work performance and a negative trend in most NOSIE scores, instead of the expected steady progress. The turning point is reached after 9 to 12 weeks. In the entrance assessment, the failure subgroup (n = 11) displayed more negative and general symptoms and fewer social skills. It seemed to be not their initial work performance but their resources to cope with the stress of the program that were insufficient. However, not every downhill trend leads automatically to failure, and some patients still have a chance of later improvement.

Three hundred and twenty-six consecutively admitted patients with definite or possible functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2.5 years. In 86 cases symptomatology had been inadequate for the patients to enter the functional psychosis study, and in 75 cases this was because the symptoms were partial or transient. These patients were compared at follow-up with those who fulfilled operational criteria for schizophrenic, affective or schizoaffective psychoses. Differences between the 'partial' cases and those fulfilling specific diagnostic criteria were few, but the transient cases fared significantly better. Although the transient illnesses were recurrent, at follow-up at 2.5 years they appeared to have a good outcome in terms of social variables and symptomatology.

The purpose of this study was to determine whether the preponderance of data support a continuum hypothesis of the psychoses or a concept of separate, autonomous illnesses. Patients (N = 70) were hospitalized for nonmanic psychoses, given structured interviews and a dexamethasone suppression test (DST), and diagnosed according to the Research Diagnostic Criteria (RDC). Patients were then evaluated at 1 year and 6 years with a structured interview. Diagnoses were made at three points of time: intake, 1 year, and 6 years. The patients were divided into groups that had a consistent (over the three points) set of affective disorder diagnoses (affective disorder or schizoaffective disorder, mainly affective [AD group]) and those that had a consistent set of schizophrenic diagnoses (schizophrenic or schizoaffective disorder, mainly schizophrenic [S group]). A third group (inconsistently diagnosed) consisted of subjects who at one point were diagnosed in the AD group and at another in the S group. A series of discriminant function analyses suggested that the AD group differs widely from the S group; and the inconsistently diagnosed group most closely resembled the AD group. The family background of the inconsistent group was similar to that of the AD group. The DST and outcome showed that the inconsistent group was more like the AD group than the S group. Using the characteristics of the medical model-clinical picture, outcome, laboratory tests, and family history-the group that was inconsistent with regard to diagnosis over time appeared similar to the AD group. Taking the follow-up evaluation into account, the data favor the possibility that patients who have a variable clinical diagnosis over time do not suffer from schizophrenia.