Chronic Psychosis Research Articles

Chronic Psychosis and its Prevention

Here is a short history of chronic psychosis: at the turn of the last century there were large public institutions for tuberculosis, leprosy and chronic psychiatric illnesses, especially schizophrenia. After enough progress was made in infectious diseases, institutions for TB and leprosy became obsolete. When chlorpromazine was discovered in 1954 there was hope that deinstitutionalization would occur in psychiatry as well. This belief led to the Community Mental Health Act (passed by the U.S. Congress in 1963). However, as of today public institutions treating chronic psychoses remain standing. To put it simply, treatment of these conditions has not made enough progress as to warrant the abolition of hospitals for their long term treatment.

Metabolic issues in patients affected by schizophrenia: clinical characteristics and medical management.

Patients affected by psychotic disorders are more likely to develop high rates of co-morbidities, such as obesity, type 2 diabetes, dyslipidemias, hypertension, metabolic syndrome, myocardial infarction, stroke etc., in the long-term. These morbidities have a significant impact on the life-expectancy of these patients. Patients with chronic psychoses show a 2–3-fold increased risk of death mostly from cardiovascular and metabolic diseases. Although there may be an independent link, between schizophrenia and metabolic conditions the cardio-metabolic risk is mostly related to an unhealthy lifestyle and the usage of antipsychotic agents (especially Second Generation Antipsychotics or atypical) even when these remain effective treatments in the management of major psychoses. Recently, many international organizations have developed screening and monitoring guidelines for the control of modifiable risk factors in order to reduce the rate of co-morbidity and mortality among patients affected by schizophrenia. This paper is a review of current knowledge about the metabolic issues of patients affected by schizophrenia and describes clinical characteristics and medical management strategies for such conditions.

Contour integration in chronic schizophrenia and first-episode psychosis

Contour integration in chronic schizophrenia and first-episode psychosis

Family Functioning in First-Episode and Chronic Psychosis: The Role of Patient's Symptom Severity and Psychosocial Functioning.

The aim of the present study was to assess the relationship between illness-related characteristics, such as symptom severity and psychosocial functioning, and specific aspects of family functioning both in patients experiencing their first episode of psychosis (FEP) and chronically ill patients. A total of 50 FEP and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) and their family caregivers participated in the study. Family functioning was evaluated in terms of cohesion and flexibility (FACES IV Package), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Patients' symptom severity (BPRS) and psychosocial functioning (GAS) were assessed by their treating psychiatrist within 2weeks from the caregivers' assessment. Increased symptom severity was associated with greater dysfunction in terms of family cohesion and flexibility (β coefficient -0.13; 95% CI -0.23, -0.03), increased caregivers' EE levels on the form of emotional overinvolvement (β coefficient 1.03; 95% CI 0.02, 2.03), and psychological distress (β coefficient 3.37; 95% CI 1.29, 5.45). Family burden was found to be significantly related to both symptom severity (β coefficient 3.01; 95% CI 1.50, 4.51) and patient's functioning (β coefficient -2.04; 95% CI -3.55, -0.53). No significant interaction effect of chronicity was observed in the afore-mentioned associations. These findings indicate that severe psychopathology and patient's low psychosocial functioning are associated with poor family functioning. It appears that the effect for family function is significant from the early stages of the illness. Thus, early psychoeducational interventions should focus on patients with severe symptomatology and impaired functioning and their families.

Challenges for group leaders working with families dealing with early psychosis: a qualitative study

BackgroundFamily work is one of the best researched psychosocial interventions for patients with chronic psychosis. However, family work is less studied for patients with a first episode psychosis and the studies have revealed contradicting results. To our knowledge, no previous studies have examined qualitatively group leaders’ experiences with family work. In the present study we wanted to explore challenges faced by mental health professionals working as group leaders for family interventions with first episode psychosis patients.MethodA qualitative exploratory study was carried out based on digitally recorded in-depth interviews and a focus group interview with nine experienced mental health professionals. The interviews were transcribed in a slightly modified verbatim mode and analysed by systematic text condensation.ResultsChallenges faced by group leaders was classified into six categories: (1) Motivating patients to participate, encouraging potential participants was demanding and time-consuming; (2) Selecting participants by identifying those who can form a functional group and benefit from the intervention; (3) Choosing group format to determine whether a single or multi-family group is best for the participants; (4) Preserving patient independence, while also encouraging them to participate in the intervention; (5) Adherence to the protocol, while customizing adjustments as needed; (6) Fostering good problem-solving by creating a fertile learning environment and choosing the most appropriate problem to solve.ConclusionsGroup leaders face challenges related to recruitment and selection of participants for family work, as well as in conducting sessions. Awareness of these challenges could help health professionals more specifically to tailor the intervention to the specific needs of patients and their families.

Mapping Thalamocortical Functional Connectivity in Chronic and Early Stages of Psychotic Disorders

There is considerable evidence that the thalamus is abnormal in psychotic disorders. Resting-state functional magnetic resonance imaging has revealed an intriguing pattern of thalamic dysconnectivity in psychosis characterized by reduced prefrontal cortex (PFC) connectivity and increased somatomotor-thalamic connectivity. However, critical knowledge gaps remain with respect to the onset, anatomical specificity, and clinical correlates of thalamic dysconnectivity in psychosis. Resting-state functional magnetic resonance imaging was collected on 105 healthy subjects and 148 individuals with psychosis, including 53 early-stage psychosis patients. Using all 253 subjects, the thalamus was parceled into functional regions of interest (ROIs) on the basis of connectivity with six a priori defined cortical ROIs covering most of the cortical mantle. Functional connectivity between each cortical ROI and its corresponding thalamic ROI was quantified and compared across groups. Significant differences in the ROI-to-ROI analysis were followed up with voxelwise seed-based analyses to further localize thalamic dysconnectivity. ROI analysis revealed reduced PFC-thalamic connectivity and increased somatomotor-thalamic connectivity in both chronic and early-stage psychosis patients. PFC hypoconnectivity and motor cortex hyperconnectivity correlated in patients, suggesting that they result from a common pathophysiological mechanism. Seed-based analyses revealed thalamic hypoconnectivity in psychosis localized to dorsolateral PFC, medial PFC, and cerebellar areas of the well-described executive control network. Across all subjects, thalamic connectivity with areas of the fronto-parietal network correlated with cognitive functioning, including verbal learning and memory. Thalamocortical dysconnectivity is present in both chronic and early stages of psychosis, includes reduced thalamic connectivity with the executive control network, and is related to cognitive impairment.

Memantine Effects On Sensorimotor Gating and Mismatch Negativity in Patients with Chronic Psychosis.

Patients with chronic psychotic disorders (CPD) exhibit deficient sensorimotor gating (measured by prepulse inhibition (PPI) of startle) and mismatch negativity (MMN). In healthy subjects (HS), N-methyl-D-aspartate (NMDA) antagonists like memantine and ketamine increase PPI, and under some conditions, memantine enhances MMN; these findings present a challenge to understanding the basis for deficient PPI and MMN in psychotic disorders, as reduced NMDA activity is implicated in the pathogenesis of these disorders. Here we assessed for the first time the effects of memantine on PPI and MMN in CPD subjects. Baseline PPI was measured in HS and patients with a diagnosis of schizophrenia or schizoaffective disorder, depressed type. Subjects (total n=84) were then tested twice, in a double-blind crossover design, comparing either: (1) placebo vs 10 mg of memantine or (2) placebo vs 20 mg memantine. Tests included measures of acoustic startle magnitude and habituation, PPI, MMN, autonomic indices, and subjective self-rating scales. Memantine (20 mg) significantly enhanced PPI in CPD subjects, and enhanced MMN across subject groups. These effects on PPI were age dependent and most evident in older CPD patients, whereas those on MMN were most evident in younger subjects. The lower dose (10 mg) either had no detectable effect or tended to degrade these measures. The NMDA antagonist, memantine, has dose-dependent effects on preconscious, automatic measures of sensorimotor gating and auditory sensory processing that are associated with enhanced cognition and function in CPD patients. Ongoing studies will determine whether these memantine-induced changes predict acute pro-cognitive or otherwise clinically beneficial effects in CPD patients.

Neuropsychological Impairment in Prodromal, First-Episode, and Chronic Psychosis: Assessing RBANS Performance.

BackgroundCognitive deficits are observed throughout all developmental phases of psychosis. However, prior studies have usually focused on a limited illness period and used a wide variety of cognitive instruments. Therefore, it has been difficult to characterize or highlight cognitive functioning in different stages of psychosis.MethodWe administered the RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) tests to 4 participant subgroups, including healthy volunteers (controls, HC, n = 28), subjects at high risk for clinical psychosis (prodrome, CHR, n = 27), first-episode schizophrenia patients (FE-Sz, n = 26), and mid-term and long-term chronic schizophrenia patients (Ch-Sz, n =147). Comparison, correlation, and regression analyses of RBANS index scores were assessed among groups. We examined clinical outcomes over 2 years between the CHR and HC subjects, and RBANS domains were used as possible predictors for conversion to psychosis.ResultsPerformance on all RBANS domains was significantly impaired during a post-onset stage of psychosis (FE-Sz and Ch-Sz), and RBANS scores declined along with disease progression. Regression analyses showed that for CHR and HC subjects, baseline impairment in delayed memory (DM) significantly predicted conversion to psychosis. Additionally, partial correlations showed that for FE-Sz and Ch-Sz subjects, DM was the only correlate with a later stage of psychosis.ConclusionsCognitive deficits broadly emerged, and diminished functioning followed along with disease progression. Impairment in DM is perhaps one domain that helps us understand the development of psychosis. A critical need is to monitor and treat memory functioning for psychotic patients throughout all phases of the disease.

Metacognition in First Episode Psychosis: Item Level Analysis of Associations with Symptoms and Engagement

Significant metacognitive impairments are observed in first episode psychosis (FEP) and chronic psychosis samples. There is evidence of associations between metacognition and presentation in FEP, but the relative contribution of metacognitive understanding of the self and the other is as yet unclear. The current study is a secondary analysis of date on metacognition, symptoms and engagement with treatment (help-seeking) in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology and help-seeking within treatment (clinician-rated service engagement) were also measured. An item level analysis of the MAS-R was conducted exploring associations between symptoms and cognitive, emotional, differentiation, integration and decentration aspects of metacognition. We report that associations between negative symptoms and deficits in the understanding of other's mental states extend across cognitive, emotional, integrative and decentration aspects of metacognition. We also report associations between negative symptoms and understanding one's own mind. We also note that cognitive and decentration aspects of metacognition were significantly associated with help-seeking once in treatment. Our findings suggest that an appreciation of metacognitive processes may inform treatment frameworks for FEP. Copyright © 2015 John Wiley & Sons, Ltd. Individual components of metacognition including the capacity to relate cognitive and emotional variables are important in first episode phychosis. Impaired metacognitive understanding of both one's own and others' mental states is associated with increased negative symptoms. Metacognitive variables may be important in understanding how different individuals seek help or engage with services after the initiation of treatment.

Metacognitive capacity as a predictor of insight in first-episode psychosis.

Impaired insight is common in the first episode of psychosis (FEP). Although considerable research has examined the factors that are associated with impaired insight in chronic psychosis, less is known about the factors that underlie and sustain poor insight in FEP. Impaired metacognition, or the ability to form integrated representations of self and others, is a promising potential contributor to poor insight in FEP. To explore this possibility, the authors assessed insight and metacognition in 40 individuals with FEP and then examined the relationship between these areas and social cognition domains, neurocognitive domains, and psychotic symptoms. Correlation analyses revealed that improved insight was associated with higher metacognition, better vocabulary and Theory of Mind scores, and fewer symptoms. The domain of metacognitive mastery also predicted clinical insight. Results support the need to develop an integrative therapeutic approach focused on improving metacognition, hence addressing poor insight in FEP.

Clinical Features of Anti-NMDAR Antibody-positive Patients Predominantly Presenting Chronic Psychosis with Acute Exacerbations. (P2.071)

Clinical Features of Anti-NMDAR Antibody-positive Patients Predominantly Presenting Chronic Psychosis with Acute Exacerbations. (P2.071)

Chronology of illness in dual diagnosis heroin addicts: The role of mood disorders

BackgroundRecent celebrity deaths have been widely reported in the media and turned the public attention to the coexistence of mood, psychiatric and substance-abuse disorders. These tragic and untimely deaths motivated us to examine the scientific and clinical data, including our own work in this area. The self-medication hypothesis states that individuals with psychiatric illness tend to use heroin to alleviate their symptoms. This study examined the correlations between heroin use, mood and psychiatric disorders, and their chronology in the context of dual diagnosis. MethodsOut of 506 dual diagnosed heroin addicts, 362 patients were implicated in heroin abuse with an onset of at least one year prior to the associated mental disorder (HER-PR), and 144 patients were diagnosed of mental illness at least one year prior to the associated onset of heroin use disorder (MI-PR). The retrospective cross-sectional analysis of the two groups compared their demographic, clinical and diagnostic characteristics at univariate and multivariate levels. ResultsDual diagnosis heroin addicts whose heroin dependences existed one year prior to their diagnoses (HER-PR) reported more frequent somatic comorbidity (p≤0.001), less major problems at work (p=0.003), more legal problems (p=0.004) and more failed treatment for their heroin dependence (p<0.001) in the past. More than 2/3 reached the third stage of heroin addiction (p=<0.001). Their length of dependence was longer (p=0.004). HER-PR patients were diagnosed more frequently as affected by mood disorders and less frequently as affected by psychosis (p=0.004). At the multivariate level, HER-PR patients were characterized by having reached stage 3 of heroin dependence (OR=2.45), diagnosis of mood disorder (OR=2.25), unsuccessful treatment (OR=2.07) and low education (OR=1.79).Limitations: The main limitation is its retrospective nature. Nonetheless, it does shed light on what needs to be done from a clinical and public health perspective and especially prevention. ConclusionsThe data emerging from this study, does not allow us to determine a causal relation between heroin use and mental illness onset. However, this data, even if requiring longitudinal studies, suggest that self-medication theory, in these patients, can be applied only for chronic psychoses, but should not be applied to patients with mood disorders using heroin.

French perspectives on psychiatric classification

This article reviews the role of the French schools in the development of psychiatric nosology. Boissier de Sauvages published the first French treatise on medical nosology in 1763. Until the 1880s, French schools held a pre-eminent position in the development of psychiatric concepts. From the 1880s until World War I, German-speaking schools exerted the most influence, featuring the work of major figures such as Emil Kraepelin and Eugen Bleuler. French schools were probably hampered by excessive administrative and cultural centralization. Between the 1880s and the 1930s, French schools developed diagnostic categories that set them apart from international classifications. The main examples are Bouffée Délirante, and the complex set of chronic delusional psychoses (CDPs), including chronic hallucinatory psychosis. CDPs were distinguished from schizophrenia by the lack of cognitive deterioration during evolution. Modern French psychiatry is now coming into line with international classification, such as DSM-5 and the upcoming ICD-11.

The Burden Among Caregivers of Patients with Chronic Psychoses.

Introduction Psychoses are severe mental disorders, which place a considerable burden on the caregivers. Families experience a lot of physical, emotional and financial distress due to a patient’s abnormal behavior, and social and occupational dysfunction. In countries like Tunisia, where rehabilitation services are almost nonexistent, the role of the family becomes more important. Objective Assess caregiver burden among relatives of patients with chronic psychoses. Methodology This is a descriptive cross-sectional study regarding 40 caregivers accompanying patients with chronic psychoses (schizophrenia, bipolar disorder and non- schizophrenic psychosis). The burden was assessed by the European version of the scale of the burden IEQ (Involvement Evaluation Questionnaire). Results The average age of our population was 48 years. Caregivers were as follows: siblings(35%), parents (27.5 %) and spouses(27.5 %). Almost all of the caregivers (80%) lived in the same household as the patient. Pathologies diagnosed in patients were schizophrenia (65%) and bipolar disorder (20%). Most caregivers have an important sense of burden (IEQ> 15) with a percentage of 77.5%. This burden was mainly due to the “tension” with a mean score of 5.6 and the 'supervision'with an average of 3.7. A significant burden was found among caregivers without occupation (p = 0.028). Patients Caregivers treated with atypical antipsychotic express less important burden (p = 0.032). Conclusion Caregivers of patients with chronic psychoses experience moderate to severe burden. Caring for the psychotic patient need to change from a patient focused approach to a combined patient and caregiver approach.

Can We Still Talk About Chronic Hallucinatory Psychosis? a Case Report

Introduction Chronic hallucinatory psychosis is a clinical picture described by Ballet in 1912 which is characterized by the presence of mental automatism, chronic hallucinations and secondary delusions. This clinical entity, from the french school, has been neglected in current psychiatry. The growing influence of international nosology has led to a progressive disuse of the concept of chronic hallucinatory psychosis and patients with such clinical condition have been classified under the diagnosis of paranoid schizophrenia, according to the Anglo-Saxon current classifications. Taking into account that psychopathological features as well as the prognosis differ from schizophrenia (main differential diagnosis) it is important to be aware of this diagnosis in order to avoid a wrong diagnosis of schizophrenia in these patients. Objectives/Aims: The aim of this poster is to highlight the modernity of Ballet’s concept of chronic hallucinatory psychosis, which can be considered a valid clinical entity as it shows clinical features that differ from other psychoses particularly the schizophrenic. Methods We report a case of a 40-year-old woman who presented a psychotic disorder ten months ago whose clinical features resemble the classical description of chronic hallucinatory psychosis. Results/Conclusions Very few recent studies on chronic hallucinatory psychosis have been carried out, which shows the loss of interest of modern psychiatry in this clinical entity. Further research in this field is needed in order to recognize the viability of this diagnosis and provide patients a better care and therapeutic management.

Cutaneous Reactions Carbamazepine-related, Dose and Time Independent, in Chronic Psychotic Patients

Anecdotal evidence suggests carbamazepine as treatment of impulsiveness in chronic psychotic patients. Several carbamazepine-related side effects have been reported in the literature and, among them, serious cutaneous reactions are the most frequent. Erythematous lesions onset, during the first carbamazepine introduction, suggest an idiosyncrasic nature of this reaction. We report here two clinical cases of two men, respectively 30 and 53 years old, affected by chronic psychosis, showing persecutory and reference delusions, auditory hallucinations and aggressive behaviour. Both were treated with carbamazepine (at a dose of 200 mg/day in the first patient, and of 400 mg/day in the second one), antipsychotics and benzodiazepines. After two weeks of carbamazepine treatment, a cutaneous reaction was shown in both cases: it was a papular and erythematous lesion, mainly spread on hands, feet and shoulders. Therefore, patients complained about pricking, fatigue and headache. Medical and allergological tests (Prick test, Patch test) were performed, but serum IgE levels were not reasonably related to an allergopathy; furthermore cutaneous tests were all negative. Carbamazepine treatment was discontinued and a steroidal i.m. therapy was performed for four days, with a gradual resolution of the symptoms. These two clinical cases suggest that cutaneous reactions carbamazepine-related could represent a serious side effect of this treatment. These reactions, dose and time independent are related to genic abnormalities involving alleles HLA-A31:01 e HLA-B15:02 (Genin et al., 2014). Pharmacogenetic studies to identify predictive factors of individual susceptibility to carbamazepine response are needed.

Research Paper A narrative review exploring the effectiveness of Compassion-Focused Therapy

Content &amp; FocusThis narrative review summarises findings of research that has shown use of Compassion-Focused Therapy (CFT) to improve psychological outcomes in clinical populations. This article reviews the research studies that have utilised CFT to treat clients experiencing a variety of mental health issues. The paper begins offering an overview of CFT theory and compassionate mind interventions. A literature search was conducted which included book chapters and articles that discussed compassion focused therapy. Twelve studies were identified which showed significant psychological improvements in clients with diagnosed trauma symptoms, brain injury, eating disorders, personality disorders, schizophrenia-spectrum disorder, chronic mental health problems and psychosis, both within groups and during one-to-one therapy. Within the context of the reviewed studies, CFT has shown itself to be an effective therapeutic intervention when combined with approaches such as Cognitive Behavioural Therapy (CBT).ConclusionThe research design of the majority of the studies examined precluded determining the extent of individual contributions that CFT made towards client recovery. Further research that uses more rigorous approaches are required to evaluate more effectively the role CFT plays in clients’ therapeutic recovery.

Differential Diagnostic Consideration of the Syndrome of Psychomotor Agitation in Geriatric Population

Syndrome of dementia, which appears as a result of deterioration of brain structure that is caused by different factors, together with syndrome of psychomotor restlessness, represents one of the most common psychiatric conditions at patients of the geriatric population (older than 75 years). Our clinical experience shows that these conditions, in this age group, at the moment of admission to hospital treatment, are much more frequent than relapse of chronic endogenous psychosis. Many somatic condition, activation of chronic diseases and subclinical disorders, consequences of previous head trauma (that patient don’t even remember), side effects of most commonly used drugs in the general and internal medicine (benzodiazepines, hypnotics, anticholinergics, antihypertensives, and drugs used in the treatment of arthritis), can cause mental confusion, anxiety and psychomotor agitation – which are conditions similar to dementia. It is very often that mild dehydration is sufficient to cause deterioration in mental status, accompanied by the emergence of nocturnal agitation, confusion, and delirious clouded consciousness. The risk of the manifestation of side effects of psychomotor drugs in geriatric patients becomes much higher due to the exhaustion of adaptive reserves of the central nervous system and cardiovascular system, and due to the delayed liver and kidney function. Implementation of antipsychotics with simpler pharmacodynamic effect is justified to calm the patient. However, later treatment should be directed to compensate the volume of fluid, to correct the electrolyte imbalance, and to treat the root causes that led to the manifestation of psychopathological phenomenology.

Metformin-induced Psychosis: a Case Report.

The psychiatric conditions secondary to substance use (whether legal or illegal drugs) are well characterized and include psychosis, mania, depression and behavior changes. We present a case of metformin-induced psychosis in a 79 years-old patient without any previous psychiatric history. She was brought to emergency room after suicide attempt by hanging. She had a one-month history of altered behavioral and presented paranoid delusional though. Hallucinations were excluded. A detailed clinical evaluation excluded dementia, late-onset chronic psychosis and primary mood disorders with psychotic symptoms and revealed that symptoms initiate few days after the introduction of metformin to treat her diabetes. After Metformin suspension, total remission of psychotic symptoms was obtained in one week and patient return to previous functionality. Psychosis secondary to metformin use is a very rare complication of oral antidiabetic drugs use but the awareness of this condition can lead to an earlier recognition and diagnosis.

Fact or Fiction? Examining a Role for N-Methyl-D-Aspartate Receptor Autoantibodies in Psychiatric Illness

Fact or Fiction? Examining a Role for N-Methyl-D-Aspartate Receptor Autoantibodies in Psychiatric Illness