Episode Of Acute Psychosis Research Articles

(339) Urologic and Psychiatric Considerations in Male Genital Self-Mutilation

Abstract Introduction Male genital self-mutilation (GSM) can be categorized into four subtypes – amputation, castration, mutilation, and combined amputation/castration. The most common psychiatric diagnosis associated with GSM is schizophrenia, followed by substance use disorders, personality disorders and gender dysphoria. Objective We discuss a case of amputation/castration GSM in a patient presenting without his severed organ. Treatment considerations in patients with active psychosis due to schizophrenia presenting with GSM are discussed. Methods A 30-year-old single male with a history of schizophrenia requiring multiple prior inpatient psychiatric admissions, obsessive compulsive disorder, and autism spectrum disorder presented to the Emergency Department with penile and bilateral testicular self-amputation. Upon inquiry regarding the method of injury, the patient stated “someone” instructed him to “cut off” his penis and testes with a pair of scissors. He subsequently disposed of his severed organs by flushing them down the toilet. Consent was obtained from the patient’s mother, who served as his healthcare proxy. He underwent operative intervention including penile “stump-plasty”, suture ligation of the bilateral spermatic cords, and scrotal Penrose drain placement with loose re-approximation of scrotal skin. He was admitted for inpatient psychiatric care for management of schizophrenia with active psychosis. Post-operatively he was observed repeatedly touching and contaminating his surgical site and developed a wound infection. The patient underwent operative wound exploration and washout on post-operative day 10. He convalesced well after completing a course of antibiotics for MRSA wound infection. Results Operative intervention options in patients presenting with GSM differ based on the presence or absence of the severed penis. In this patient who presented without the severed penis, possible operative intervention includes primary closure with urethral advancement (stump-plasty), debridement and delayed repair with skin grafting, and perineal urethrostomy. Our patient underwent stump-plasty, and was able to void while standing in the post-operative period. Penile replantation can be considered when the organ has not been discarded. Considerations in psychiatric patients presenting with self-inflicted injuries secondary to a psychotic episode include the patient’s ability to provide informed consent, insight into the patient’s condition, history and severity of mental illness, and increased likelihood of future attempts at self-harm. Severe schizophrenia is associated with increased perioperative complications, including sepsis, acute kidney injury, increased length of stay, and operative wound infections, as well as increased odds of having an adverse operative outcome. Risk factors for GSM include psychotic experiences, personality disorders, prior history of GSM, alcohol and drug use, guilt toward sexual feelings, and early father loss. Patients presenting with an acute episode of psychosis and GSM have increased risk of future GSM, with up to one-third of these patients making a repeated attempt at GSM. Conclusions In a patient with GSM who presents without the severed organ, the physician should consider the patient’s psychiatric history. In patients with an acute psychotic episode and severe schizophrenia, physicians should consider primary closure with urethral advancement versus perineal urethrostomy rather than delayed repair with skin grafting to avoid the risk of wound infection. Disclosure No

Severe acute myxedematous psychosis; rare complication of hypothyroidism

Background: Severe acute myxedematous psychosis, or myxedema madness, is a rare and serious psychiatric complication of hypothyroidism. It is most often misdiagnosed, but it remains reversible after treatment with thyroid hormones. Case Presentation: We report a case of a patient without a known past medical history who underwent total thyroidectomy for papillary thyroid carcinoma. During her withdrawal from thyroid hormone therapy to perform a diagnostic radioiodine wholebody scintigraphy, she presented with anxiety, delirium, and hallucinations, culminating in a suicide attempt. Laboratory testing revealed a high sensible-thyroid stimulating hormone (TSH) value of 35 µIU/ml. The patient was hospitalized in a psychiatric unit, where she received antipsychotic medication and was started on thyroid hormones. After a week, there was a dramatic improvement. Psychiatric symptoms were completely gone a month later justifying the discontinuation of antipsychotics. Recombinant human TSH (rh-TSH) was necessary injected before radioiodine therapy to avoid thyroid hormone therapy suppression and to prevent a second episode of acute psychosis. Conclusion: rh-TSH interest is both in the pre Ira therapy stimulation and for the post-treatment monitoring of patients with thyroid cancer, and helps avoiding hormonal treatment suppression.

Testing the robustness of emergency department process pathways using multidisciplinary team in-situ simulation

Delivering safe and best practice is dependent on robust structural processes and optimal acquisition of skills and knowledge across disciplines [1]. An in-situ simulation-based education model was implemented to optimise the provision of best practice in emergency medicine [2]. In-situ simulation cases were developed based on critical incidents, complaints, and interesting cases. These simulations were designed to be complex cases, aimed at high-level multi-specialty working. Maintaining the real-life integrity of the simulation cases was paramount. The simulations were run in a busy Emergency Department (ED), during the working day while the normal service continued. Participants were instructed to make-up medication, collect blood products, and contact specialities in real time. Debriefing initially included identifying communication, human factor and process issues, and concluded with medical teaching on the topic covered, and included the speciality perspective on optimal medical management. Logistical support was provided by the simulation faculty. Data from feedback forms was collected. Over 12 months, 20 simulations cases were conducted in the resuscitation area of the ED. Simulations involved multidisciplinary, multi-speciality workforce covering the management of acute bronchitis in an infant, an episode of acute psychosis, upper gastrointestinal bleed requiring major haemorrhage protocol activation, and many other emergencies covering the full spectrum of specialities. All feedback strongly agreed/agreed that the simulation exercises were beneficial and would lead to an improvement in the participants’ clinical practice. The multidisciplinary approach was key to the discovery of system weaknesses and risk-factors. These were then addressed and improvements in system learning, and processes were proven by the re-running of similar scenarios. The learning points were communicated via the hospital ED guideline application (AskEarl) and departmental communication channels. Changes have included updating standard operating procedures, guidelines, and the application of a business case for a blood fridge located in ED to reduce blood administration length of time. These detailed simulations successfully tested the current hospital processes and resulted in significant improvements to the daily structural delivery of best practise. Additionally, the SBE model decreased clinician teaching preparation burden and increased simulation efficiency and effectiveness. After the success of this model, it is being rolled out to other specialities. We would like to acknowledge and thank the Dinwoodie Charitable Company for their support. 1. Gressgård LJ. Knowledge management and safety compliance in a high-risk distributed organizational system. Safety and health at work. 2014;5(2):53–59. 2. Petrosoniak A, Auerbach M, Wong AH, Hicks CM. In situ simulation in emergency medicine: moving beyond the simulation lab. Emergency Medicine Australasia. 2017;29(1):83–88.

Ictal Psychosis under Disguise of Mania: How to Unravel

Background: Ictal psychosis without remarkable cognitive impairment is uncommon occurrence, presents diagnostic challenges to clinicians, often misdiagnosed as functional psychosis. Case Presentation: We present 3 cases of young adult men admitted to psychiatric ward as functional psychosis. They presented with irritability, physical aggression and mild cognitive impairment with intense emotional symptoms, and persecutory ideas and delusions. Two were wrongly diagnose as mania while the third was mimicking schizophrenia in its presentation. They received antipsychotic treatment and misdiagnosed as functional psychosis. They did not respond well to such treatment, until, series electroencephalograms were taken which revealed evidence of ictal psychosis. All, thence, responded well to addition of antiepileptic treatment. This, not only, proves to be effective, but also determined future management and prognosis. Conclusion: These cases shine light onto the role of the frontal cortex in the genesis of quasi-manic episodes and highlight the importance of EEG investigations in first episode of acute psychosis.

Shifts in positive and negative psychotic symptoms and anger: effects on violence.

Changes in positive and negative symptom profiles during acute psychotic episodes may be key drivers in the pathway to violence. Acute episodes are often preceded by fluctuations in affect before psychotic symptoms appear and affective symptoms may play a more important role in the pathway than previously recognised. We carried out a prospective cohort study of 409 male and female patients discharged from medium secure services in England and Wales to the community. Measures were taken at baseline (pre-discharge), 6 and 12 months post-discharge using the Positive and Negative Syndrome Scale. Information on violence was obtained using the McArthur Community Violence Instrument and Police National Computer. The larger the shift in positive symptoms the more likely violence occurred in each 6-month period. However, shifts in angry affect were the main driving factor for positive symptom shifts associated with violence. Shifts in negative symptoms co-occurred with positive and conveyed protective effects, but these were overcome by co-occurring shifts in anger. Severe but stable delusions were independently associated with violence. Intensification of angry affect during acute episodes of psychosis indicates the need for interventions to prevent violence and is a key driver of associated positive symptoms in the pathway to violence. Protective effects against violence exerted by negative symptoms are not clinically observable during symptom shifts because they are overcome by co-occurring anger.

Disturbed glutathione antioxidative defense is associated with structural brain changes in neuroleptic-naïve first-episode psychosis patients

BackgroundOxidative stress and impaired antioxidant defense are reported in schizophrenia and are thought to be associated with disturbed neurodevelopment, brain structural alterations, glutamatergic imbalance, negative symptomatology, and cognitive impairment. To test some of these assumptions we investigated the glutathione (GSH) antioxidant defense system (AODS) and brain structural abnormalities in drug-naïve individuals with first acute episode of psychosis (FEP). MethodThe study involved 27 drug-naïve FEP patients and 31 healthy controls (HC). GSH AODS markers and TBARS (thiobarbituric acid reactive substances) were measured in blood plasma and erythrocytes. High-resolution T1-weighted 3T MRI were acquired from all subjects. To investigate brain structural abnormalities and effects of illness on interactions between GSH metabolites or enzyme activities and local grey matter density, voxel-based morphometry (VBM) with the computational anatomy toolbox (CAT12) was used. Symptomatology was assessed using the Positive and Negative Syndrome Scale (PANSS) and the Symptom Checklist 1990 revised (SCL-90-R). Results(i) In FEP patients, glutathione reductase activity (GSR) was lower than in the HC group. GSR activity in plasma was inversely correlated with SCL-90-R scores of depression and PANSS scores of the negative symptom subscale. (ii) A reduction of GM was observed in left inferior frontal, bilateral temporal, as well as parietal cortices of FEP patients. (iii) Interaction analyses revealed an influence of illness on GSR/GM associations in the left orbitofrontal cortex (BA 47). ConclusionOur findings support the notion of altered GSH antioxidative defense in untreated acute psychosis as a potential pathomechanism for localized brain structural abnormalities. This pathology relates to a key brain region of social cognition, affective motivation control and decision making, and is clinically accompanied by depressive and negative symptoms.

Conceptualizing and Treating Psychosis: A Lacanian Perspective

Starting from the hypothesis that psychosis makes up a structure with a precise status for the unconscious, the author explores how, from a Lacanian point of view, the treatment of psychosis is organized. Special attention is paid to the specificity of the psychotic symptom and the way transference characteristically takes shape. It is indicated that the occurrence of psychotic symptoms bears witness to a subjective crisis, in which no signifiers provide support when, at the level of the unconscious, the subject is dealing with fundamental self‐directed epistemic questions (‘who am I?’) and questions concerning the intentionality of the other (‘what do you want?’). Characteristically, such questions are organized around intimate topics like dealing with parenthood and authority; life in the light of death; sexuality in relation to love and procreation; and sexual identity. Psychotic crises are triggered upon confrontations with such issues in daily life, while no support by means of a master signifier or Name‐of‐the‐Father can be found. Crucial to the Lacanian approach to treatment is that the psychoanalyst aims at restoring a place for the subject in relation to the Other, which is threatened in episodes of acute psychosis. Clinical material from Lacanian work with a female patient suffering from manic‐depressive psychosis is discussed.

Antibodies to surface dopamine‐2 receptor and N‐methyl‐D‐aspartate receptor in the first episode of acute psychosis in children

Antibodies to surface dopamine‐2 receptor and <i>N</i>‐methyl‐D‐aspartate receptor in the first episode of acute psychosis in children

Acute psychosis as a harbinger of a tumor: A case of anti-N-methyl-D-aspartate receptor encephalitis

An obese but otherwise healthy 22-year-old female presented to the hospital with an episode of acute psychosis. On exam the patient was febrile and had labile systolic blood pressure. Urine drug screen and infectious workup were negative. A CSF Anti-N-methyl-D-aspartate (Anti-NMDA) receptor antibody was positive. Brain magnetic resonance imaging (MRI) showed hyperintensity in the left hippocampus on diffusion weighted imaging (DWI). The patient was started on prednisone, intravenous immunoglobulins, and rituximab. Hospital course was complicated by seizures and autonomic instability, requiring prolonged stay in the ICU. Cognitive, motor, and autonomic function gradually improved with therapy. Magnetic resonance imaging of the pelvis revealed a 3 cm × 3 cm left ovarian teratoma that was removed with oophorectomy. The patient was discharged to rehab hospital for continued treatment and physical therapy.

Acute psychosis as a harbinger of a tumor: A case of anti-N-methyl-D-aspartate receptor encephalitis

An obese but otherwise healthy 22-year-old female presented to the hospital with an episode of acute psychosis. On exam the patient was febrile and had labile systolic blood pressure. Urine drug screen and infectious workup were negative. A CSF Anti-N-methyl-D-aspartate (Anti-NMDA) receptor antibody was positive. Brain magnetic resonance imaging (MRI) showed hyperintensity in the left hippocampus on diffusion weighted imaging (DWI). The patient was started on prednisone, intravenous immunoglobulins, and rituximab. Hospital course was complicated by seizures and autonomic instability, requiring prolonged stay in the ICU. Cognitive, motor, and autonomic function gradually improved with therapy. Magnetic resonance imaging of the pelvis revealed a 3 cm × 3 cm left ovarian teratoma that was removed with oophorectomy. The patient was discharged to rehab hospital for continued treatment and physical therapy.

Should psychiatrists be more cautious about the long-term prophylactic use of antipsychotics?

Patients who recover from an acute episode of psychosis are frequently prescribed prophylactic antipsychotics for many years, especially if they are diagnosed as having schizophrenia. However, there is a dearth of evidence concerning the long-term effectiveness of this practice, and growing concern over the cumulative effects of antipsychotics on physical health and brain structure. Although controversy remains concerning some of the data, the wise psychiatrist should regularly review the benefit to each patient of continuing prophylactic antipsychotics against the risk of side-effects and loss of effectiveness through the development of supersensitivity of the dopamine D2 receptor. Psychiatrists should work with their patients to slowly reduce the antipsychotic to the lowest dose that prevents the return of distressing symptoms. Up to 40% of those whose psychosis remits after a first episode should be able to achieve a good outcome in the long term either with no antipsychotic medication or with a very low dose.

Antibodies to Surface Dopamine-2 Receptor and N-Methyl-D-Aspartate Receptor in the First Episode of Acute Psychosis in Children

BackgroundThe dopamine and glutamate hypotheses are well known in psychosis. Recently, the detection of autoantibodies against proteins expressed on the surface of cells in the central nervous system has raised the possibility that specific immune-mediated mechanisms may define a biological subgroup within psychosis, although no cohort of a first episode of psychosis in children has been investigated. MethodsSerum taken during the acute presentation of 43 children with first episode of psychosis and serum from 43 pediatric control subjects was assessed for the presence of immunoglobulin (Ig)G, IgM, or IgA antibodies to dopamine-2 receptor (D2R) and NR1 subunit of the N-methyl-D-aspartate receptor using a flow cytometry live cell-based assay and immunolabeling of murine primary neurons. ResultsUsing a cutoff of three SD above the control mean, serum antibodies to D2R or NR1 were detected in 8 of 43 psychotic patients but not detected in any of 43 control subjects (p < .001). Positive immunoglobulin binding to D2R was found in 3 of 43 psychosis patients (3 IgG, 1 IgM, 0 IgA) and to N-methyl-D-aspartate receptor in 6 of 43 patients (5 IgG, 1 IgM, 1 IgA). Specificity of antibody was confirmed by immunoaffinity purification and immunoabsorption. Significant differences in antibody binding to live, fixed, and fixed and permeabilized neurons were observed, confirming that only live cells can define surface epitope immunolabeling. ConclusionsThis is the first report of serum antibodies to surface D2R and NR1 in pediatric patients with isolated psychosis, which supports the hypothesis that a subgroup of patients may be immune-mediated.

EPA-1632 – Phenomenology of acute psychosis

The experience of an inaugural episode of acute psychosis is initially a confrontation with an indefinable experience. However, with the introduction of operationalized classifications (for example the DSM), the clinicians attaches sometimes less importance to the subjective patient's experience than to the possible presence of symptoms, lidding to a not-comprehensibility of delusional experience. Following the phenomenological tradition of Minkowski, Binswanger, Conrad, Tellenbach Blankenburg and Kimura, some authors from the end of the twentieth century like Stanghellini, Parnas, Bovet and Grivois reaffirmed this approach that put between brackets the 'objective’ concepts of descriptive psychopathology to make possible a more immediate encounter with patient. Thus, the intersubjectivity becomes a principal object of analysis. For example, Minkowski speaks about a diminished sense of dynamic and vital connection to the world, 'the loss of vital contact’; and Blankenburg emphasizes the patient's loss of the normal sense of obviousness or 'natural self-evidence’. In a more empirical way, Conrad studied the first 117 episodes of psychosis and proposed a nomenclature of the initial phases of the disease (trema, apophany, anastrophe and apocalypses), to describe the becoming of the patient in a strange world, that's finish in a subjective’reorganization of meaning’. The objective of the present article is to review the different phenomenological concepts from Minkoswki to nowadays authors to offer a better comprehensibility of psychotic experience.

Quetiapine and the development of the metabolic syndrome: Table 1

A 21-year-old Asian male presented to accident and emergency department in November 2011 with a short history of non-specific abdominal pain and vomiting. Systemic enquiry revealed 20 kg weight gain over 8 months and a 3-week history of worsening polydipsia and polyuria. Past medical history included schizophrenia only, which was well-controlled on Quetiapine. This had been commenced 1 year prior to admission following an episode of acute psychosis, and he took no other regular medications. He had a 2 pack-year smoking history and, although abstinent for 10 months prior to admission, a history of alcohol excess. He was unemployed and denied undertaking any regular exercise. He had a positive family history for diabetes, with both parents on Metformin for type 2 diabetes. His father additionally suffered from hypercholesterolaemia, hypertension and cardiac failure. Observations on admission included a heart rate of 103 bpm, blood pressure of 150/99 mmHg, blood glucose of 21 mmol/l and temperature of 37°C. On examination, significant findings included generalized abdominal tenderness, central obesity, acanthosis nigricans, and a medial thigh abscess. Arterial blood gas revealed a metabolic acidosis (pH 7.30) and urinalysis was significantly positive for ketones, subsequently leading to a diagnosis of diabetic ketoacidosis (DKA). This was treated effectively with intravenous Insulin and aggressive fluid resuscitation. Antibiotics were administered and following resuscitation, he underwent incision and drainage of the abscess. All inpatient blood samples were reported by the laboratory as turbid. Consequently, various blood parameters could not be measured, …

Amphetamine Versus Non Amphetamine-Related First Episode Psychosis in Saudi Arabian Patients

Background: Amphetamines are illicit psychostimulant drugs that can induce psychotic symptoms. Very few studies have been conducted in Kingdom of Saudi Arabia (SA) on amphetamine abuse and related psychosis. Recently, the pattern of amphetamine abuse in SA showed a significant trend of increased frequency. Objectives: To investigate the extent of amphetamine abuse in a sample of Saudi patients hospitalized for first episode of acute psychosis. Also, to compare in that sample between amphetamine psychosis and other psychoses regarding demographic data, premorbid personality and symptoms profile. Method: 106 patients with acute psychosis were hospitalized and screening of urine for amphetamine was conducted for all. Patients’ psychiatric evaluation included interviewing, and ICD-10 criteria for personality disorders. 30 healthy subjects were also included for comparison with patients. Results: 34/106 of psychotic patients (32%) were positive for amphetamine in urine (≥ 1000 ng/ml). The frequency of personality disorders was significantly higher (P < 0.01) in the patients (54/106; 51%) compared with healthy subjects (6/30; 20%). Also, the incidence of personality disorders was significantly higher (P < 0.01) in amphetamine positive psychosis (25/34; 73.5%) compared with amphetamine negative psychosis (29/72; 40%). Cluster B personality disorders particularly the antisocial and borderline were significantly higher in amphetamine positive psychosis (13/34; 38%) compared with amphetamine negative psychoses (6/72; 8%). The symptom profile showed significant difference between amphetamine positive and amphetamine negative psychosis as regards ideas of reference (50% vs. 14%), suspiciousness (44% vs. 11%), suicidal ideation (38% vs. 23%), paranoid delusions (29% vs. 17%) and increased pulse or blood pressure (29% vs. 7%) respectively. Conclusion: Screening of amphetamine in urine among patients with first episode of acute psychosis can help and support the clinical distinction of amphetamine psychosis from other types of psychosis. This is therapeutically critical since the line of treatment may be different between the two types of psychoses.

Alteration of serum bilirubin level in schizophrenia

Objective. Alteration of serum bilirubin level in acute episodes of psychosis in patients with schizophrenia has been reported but the pattern of this alteration is controversial. Methods. Patients diagnosed as schizophrenia (162, group S) or bipolar disorder (155, group B) entered the study. The control group consisted of 95 patients admitted to cardiac care unit who had no personal or family history of major psychiatric disorders. Pre- and post-admission levels of bilirubin were measured and compared within and between the groups. Patients were examined to exclude all other causes of hyperbilirubinemia. Group S and B participants were also evaluated using positive and negative syndrome subscale (PANSS) both at admission and discharge. Results. The mean admission bilirubin levels of all the groups were in the normal range (significantly higher in group S than groups B and C) and were affected by the score of general psychopathology subscale rather than the scores of positive symptoms subscale. Conclusions. Although bilirubin decreased in all three groups at discharge, the rate of decrease was significantly higher in group S. The reason for this is not clear and needs further study.

Canada: Psychosis in the Immigrant Caribbean Population

Many reports from European countries suggest that acute episodes of psychosis are more frequent among immigrants from the Caribbean than among their non-immigrant peers. The aim of this selective review is to examine how the social correlates of migration to Canada interact with biological mechanisms to contribute to psychosis in the Caribbean population. PubMed and JSTOR social science databases (between 1966 and 2010) were searched using the following search terms: psychiatric genetics; dopamine pathways; Caribbean family structure and child rearing; cannabis and psychosis; obstetric complications and schizophrenia; social defeat; social capital; racial discrimination; urbanicity; immigration; assimilation; and immigration. This was followed by the cross-checking of references pertinent to Canada. There was no information about the prevalence of psychosis in Afro-Caribbean immigrant groups to Canada. There was a suggestion that the form the acute episode takes may differ, depending perhaps on the island of origin. Ethnicity and migration influence susceptibility and response to psychotic illness in a number of distinct and interacting ways depending both on the host country and the country of origin. Understanding the pathways can help to protect the health of immigrants.

Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation

BackgroundHepatic artery thrombosis is a devastating complication after orthotopic liver transplantation often requiring revascularization or re-transplantation. It is associated with considerably increased morbidity and mortality. Acute cognitive dysfunction such as delirium or acute psychosis may occur after major surgery and may be associated with the advent of surgical complications.Case presentationHere we describe a case of hepatic artery thrombosis after living-donor liver transplantation which was not preceded by signs of liver failure but rather by an episode of acute psychosis. After re-transplantation the patient recovered without sequelae.ConclusionThis case highlights the need to remain cautious when psychiatric disorders occur in patients after liver transplantation. The diagnostic procedures should not be restricted to medical or neurological causes of psychosis alone but should also focus vascular complications related to orthotopic liver transplantation.

Early psychosis, activity performance and social participation: A conceptual model to guide rehabilitation and recovery.

In this paper we present a conceptual model focusing on activity performance and social participation of individuals in the period prior to their first acute episodes of psychosis. The model was developed using the constructivist grounded theory method. Data from interviews and documents was collected from 25 primary participants. Interviews were also conducted with 15 members of the participants' support networks and six experts in the field of early psychosis and rehabilitation. The model illustrates how the core constructs of activity performance and social participation are set against the natural context and influenced by shifts in three determinants: faltering personal capacities, negotiating for success and risk factors. The model suggests rehabilitation and recovery practices in early intervention work.

Reduced size of the pre-supplementary motor cortex and impaired motor sequence learning in first-episode schizophrenia

Increasing evidence suggests that schizophrenia is associated with various morphological and functional abnormalities of the frontal cortex. So far research has concentrated on the dorsolateral and orbitofrontal cortex. Behavioral evidence suggests however that regions responsible for higher motor control are compromised in schizophrenia as well. The current study assessed volumes of the anterior supplementary motor area (pre-SMA) and implicit motor sequence learning in 15 subjects with first-episode schizophrenia and 15 healthy matched controls. Pre-SMA volumes were assessed by three-dimensional structural magnetic resonance imaging (3D-MRI) and manual parcellation according to an established protocol. Implicit motor sequence learning was assessed using the Serial Reaction-Time Task (SRTT). Compared with control subjects, schizophrenia subjects had significantly smaller volumes of the left pre-SMA (16%). Subjects with schizophrenia were severely impaired on sequence-specific implicit motor learning. Size of the left pre-SMA of schizophrenia subjects was significantly related to impaired implicit learning. We conclude that subjects with first-episode schizophrenia have a morphological abnormality of the left pre-SMA that might predispose them to develop disturbances of higher motor control during acute episodes of psychosis. These structural and behavioral abnormalities might be conceptualized within a broader model that views schizophrenia as a disorder of disturbed coordination of thought and action.