Higher Levels Of Positive Symptoms Research Articles

Pre-morbid and outcome correlates of first episode mania with psychosis: Is a distinction between schizoaffective and bipolar I disorder valid in the early phase of psychotic disorders?

Objectives The validity of schizoaffective disorder (SA) diagnosis has for long been a matter of controversy and its delineation from bipolar I disorders (BD) has often been questioned. However, most studies have been conducted in chronic samples and have therefore been biased towards patients with poorer outcome, which may have hampered the possibility to identify significant differences between both diagnoses. Methods 108 subjects presenting a first DSM-III-R manic episode with psychotic features were assessed at baseline and 12 months after stabilisation on symptoms and functional characteristics, and patients with BD ( n = 87) were compared with those with SA bipolar subtype (SAB) ( n = 21). Results SAB patients had a higher prevalence of first degree relatives with schizophrenia and a lower premorbid functional level. They had a longer prodromal phase, a longer duration of untreated psychosis and remained symptomatic for a longer period. They also had higher levels of positive symptoms in the acute manic phase; however, with two exceptions, the type of psychotic symptoms were similar in both groups. At stabilisation and 12 months after stabilisation, SA patients had higher levels of negative symptoms, with poorer functional level at 12 months. Conclusions These data suggest SA is a valid diagnosis in the early phase of psychotic disorders considering it defines a subgroup of first episode psychotic mania patients with distinct characteristics compared to BD. While a dimensional approach to diagnosis may be more adapted to this phase of illness, SA disorder offers, in the context of categorical classifications, a useful intermediate category that reflects a clinical reality.

Predictors of long-term outcome of first-episode schizophrenia: A ten-year follow-up study

Objective:Schizophrenia is a severe mental disorder for which final outcomes continue to be unfavorable. The main objectives of this research were to examine and determine the baseline predictors of outcome status of first-episode schizophrenia in a long-term follow-up of ten years and of recovery ten years later.Materials and Methods:The study was carried out in a non-governmental, psychiatric hospital and participants consisted of patients available for assessment ten years following their initial diagnosis. Outcome was assessed on clinical and social parameters. Clinical measures of outcome included psychopathology, hospitalization, and suicidality. Social parameters included quality of life functioning, employability, interpersonal functioning, and the ability to live independently.Results:In our sample, mean positive symptoms’ score were reduced by more than 65% between baseline and endpoint. The percentage of reduction in scores of negative symptoms is much less than reduction in positive symptoms. It was observed that only 23-25% patients showed social recovery on two or three different parameters. Additionally, fewer negative symptoms, lower depression scores, and low levels of aggression at baseline predicted good outcome. A higher level of positive symptoms at baseline also predicted recovery. The two social variables that predicted later outcomes were initially high levels of work performance and the ability to live independently at baseline.Conclusions:Clinical information is not sufficient to make an accurate prediction of outcome status; rather, outcome depends upon multiple factors (including social parameters). A major implication of this research is the argument for moving toward a comprehensive assessment of outcome and to plan management accordingly. Bringing social outcome measures to the forefront and into the communities will allow for a more patient-centric approach. It also opens newer vistas for addressing the complex interaction of clinical and social parameters.

Negative symptoms and concordant impairments in attention in schizophrenia: Associations with social functioning, hope, self-esteem and internalized stigma

Research has suggested that negative symptoms in schizophrenia may be closely linked to impairments in schizophrenia. Research on the strength and nature of this association has been equivocal, however. One possible explanation is that there are two distinct groups of persons with negative symptoms: those with and those without attentional impairments. To examine this question we performed a cluster analysis on 99 adults with schizophrenia or schizoaffective disorder on the basis of their level of negative symptoms and performance on a continuous performance task. Four groups were found: low negative/relatively better attention ( n = 31), low negative/relatively poor attention ( n = 20), high negative/ relatively poor attention ( n = 28), and high negative/relatively better attention ( n = 20). To determine whether these groups differed meaningfully from one another, we next compared their performance on other assessments of positive symptoms, social function, self-esteem and stigma. A MANOVA found significant differences (Wilks' lambda F = 3.2; p < .01) with the high negative/poor attention group having poorer self esteem and greater acceptance of stigma than the other three groups and the high negative/relatively better attention group having higher levels of positive symptoms than the other groups. Implications for research and treatment are discussed.

Successful Tobacco Dependence Treatment in Schizophrenia

Individuals with schizophrenia smoke at rates three times higher than the general population in the United States, with smoking prevalence rates of at least 60% (1, 2). International studies have also typically found increased rates of smoking among persons with schizophrenia (3). A pattern of heavy smoking (more than 20 cigarettes per day) and severe nicotine dependence (4, 5) is characteristic. Smokers with schizophrenia have increased nicotine and cotinine levels that are attributed to increased nicotine intake per cigarette (6–8). Higher blood nicotine levels are associated with greater severity of tobacco dependence and more difficulty quitting. High nicotine levels may be needed for activation of low-affinity alpha-7 nicotinic receptors, which are reduced in both number and function in schizophrenia (9, 10). Evidence for this self-medication hypothesis comes from abnormal electrophysiological measures and saccadic eye movements that are reversed or improved when nicotine is administered by smoking cigarettes or with high-dose nicotine gum or nasal spray (11–13). Despite nicotine being beneficial, tobacco is not a pharmaceutical and is associated with more than 4,000 toxins and more than 60 carcinogens. Nicotine can be delivered more safely in commercially available nicotine products, including gum, nasal spray, inhalers, and patches. Schizophrenia is associated with a 20% reduced life expectancy and increased rates of smoking-related respiratory and cardiovascular diseases compared to members of the general population (14, 15). A 10-year study of elevated risk of coronary heart disease in schizophrenia showed that the risk remained extremely high even after control was added for factors such as weight and body mass index and was attributable mainly to smoking (16). Besides health, tobacco use results in other consequences, with smokers suffering financially and socially. Smokers with schizophrenia spend almost one-third of their monthly disability income on cigarettes (17). Smoking influences community integration because smokers have less income to spend on clothing and housing. As the smoking rate decreases among the general population, there is also the stigma in being a smoker in addition to the stigma of having mental illness. This can reduce success in obtaining employment, housing, or interpersonal relationships. Studies have found that heavy smoking among individuals with schizophrenia is associated with higher levels of positive symptoms and higher antipsychotic medication doses (18, 19). Despite the magnitude of tobacco use problems, quit rates for seriously mentally ill smokers are significantly lower than in the general population (5, 20). Individuals with schizophrenia are able to quit smoking, although the success is about half that of other groups (21–23). Contributing factors likely include lower motivation to quit tobacco use, fewer lifetime quit attempts, and increased severity of nicotine dependence. Another important consideration is that access to treatment for this group is reduced. Few mental health professionals identify and treat tobacco use in their patients (24, 25). Tobacco dependence interventions provided in primary care and public health settings are often brief and may lack the intensity or specialization needed for this population to stop smoking. These services often rely on a highly motivated and organized client who is ready to quit. In 2001, the University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School and Tobacco Dependence Program both collaborated to develop specialized services for smokers with schizophrenia and other mental illnesses. These differed from traditional services in several ways: services were open ended and not limited to a set number of contacts, all patients were encouraged to use a combination approach of pharmacotherapy and counseling, and there was no requirement to set a quit date to be in treatment. An addictions psychiatrist and mental health social worker that was also a certified tobacco treatment specialist provided most services. Both individual and group counseling services were available. More than 300 smokers with schizophrenia and other serious mental illnesses have received these specialty services and achieve long-term abstinence rates as high as those without a history of mental health problems (26). We describe here the treatment of one such patient.

Psychopathological characteristics and treatment response of first episode compared with multiple episode schizophrenic disorders

ObjectiveThe aim was to investigate the hypothesis that patients with first episode schizophrenic disorders have a more favorable treatment response than those with multiple episodes.MethodA total of 400 inpatients from an ongoing multi-centre, follow-up program who fulfilled ICD-10 criteria for schizophrenic disorders (F2) were assessed at admission to and discharge from hospital using the Positive and Negative Syndrome Scale (PANSS).ResultsAt admission, first episode patients (n = 121) showed higher levels of positive symptoms (PANSS positive subscore) and lower ones of negative symptoms (PANSS negative subscore) than multiple episode patients (n = 279), whereas the global disease severity (PANSS total score) was comparable. Analyses of covariance revealed that treatment response (adjusted symptom levels at discharge) was more favorable in first-episode patients, with respect to both positive and negative symptoms.ConclusionThe results are compatible with the hypothesis that treatment response becomes less favorable during the course of schizophrenic illness. This finding might be associated with progressive neurobiological alterations.

Cluster B and C Personality Traits, Symptom Correlates, and Treatment Utilization in Postacute Schizophrenia

Unusually high levels of Cluster B and C personality traits have been observed in schizophrenia. While these have been linked to poorer function, less clear is the association of these personality traits with symptoms and service utilization. To examine this issue, 46 participants with schizophrenia or schizoaffective disorder were administered the Millon Clinical Multiaxial Inventory, Third Edition, and the Positive and Negative Syndrome Scale, and an inventory was taken of medical and psychiatric service utilization. Two sets of multiple regression analyses using Cluster B and C traits to predict treatment utilization and symptoms revealed that emotional discomfort symptoms were significantly related to level of borderline traits. Higher levels of positive symptoms were linked with more avoidant traits and fewer dependent traits. Higher levels of negative symptoms were linked with greater avoidant traits. Service utilization was predicted by borderline, antisocial, and avoidant traits. Implications for rehabilitation and treatment are discussed.

A prospective evaluation of adherence to medication in first episode schizophrenia

The aim of this study was to identify the features of first episode schizophrenia that predict adherence antipsychotic medication at six-month follow-up. We used validated instruments to assess clinical and socio-demographic variables in all patients with first episode schizophrenia from a defined geographical area admitted to a Dublin psychiatric hospital over a four-year period ( N = 100). At six-month follow-up ( N = 60) we assessed adherence to medication using the Compliance Interview. One third of patients with schizophrenia were non-adherent with medication within six months of their first episode of illness. High levels of positive symptoms at baseline, lack of insight at baseline, alcohol misuse at baseline and previous drug misuse predict non-adherence. These results indicate that an identifiable subgroup of patients with first episode schizophrenia is at high risk of early non-adherence to medication. While high positive symptom scores pre-date and predict non-adherence in most patients, reduced insight is the best predictor of non-adherence in patients who do not misuse alcohol or other drugs.

Personal Narratives of Illness in Schizophrenia: Associations with Neurocognition and Symptoms

Controversy exists regarding whether unawareness/denial of illness in schizophrenia results from neurocognitive deficits or a rejection of stigmatized social roles. One possibility is that some elements of a narrative of mental illness are primarily a matter of personal/social construction while others may be uniquely curtailed by neurocognitive deficits. Accordingly, we gathered narratives of illness among 52 persons with schizophrenia spectrum disorders using a semi-structured interview. Ratings of the plausibility, adequacy of detail, and temporal conceptual organization of each narrative were correlated with assessments of neurocognition, symptoms, and traditional insight measures. Degree of plausibility was significantly related to performance on the Wisconsin Card Sorting Test (WCST), a measure of executive function and levels of Positive symptoms on the Positive and Negative Syndrome Scale (PANSS). When entered into a regression to predict plausibility, positive symptoms and WCST performance made unique contributions (R2 = .51, p < .0001). Higher levels of Positive symptoms were associated with poorer temporal conceptual organization within narratives. Adequacy of detail within narratives of illness was related to traditional insight measures but not neurocognition or symptoms.

Duration of untreated psychosis: impact on 2-year outcome

The duration of untreated psychosis has been postulated to be a predictor of clinical outcome in schizophrenia. Although several prospective studies support the relationship, some studies do not. These differences may be due to a number of methodological issues. The objectives of this study are: (i) to address many of the methodological limitations of earlier studies such as variations in sample size and selection, type of treatment provided, differences in measurement of DUP and outcome, and length of follow-up; and (ii) to examine the relationship between DUP and outcome in a prospective longitudinal study. The DUP of 200 consecutive admissions to a first-episode programme was determined. The sample was followed over 2 years and pre-morbid functioning, symptoms, social and cognitive functioning and substance use were assessed longitudinally. Two years after admission to the programme, longer DUP was significantly associated with high levels of positive symptoms and poor social functioning. Independently of other variables, DUP predicted positive symptoms and social functioning at 1 and 2 years. There is evidence that long DUP continues to have an influence on outcome up to 2 years. These results support ongoing efforts for early detection and intervention.

Health-related quality of well-being in chronically hospitalized patients with schizophrenia: comparison with matched outpatients

Quantifying the functional consequences of illness in terms of quality of life can enhance our understanding of both mental and physical disorders. However, little is known about the quality of life among older inpatients vs. outpatients with schizophrenia. We present the results of health-related quality of life assessments in 54 middle-aged and elderly long-term inpatients with schizophrenia and a demographically matched outpatient sample. Assessments were performed using the Quality of Well-Being (QWB) scale, along with standard measures of psychopathology and global cognitive impairment. Compared with outpatients, the inpatients had a significantly lower health-related quality of life, as measured by the QWB. In the inpatient and outpatient groups, higher levels of positive symptoms were associated with lower health-related quality of life. Health-related quality of life remained fairly stable among the inpatients who remained hospitalized over 6 months. In both inpatients and outpatients, baseline cognitive status and psychopathology predicted QWB scores at the 6-month follow-up. These findings further support the use of the QWB in severely mentally ill populations; implications for improving health-related quality of life among older patients with schizophrenia are discussed.

PTSD and comorbid psychotic disorder: comparison with veterans diagnosed with PTSD or psychotic disorder.

Symptoms of posttraumatic stress disorder (PTSD), psychosis, general psychopathology, role functioning, violence potential, and cognitive and emotional aspects of psychotic states were compared in three groups of veterans. Groups were defined on the basis of their DSM-IV diagnoses: Psychotic disorder and war-related PTSD, war-related PTSD without psychotic symptoms, and psychotic disorder without PTSD. Veterans with PTSD and a comorbid psychotic disorder showed significantly higher levels of positive symptoms of psychosis, general psychopathology, paranoia, and violent thoughts, feelings, and behaviors than the other two groups. These data show that patients with comorbid PTSD and psychotic disorder show levels of cognitive, emotional, and behavioral disturbance that far exceed the levels of disturbance seen in patients with PTSD without psychosis or in patients with psychotic disorder.

Risk factors for homelessness among schizophrenic men: a case-control study.

To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

The short-term course of familial and nonfamilial schizophrenic-spectrum disorder

This study was designed to determine in familial and nonfamilial forms of schizophrenia show a different short-term illness course. Sixteen familial and 22 nonfamilial schizophrenics were evaluated on three occasions at regular 6-month intervals over an 18-month period. The familial and nonfamilial groups were compared for differences in positive and negative symptoms of psychosis and interpersonal and occupational role functioning. The data show that familial schizophrenics experience significantly higher levels of positive symptoms of psychosis and significantly worse occupational role functioning. Significant time by family history interactions indicates that the negative symptoms and interpersonal role functioning of the familial schizophrenics changed over the course of follow-up while remaining stable over time in the nonfamilial group. These data provide preliminary support for the hypothesis that familial schizophrenics show a higher degree of impairment during follow-up than nonfamilial schizophrenics.

Assessment of Contributions to Disability in People with Schizophrenia during Rehabilitation

The aim of this study was to assess a number of the components of disability in patients diagnosed with DSM-IIIR residual schizophrenia. Forty-one patients undergoing hospital and community rehabilitation programs were tested. A range of disability levels was defined with a measure of global assessment of function. A large proportion of the patients also had poor results on frontal lobe testing, persistent positive symptoms, and high levels of emotional distress. There was a trend for higher levels of positive symptoms to be associated with increases in global levels of disability, frontal lobe impairment and emotional distress. The work suggests that rehabilitation programs could be more focused if patients were assessed not only for their overall level of functional disability but also for the level of treatment resistant positive symptoms, frontal lobe impairment and the amount and type of emotional distress and insight.