RESUMEN

BACKGROUND: Several questions remain unanswered regarding the magnitude and time course of cognitive improvement in response to antipsychotic treatment. The purpose of this study was to assess changes in cognitive performance in antipsychotic-naive or minimally medicated patients with first-episode schizophrenia during the first 12 months of treatment, in a case-control design. Patients were treated with flupenthixol decanoate depot injection, according to a standard algorithm. The primary outcome measure was change in MATRICS Cognitive Consensus Battery (MCCB) composite score over 12 months. METHOD: The sample comprised 92 patients and 100 healthy controls matched for age, sex, ethnicity and educational status. Cognitive function was assessed by means of the MCCB. RESULTS: A mixed-effects model identified a significant group × time effect (p ≤ 0.0001) for the MCCB composite score, with patients showing a greater degree of change than the controls. For the other MCCB domains there were significant group × time effects at adjusted significance level for attention and vigilance (p ≤ 0.0001), visual learning (p ≤ 0.0001), verbal learning (p = 0.005) and working memory (p ≤ 0.0001), but not for reasoning and problem solving (p = 0.04), speed of processing (p = 0.03) and social cognition (p = 0.06). There were moderate correlations between change in MCCB composite score and change in symptomatology as assessed by Positive and Negative Syndrome Scale factor analysis-derived domains. CONCLUSIONS: Substantial improvements in cognitive function were observed over and above a practice effect, and were significantly correlated with improvements in psychopathology and functionality.

Asunto(s)

RESUMEN

OBJECTIVES: To assess changes in body mass and metabolic profiles in patients with first-episode schizophrenia receiving standardised, assured treatment and to identify predictors and moderators of the effects. METHODS: We investigated the changes in body mass, fasting blood glucose and lipids in 107 largely antipsychotic naïve, first-episode schizophrenia patients who were treated according to a standard algorithm with long-acting injectable flupenthixol decanoate over 12 months. RESULTS: Eighty-three (78%) participants completed the 12 months of treatment, and 104 (97%) received 100% of the prescribed injections during their participation. There were significant increases in BMI (P<.0001), waist circumference (P=0.0006) and triglycerides (P=0.03) and decrease in HDL (P=0.005), while systolic (P=0.7) and diastolic blood pressure (P=0.8), LDL (P=0.1), cholesterol (P=0.3), and glucose (P=0.9) values did not change over time. The triglyceride: HDL ratio increased by 91%. Change in BMI was only correlated with change in triglycerides (P=.008). The only significant predictor of BMI increase was non-substance abuse (P=.002). CONCLUSIONS: The risks of weight gain and metabolic syndrome associated with antipsychotic treatment in first-episode schizophrenia are not restricted to second generation antipsychotics. This is a global problem, and developing communities may be particularly susceptible.

Asunto(s)

RESUMEN

OBJECTIVE: Medically unexplained symptoms (MUS) are commonly encountered in medical practice. In psychiatry, they are classified mostly as Somatoform Disorders and are often associated with anxiety and depression. The literature suggests that, in some cases, MUS may be ascribed to Somatoform Disorders when, fact, they are "organic" syndromes that are misdiagnosed. In developing countries, with fewer resources, MUS may be more difficult to assess. METHOD: We undertook a retrospective chart review to examine the demographics, referral pathway, management and diagnostic outcome of subjects (n = 50) referred to psychiatry with MUS over an 18 month period. RESULTS: Subjects with MUS accounted for only 4.5% of the total number of files reviewed. In only 38% of cases did the final diagnosis in psychiatry concur with the referral diagnosis. In 28% of cases a new "organic" diagnosis was made and in 72% of cases a new psychiatric diagnosis was made. Subjects who were diagnosed with "organic" illness were seen fewer times prior to referral to psychiatry and were significantly older than other subjects. CONCLUSION: In developing countries like SA, a significant number of patients with MUS may have underlying "organic" illness, and most may have psychiatric disorders. Patients with MUS, especially older patients, should be more extensively investigated. Psychiatric referral of these patients is very appropriate.

Asunto(s)

RESUMEN

BACKGROUND: Lack of awareness of tardive dyskinesia (TD) and poor insight into mental illness are common in schizophrenia, raising the possibility that these phenomena are manifestations of a common underlying dysfunction. METHODS: We investigated relationships between low awareness of TD and poor insight into mental illness in 130 patients with schizophrenia and TD. We also examined selected demographic and clinical correlates of these two phenomena. RESULTS: Sixty-six (51%) patients had no or low awareness of TD and 94 (72%) had at least mild impairment of insight into their mental illness. Low awareness of TD was not significantly correlated with greater impairment of insight into mental illness. Regression analyses indicated that the Positive and Negative Syndrome Scale (PANSS) disorganised factor (ß=0.72, t=11.88, p<0.01) accounted for 52% of the variance in insight into mental illness (adjusted R(2)=0.55) (F[2, 127]=81.00, p<0.01) and the Extrapyramidal Symptom Rating Scale (ESRS) dyskinesia subscale score (ß=0.47, t=6.80, p<0.01), PANSS disorganised factor (ß=-0.26, t=-3.73, p<0.01), and ESRS parkinsonism subscale score (ß=0.31, t=4.55, p<0.01) together accounted for 37% of the variance in awareness of TD (adjusted R(2)=0.37) (F[3, 126]=26.87, p<0.01). CONCLUSION: The two phenomena appear to be dissociated, and may be domain-specific.

Asunto(s)

RESUMEN

Objective: Medically unexplained symptoms (MUS) are commonly encountered in medical practice. In psychiatry; they are classified mostly as Somatoform Disorders and are often associated with anxiety and depression. The literature suggests that; in some cases; MUS may be ascribed to Somatoform Disorders when; fact; they are ""organic"" syndromes that are misdiagnosed. In developing countries; with fewer resources; MUS may be more difficult to assess. Method: We undertook a retrospective chart review to examine the demographics; referral pathway; management and diagnostic outcome of subjects (n = 50) referred to psychiatry with MUS over an 18 month period. Results: Subjects with MUS accounted for only 4.5of the total number of files reviewed. In only 38of cases did the final diagnosis in psychiatry concur with the referral diagnosis. In 28of cases a new ''organic"" diagnosis was made and in 72of cases a new psychiatric diagnosis was made. Subjects who were diagnosed with ""organic"" illness were seen fewer times prior to referral to psychiatry and were significantly older than other subjects. Conclusion: In developing countries like SA; a significant number of patients with MUS may have underlying ""organic"" illness; and most may have psychiatric disorders. Patients with MUS; especially older patients; should be more extensively investigated. Psychiatric referral of these patients is very appropriate."

Asunto(s)

RESUMEN

OBJECTIVE: Recent findings suggest that premature death in patients with severe mental illness (SMI) can be attributed to the high comorbidity of cardio-metabolic disorders. This study investigated the prevalence and monitoring of some risk factors for cardio-metabolic disease in a cohort with SMI, compared to the general medical population. METHOD: 101 participants with SMI and 100 controls were recruited from a primary care clinic. Assessments of risk factors with standard clinical measurements were done after healthcare workers and patient-participants had completed the structured questionnaires. Clinical files were reviewed to determine frequency of monitoring of risk factors. RESULTS: We found no differences between the groups in demographic variables. A similar prevalence of abnormal blood pressure (BP), increased Body Mass Index (BMI) and increased waist circumference was noted in both groups. Females in both groups were more likely to have an abnormal waist circumference. Patients with SMI were significantly less likely to have recordings of their weight or BP in their clinic file. Healthcare workers and patients with SMI were largely unaware of the increased risk of cardio-metabolic illness. CONCLUSION: This study suggests that patients with SMI received poorer health monitoring than other patients attending a primary care clinic and that both healthcare workers and patients were poorly informed about the increased risk of cardio-metabolic disorders in patients with SMI.

Asunto(s)

RESUMEN

The inclusion of dimensional elements in the psychiatric diagnostic systems have been advocated for many years, however it has been resisted due to concerns about clinical utility. Recent suggestions have been for a combination of categorical and dimensional data in future diagnostic classification systems. In this paper we discuss the overlap in symptom complexes between mood disorders and schizophrenia and a multi-dimensional model of the mood-psychosis interface. We propose that the personality diagnoses should be included in Axis I and suggest the inclusion of a five factor dimensional diagnosis of mood and psychotic disorders on Axis II of DSM-V/ICD-11.

RESUMEN

Although the integration of psychiatric services into the community has potentially been beneficial to many patients, this transition has not been without problems. A major obstacle to establishing successful community-based treatment in South Africa has been that the reduction in number of inpatients beds did not coincide with the development of adequate community resources. This, in combination with our patients' poor socio-economic circumstances, has contributed to a substantial increase in the so-called "revolving door" or high frequency use phenomenon in state psychiatric facilities. Clearly, there is need for a renewed approach to address this problem in our setting. With this in mind the APH in the Western Cape appointed three community treatment teams in January 2007. This publication serves to give an overview of the Stikland Psychiatric Hospital team's experiences in the first 12 months since establishment. To date, we have been confronted by several challenges that complicate the successful implementation of an "assertive" outreach service in the South African context. However, there seems to be some hope as early findings demonstrate a reduction in number of admissions as well as inpatient days. Furthermore there has been a very positive response from service users, their families and other staff members leaving us to conclude that this initiative seems to be a much needed step in the right direction.

RESUMEN

Patients with severe mental illness have higher than expected prevalence rates of co-morbid general medical conditions, particularly metabolic and cardiovascular disease. They are also at increased risk of contracting HIV. Conversely, these and other medical disorders also increase the risk of developing mental disorders. Mental illness and general medical conditions have mutually adverse effects on long-term outcome. This interaction of diseases contributes significantly to the excess morbidity in and higher than expected standard mortality ratios for patients with mental illness. As medical practice becomes more specialized and arguably compartmentalized it may increasingly fail to integrate health care for patients with severe mental illness. In this paper we discuss the high co-morbidity of mental illness with other medical disorders as well some of the potential mechanisms involved. We furthermore argue that the bidirectional relationship between mental and medical disorders should be considered in the planning of treatment for either group of disorders. The central role of the psychiatrist in co-ordinating and integrating the health care of patients with severe mental illness is emphasized.

Asunto(s)

RESUMEN

OBJECTIVE: Post traumatic stress disorder (PTSD) is a common, debilitating anxiety disorder characterized by emotional and physical symptoms that may occur after exposure to a severely traumatic event. Since it occurs commonly as a comorbid diagnosis with other mood- and anxiety disorders, we postulated that this disorder may be under- diagnosed in therapeutic wards where anxiety and mood disorders are treated. The study thus sought to determine the prevalence of undiagnosed PTSD in an inpatient population, and to compare the demographic details and comorbid diagnoses of subjects with and without PTSD. METHOD: The Clinician-administered PTSD Scale for DSM-IV (CAPS) was administered to 40 subjects who were inpatients in a therapeutic ward of a large psychiatric hospital and who had never had a diagnosis of PTSD before. RESULTS: 16 (40%) subjects met the DSM-IV criteria for PTSD. We did not find significant clinical differentiating factors between subjects with and without PTSD; however subjects with PTSD were more likely to use cannabis. CONCLUSIONS: PTSD remains undiagnosed in many patients admitted to therapeutic units.

Asunto(s)

RESUMEN

Patients with severe mental illness have higher than expected prevalence rates of co-morbid general medical conditions; particularly metabolic and cardiovascular disease. They are also at increased risk of contracting HIV. Conversely; these and other medical disorders also increase the risk of developing mental disorders. Mental illness and general medical conditions have mutually adverse effects on long-term outcome. This interaction of diseases contributes significantly to the excess morbidity in and higher than expected standard mortality ratios for patients with mental illness. As medical practice becomes more specialized and arguably compartmentalized it may increasingly fail to integrate health care for patients with severe mental illness. In this paper we discuss the high co-morbidity of mental illness with other medical disorders as well some of the potential mechanisms involved. We furthermore argue that the bidirectional relationship between mental and medical disorders should be considered in the planning of treatment for either group of disorders. The central role of the psychiatrist in co-ordinating and integrating the health care of patients with severe mental illness is emphasized

Asunto(s)

RESUMEN

OBJECTIVE: To investigate the association between duration of untreated psychosis (DUP) and treatment outcome in a sample of subjects from a developing country. METHOD: Forty-eight subjects with a first episode of psychosis were evaluated prior to treatment and at 3-month intervals over a period of 24 months. We first examined correlations between DUP and symptom improvement as measured on the Positive and Negative Symptom Scale (PANSS), and then performed multivariate analysis to determine the validity of DUP as a predictor of outcome. RESULTS: DUP was significantly correlated with improvement in PANSS total and negative subscale scores as well as the PANSS depression factor at 21 and 24 months. Multivariate analysis found DUP to be the only significant predictor of improvement in negative symptoms at 24 months. CONCLUSION: DUP was a significant predictor of outcome in a cohort form a developing country. This study provides support for early detection and intervention strategies.

Asunto(s)

RESUMEN

This study investigated demographic variables, including affected sibling pair status, as risk factors for suicidal behavior in schizophrenia patients of African (Xhosa) descent. Xhosa subjects with schizophrenia were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and then stratified into two groups: those with ( n = 90) and those without ( n = 364) a history of previous suicide attempts. Demographic parameters (including gender, age, and social circumstances, sib ship) were then compared across these groups. Demographic predictors of suicide included sib ship status ( p = 0.038; OR = 1.7) and age of onset of illness ( p = 0.008; OR = 2.5). On further analysis of suicide in siblings, only a minority of sib pairs was found to be concordant for a lifetime history of suicide attempts (3%). These findings raise the possibility that affected sib pair status may be protective in nature. Given the counter-intuitive nature of this finding, further work is needed to replicate it, and to explore possible underlying mechanisms.

Asunto(s)

RESUMEN

BACKGROUND: 'Amafufunyana' and 'ukuthwasa' are two culture-specific descriptive terms used by Xhosa traditional healers to explain aberrant behavioral and psychological phenomena. Some overlap between these conditions and schizophrenia (DSM-IV) is apparent. The aim of this study was to determine the extent to which amafufunyana and ukuthwasa were used as cultural explanatory models by traditional healers for DSM-IV-defined schizophrenia and whether there were significant phenomenological differences in schizophrenia symptoms in patients with the diagnosis of amafufunyana rather than ukuthwasa. SAMPLING AND METHODS: Xhosa patients with schizophrenia underwent a structured clinical diagnostic interview (Diagnostic Interview for Genetic Studies). The use of traditional diagnostic and treatment methods was assessed by structured open-ended interviewer-rated questions. The sample was then stratified for the presence/absence of a past/current diagnosis of amafufunyana and/or ukuthwasa. The clinical parameters were compared across groups by means of the chi2 or Student t tests. RESULTS: 247 adult subjects participated in the study. 106 (53%) patients reported a previous diagnosis of amafufunyana, and 9 (4.5%) reported a diagnosis of ukuthwasa. A family history of schizophrenia (p = 0.004) or any psychiatric disorder (p = 0.008) was more common in the ukuthwasa group. Subjects with a primary diagnosis other than amafufunyana or ukuthwasa were more likely to be married (p = 0.004), to have a history of stressor(s) prior to illness onset (p = 0.026), to be from a rural environment (p = 0.007) or to have a history of cannabis abuse/dependency (p = 0.015). CONCLUSION: The culture-bound syndrome amafufunyana and the culture-specific phenomenon of ukuthwasa are both used to explain symptoms in patients with schizophrenia (DSM-IV). Identification of cases as amafufunyana and ukuthwasa may correlate with a distinction between familial and sporadic cases of schizophrenia. Whether the positive connotations associated with ukuthwasa, as opposed to the more negative connotations associated with amafufunyana, hold any implications for the treatment or prognosis of schizophrenia remains to be clarified.

Asunto(s)

RESUMEN

It has recently been suggested that muscle dysmorphia, a pathological preoccupation with muscularity, is a subtype of body dysmorphic disorder (BDD). There are, however, few studies of the phenomenology of this putative entity. Twenty-eight amateur competitive body builders in the Western Cape, South Africa, were studied using a structured diagnostic interview that incorporated demographic data, body-building activities and clinical questions focusing on muscle dysmorphia and BDD. There was a high rate of muscle dysmorphia in the sample (53.6%). Those with muscle dysmorphia were significantly more likely to have comorbid BDD based on preoccupations other than muscularity (33%). Use of the proposed diagnostic criteria for muscle dysmorphia indicated that this is a common and relevant entity. Its conceptualization as a subtype of BDD seems valid. The disorder deserves additional attention from both clinicians and researchers.

Asunto(s)

RESUMEN

Most studies investigating the symptom dimensions of schizophrenia utilising the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS) favour a three factor model. This study sought to investigate the factor structure of both the global and individual items of the SANS and SAPS in a large sample of South African Xhosa patients with schizophrenia. A total of 422 subjects participated. Both principal components and factor analytical procedures were applied. For the global items, a two-factor solution representing positive and negative symptoms accounted for 59.9% of the variance. Alternatively, the three-dimensional model of negative, psychotic and disorganisation factors was supported by a five-factor solution if the more heterogeneous items of attention and alogia were ignored. Analysis of the individual items yielded a five-factor solution with the negative symptoms splitting into diminished expression and disordered relating, and the positive symptoms separating into factors for psychosis, thought disorder and bizarre behaviour. Our findings are very similar to those from other parts of the world, providing evidence that the factor structure for the symptoms of schizophrenia is relatively resistant to cultural influences. This is particularly true for negative symptoms.

Asunto(s)

RESUMEN

Uncertainty exists as to the most appropriate dose of haloperidol in first-episode psychosis. This study set out to determine whether ultra-low doses of haloperidol could successfully treat patients with first-episode psychosis. Thirty-five patients with a first episode of psychosis were treated with haloperidol in an open label, fixed protocol over a 12-week period with doses restricted to 1 mg per day for the first 4 weeks. Twenty-nine (83%) remained on haloperidol after 12 weeks at a mean dose of 1.78 mg per day, 16 (55%) had stabilized on 1 mg/day or less. The mean percentage reduction in Positive and Negative Symptom Scale score between baseline and 6 and 12 weeks was 30.3% (SD 20.9%) and 41.4% (SD 16.6%), respectively. There were no significant differences in mean extrapyramidal symptom ratings between baseline and 12 weeks. Ultra-low doses of haloperidol are effective and well tolerated in first-episode psychosis. Initial doses should be maintained for a sufficient period of time to allow for the medication to take full effect.

Asunto(s)

RESUMEN

Relatively few studies of the psychobiology of hypersexuality have been undertaken. Nevertheless, the literature does suggest the possibility of a neurobiology of hypersexuality. Three cases of hypersexual behavior are presented in the context of neuropsychiatric disorders, and the literature on this phenomenon is briefly reviewed. These case studies and the literature provide evidence that different brain systems may play a role in this disorder. Frontal lesions may be accompanied by disinhibition, including impulsive hypersexual response to external cues, while striatal lesions may be accompanied by repetitive triggering of internally generated response patterns. Temporal-limbic lesions may be accompanied by disturbances in sexual appetite itself, including change in the direction of sexual drive. These case studies demonstrate that a neurobiology of hypersexuality may prove of some heuristic value in the clinic. However, further research is required to consolidate the literature in this area.

RESUMEN

BACKGROUND: Symptoms of depression and anxiety are frequently encountered in the course of schizophrenia and are of considerable clinical importance. They may compromise social and vocational functioning, and they are associated with an increased risk of relapse and suicide. Various treatment approaches have been reported to be successful. METHOD: The sample comprised 177 patients with DSM-III-R or DSM-IV schizophrenia or schizophreniform disorder who were participants in multinational clinical drug trials at our academic psychiatric unit over a 7-year period and who were assessed by means of the Positive and Negative Syndrome Scale (PANSS). Analysis was performed on baseline PANSS scores. The depression/anxiety score was compared in the men and women, first-episode and multiple-episode patients, and those with predominantly positive and negative syndromes. Correlations were sought between depression/anxiety scores and age, total PANSS score, positive score, negative score, general psychopathology score, and treatment outcome. Multivariate analysis was applied to determine contributions of individual variables toward depression/anxiety and outcome scores. RESULTS: Depression and anxiety symptoms were more severe in women (p = .007), first-episode patients (p = .02), and those with predominantly positive symptoms (p < .0001). Depression/anxiety scores were significantly correlated to age (r = -0.31, p < .0001), PANSS positive scores (r = 0.39, p < .0001), and treatment outcome (r = 0.25, p = .006). Multivariate analysis bore out these results, with the exception that first episode was not a significant predictor of depression and anxiety scores. CONCLUSION: PANSS depressive/anxiety scores were generally low in our sample, perhaps because patients with schizoaffective disorder were excluded. The finding that these symptoms were more prominent in women and first-episode patients is in keeping with previous literature. The higher scores in first-episode patients are likely due to the higher positive symptom scores in these patients. The association between depressive/anxiety scores and positive symptoms but not with negative symptoms points to a specific relationship between affective symptoms and the positive symptom domain of schizophrenia. The presence of depressive and anxiety symptoms may predict a more favorable outcome to treatment, although this may only apply to the acute exacerbations of the illness.

Asunto(s)

RESUMEN

OBJECTIVE: The aim of this paper is to describe the development of a questionnaire, the Dysmorphic Concern Questionnaire (DCQ), for the assessment of dysmorphic concern, and to establish correlations with clinical variables. METHOD: Consecutive admissions to a psychiatric hospital were surveyed. RESULTS: The DCQ showed good internal consistency, with most of the variance being explained by a single factor. Strong correlations with distress and work and social impairment lend face validity to the questionnaire. Dysmorphic concern was not significantly influenced by the patient's age, sex or diagnosis. In terms of specific psychotic symptoms, there were weak positive correlations with thought interference and persecutory ideation. However, the strongest correlations were with depressed mood, according to the Beck Depression Inventory (BDI) but not the Montgomery Asberg Depression Rating Scale; the discrepancy was largely accounted for by the 'cognitive' depressive items on the BDI. In terms of objective assessment of dysmorphic features, ratings on the Waldrop scale for minor physical anomalies showed no correlation with concern expressed by the patient. CONCLUSIONS: The strong correlation with depressive cognitions suggests that dysmorphic concern is often a reflection of a depressive cognitive set rather than being a diagnosis in itself.

Asunto(s)