Comprehensive Psychiatry

2012-05-01

Masthead

2012-05-01

Insight in schizophrenia and risk of suicide: a systematic update

Javier D. López-Moríñigo, Ramón Ramos-Ríos, Anthony S. David, Rina Dutta — 2011-08-08

Abstract: Background: Suicide has been shown to represent the major single cause of premature death among patients with schizophrenia spectrum disorders. Insight has been proposed to increase such risk. However, this subject has not been sufficiently investigated, and inconclusive results have been reported.Objective: The objective of this study is to systematically examine the role of insight in the risk of suicide attempts and completed suicide among patients with schizophrenia and related disorders.Method: Articles assessing insight and suicidality in patients with schizophrenia spectrum disorders published between 1977 and 2010 were reviewed. A MEDLINE search strategy was used to identify studies using keywords. Application of meta-analytic techniques to selected studies was not possible because of important methodological differences between them.Results: Fifteen studies met predetermined selection criteria. Ten failed to demonstrate a positive association between insight and risk for suicide.Discussion: There is little evidence to support the suggestion that insight may represent a risk factor for suicide in patients with schizophrenia. If there is an association between such risk and insight, it appears to be mediated by other variables such as depression and, above all, hopelessness. Further studies with larger samples and longer follow-up periods in naturalistic conditions, in which insight should be evaluated from a multidimensional approach, are required to analyze this issue in depth, given the crucial implications that it may have on the development of a model for suicide prevention in schizophrenia.

Examination of the structure of psychopathology using latent class analysis

2011-07-15

Abstract: Several recent studies using factor analytic methods find that the structure of psychopathology reflects broad internalizing and externalizing dimensions, with the internalizing dimension being further divided into fear and distress disorders. Although these variable-centered studies have provided important insights into the structure of psychopathology, they provide limited information about the classification of individual cases. The present study examines patterns of lifetime internalizing and externalizing psychopathology in participants from the Oregon Adolescent Depression Project using latent class analysis that classifies individuals rather than variables. A 4-class solution best fits the data. The largest class (62.5%) included individuals with relatively little psychopathology; 1 class (16.4%) was largely characterized by internalizing disorders, 1 class (16.9%), largely characterized by externalizing disorders; and the final class (4.2%), characterized by both internalizing and externalizing disorders. The validity of the classes was further examined using data on psychiatric morbidity, temperament, and family aggregation of psychopathology. Classes differed on indices of positive, negative, and disinhibited temperament in ways that were consistent with theoretical predictions. Patterns of familial aggregation of psychopathology demonstrated relative specificity of transmission of different disorders. Overall, the findings support conclusions from studies of dimensional models of internalizing and externalizing disorders, and extend them to person-centered approaches to classification.

Personality disorders and autism spectrum disorders: what are the connections?

Tove Lugnegård, Maria Unenge Hallerbäck, Christopher Gillberg — 2011-08-08

Abstract: Background: The relationship between autism spectrum disorders/pervasive developmental disorders and personality disorders is not completely clear, although both concepts imply lifelong impairment. The purpose of the present study was to investigate the presence of possible personality disorders in a group of young adults with Asperger syndrome.Method: Fifty-four young adults with a clinical diagnosis of Asperger syndrome were assessed with Structured Clinical Interview for DSM-IV Axis II disorders to evaluate the presence of a concomitant personality disorder and completed the Autism Spectrum Quotient to measure level of autistic features. Autism spectrum diagnosis was confirmed by Diagnostic Interview for Social and Communication Disorders with a collateral informant.Results: Approximately half of the study group fulfilled criteria for a personality disorder, all belonging to cluster A or C. There was a significant difference across sex: men with Asperger syndrome meeting personality disorder criteria much more often than women with Asperger syndrome (65% vs 32%). Participants fulfilling criteria for a personality disorder showed more marked autistic features according to the Autism Spectrum Quotient.Conclusions: There is a considerable overlap in symptoms between Asperger syndrome and certain personality disorders. Similarities and differences of the two concepts are discussed in the framework of the Diagnostic and Statistical Manual of Mental Disorders classification system.

Some suggestions for the DSM-5 schizotypal personality disorder construct

Benjamin Hummelen, Geir Pedersen, Sigmund Karterud — 2011-07-11

Abstract: This study relates to the schizotypal personality disorder (SPD) proposal of the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by investigating the construct validity of SPD as defined by DSM-IV in a large sample of patients from the Norwegian Network of Personality-Focused Treatment Programs (N = 2619), assessed by structured diagnostic interviews and the Longitudinal, Expert All Data standard. We investigated factor structure and psychometric properties of the SPD criteria, as well as co-occurrence patterns between SPD and other PDs. Thirty-six patients were diagnosed with SPD and 513 patients (21%) endorsed at least 2 schizotypal criteria. We found that 2 factors were specific for SPD, a cognitive-perceptual factor (ideas of reference, magical thinking, and unusual perceptual experiences) and an oddness factor (odd thinking and speech, constricted affect, and odd appearance or behavior). The criteria belonging to these factors had appropriate psychometric properties. The criteria of the cognitive-perceptual factor were more strongly associated with borderline personality disorder (PD) than with the other PDs. We did not find support for a consistent factor that reflected interpersonal problems. The criteria that used to be part of this factor (suspiciousness, lack of friends or confidants, and excessive social anxiety) performed poorly as specific SPD criteria. SPD was more strongly associated with antisocial PD and paranoid PD than with the other PDs. We suggest that ideas of reference should be included explicitly under the schizotypal facet of cognitive dysregulation in DSM-5, with less emphasis on the social phobic aspects of this feature. Furthermore, there should be more emphasis on the cognitive aspects of suspiciousness in SPD, and it should be considered to split up the affectivity criterion into constricted affect and inappropriate affect, with the latter type of affect being the expression of problems with intersubjective regulation. Finally, it is suggested that interpersonal dysfunction is secondary to the 2 primary SPD factors. Therefore, the SPD narrative should start by describing eccentricity and cognitive-perceptual aberrations rather than interpersonal difficulties.

Are there temperament differences between major depression and dysthymic disorder in adolescent clinical outpatients?

Elek Dinya, Janos Csorba, Zsofia Grósz — 2011-08-12

Abstract: Aims: The aim of the study was to explore possible differences in temperament and character dimensions between 2 monodiagnostic adolescent groups of depression, namely, one with a present episode of major depression and subjects with the other being their dysthymic peers.Sample: From a multisite Western Hungarian sample of consecutively referred 14- to 18-year-old new psychiatric adolescent outpatients, 2 groups were compared: group I, n = 56 (9 males, 47 females), with major depressive disorder (MDD) and group II, n = 27 (6 males, 21 females), with a diagnosis of dysthymic disorder (DD). All other comorbid diagnoses including bipolar and double depression (MDD + DD) cases were excluded. Present suicide events, if the attempter had an underlying diagnosis of depression, were not causes for exclusion. Assessment methods used were the adapted Hungarian versions of the Mini International Neuropsychiatric Interview and the Junior Temperament (Cloninger) Character Inventory.Results: The only difference between the major depressive and dysthymic adolescents was harm avoidance, adolescents with major depression having a higher level practice of harm avoidance, whereas the temperament type of MDD vs DD seems to differ only in the aspect of avoiding painful stress. Expectations regarding a worse degree of self-directedness and lower levels of persistence and cooperativeness in the MDD sample were not proved.Conclusions: No essential temperament differences were found between the 2 adolescent depressive groups. Scarce differences between temperament qualities of MDD and DD may support Akiskal's continuum theory of depressive disorders. More research and the use of closer clinical personality typologies are warranted to explore possible personality trait differences (if they exist) between clinical diagnostic groups of adolescent patients.

Personality disorders among patients accessing alcohol detoxification treatment: prevalence and gender differences

2011-08-08

Abstract: Background: Alcohol abuse and dependence are frequently associated with psychiatric disorders and personality disorders (PDs) with differences among gender. However, only few studies investigated gender differences in PDs among alcoholics. The aim of this study was to investigate PDs in a sample of patients accessing inpatient alcohol detoxification treatment and to describe gender differences in prevalence and comorbidity of PDs.Methods: The study population consisted of 206 patients entering alcohol detoxification treatment in a specialized clinic in Italy. At enrollment, patients filled in the Millon Clinical Multiaxial Inventory-III for the assessment of PDs.Results: The sample consisted of 150 males and 56 females. Twenty-five percent of males vs 12.5% of females had 1 PD; 16% vs 23%, 2 PDs; and 46% vs 48%, more than 3 PDs. A statistically significant higher proportion of females got high scores on avoidant (21.4% vs 9.3%), self-defeating (50.0% vs 24.0%), and borderline scales (42.9% vs 25.3%). Depressive, self-defeating, and borderline PDs were frequently associated both to other PDs and among each other, particularly among females.Conclusions: Borderline PD is confirmed to be more frequent among females than among males accessing alcohol detoxification treatment. More studies are needed to clarify prevalence and associations of PDs, prognosis, and gender differences in alcoholics patients.

Dissociative symptoms in patients with schizophrenia: relationships with childhood trauma and psychotic symptoms

2011-07-08

Abstract: Objective: This study sought to examine the stability of dissociative symptoms in patients with schizophrenia spectrum disorders as well as relationships between psychotic symptoms, childhood trauma, and dissociation.Method: One hundred forty-five patients with schizophrenia spectrum disorders (72% schizophrenia, 67% men) were examined at admission to inpatient treatment and 3 weeks later using the Positive and Negative Syndrome Scale, the Childhood Trauma Questionnaire, and the Dissociative Experiences Scale.Results: Dissociative symptoms significantly decreased over time (mean, 19.2 vs 14.1; P < .001). The best predictor of dissociative symptoms at admission was the Positive and Negative Syndrome Scale positive subscale (Finc 3,64 = 3.66, P = .017), whereas childhood sexual abuse best predicted dissociation when patients were stabilized (Finc 10,80 = 2.00, P = .044).Conclusion: Dissociative symptoms in patients with schizophrenia spectrum disorders are related to childhood trauma. Dissociation seems to be state dependent in this diagnostic group. Moreover, diagnostic interviews, in addition to the Dissociative Experiences Scale, should be considered to avoid measurement artifacts.

Increase in harm avoidance by genetic loading of schizophrenia

Minyoung Sim, Jin Hun Kim, Seon Jin Yim, Seong-Jin Cho, Seog Ju Kim — 2011-06-22

Abstract: Background: Schizophrenia is highly familial neuropsychiatric disorder with heritability estimated at 60% to 90%. Even unaffected first-degree relatives of schizophrenia manifested some neuropsychologic abnormalities, neurologic soft sign, and morphologic anomalies. Because personality traits are under genetic influence and considerable heritability, we intended to evaluate temperament and character of first-degree relatives of schizophrenia and the influence of schizophrenia genetic loading on their temperament and character.Methods: Temperament and Character Inventory was completed by 97 first-degree relatives of schizophrenia or schizoaffective disorder, 48 schizophrenic probands (44 patients with schizophrenia and 4 patients with schizoaffective disorder), and 106 control subjects. Within first-degree relatives, parents who have additional probands with schizophrenia spectrum disorder in their ascendant or collateral pedigree and siblings who have offspring with schizophrenia spectrum disorder were defined as presumed carriers (n = 20). Group differences in Temperament and Character Inventory scores were compared using a mixed-model analysis of variance with family as a random effect and age as a covariate.Results: Harm avoidance (HA) scores increased in the order of control subjects, the first-degree relatives, and probands. Among the relatives, presumed carriers, but not presumed noncarriers, had higher HA compared with control subjects. In addition, probands showed significantly low reward dependence, low self-directedness, and low cooperativeness scores compared with the first-degree relatives and control subjects. Probands had also higher self-transcendence scores than the first-degree relatives and had lower persistence scores than control subjects.Conclusions: Our findings that HA increases in proportion to the genetic loading of schizophrenia suggest that it may be a potential endophenotype of schizophrenia.

Characteristics and comorbidity of ADHD sib pairs in the Central Valley of Costa Rica

2011-06-22

Abstract: Background: While genetic epidemiological studies demonstrate a substantial degree of genetic predisposition for attention-deficit/hyperactivity disorder (ADHD), they also suggest that the genetics are complex and may differ between populations or ethnic groups.Objective: This study describes the phenomenology of siblings with ADHD from the genetically isolated population of the Central Valley of Costa Rica.Methods: Rates of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)–defined ADHD subtypes and comorbid conditions were calculated in a sample of 157 ADHD-affected children (probands and siblings) recruited for genetic studies using standardized approaches. Sib-sib comparisons and logistic regressions were conducted to identify significant patterns of concordance.Results: Combined-type ADHD (69.5%) was the most common subtype among probands, followed by the inattentive (27.4%), and hyperactive-impulsive (3.2%) subtypes. Anxiety disorders were prevalent (55.9%), as were disruptive behavior disorders (30.9%) and Tourette disorder (17.0%). Probands and siblings showed high sib-sib concordance for anxiety disorders.Conclusions: ADHD in Costa Rica is similar in clinical and demographic characteristics to ADHD seen in other parts of the world, although the rates of co-occurring psychiatric disorders differ somewhat from those previously reported in Latin American samples. Comorbid anxiety is prevalent, with high rates of sib-sib concordance, and may represent a distinct, homogeneous subgroup suitable for genetic studies.

Quality of life in major depressive disorder: the role of pain and pain catastrophizing cognition

Ka-Fai Chung, Kwok-Chu Tso, Wing-Fai Yeung, Wei-Hui Li — 2011-06-20

Abstract: Objective: Pain symptoms are frequent complaints in patients with major depressive disorder (MDD). Although it is known that pain intensity and pain-related cognition predict quality of life (QOL) in patients with chronic pain, limited studies have examined their roles in MDD. The study aimed to determine whether pain and pain catastrophizing were independent predictors of QOL in MDD after accounting for the impact of anxiety and depression.Methods: This is a prospective, naturalistic follow-up study. Ninety-one Chinese patients were enrolled during an acute episode of MDD, 82 of them were reassessed 3 months later using the same assessment on pain, anxiety, depression, and QOL. Pain intensity was evaluated using a verbal rating scale and a visual analog scale. Quality of life was assessed using the 36-item Short Form Health Survey. Pain-related cognition was assessed at baseline with the Pain Catastrophizing Scale.Results: There was significant improvement in pain, anxiety, depression, and QOL from baseline to 3-month follow-up. Hierarchical regression analyses showed that pain intensity was significantly associated with QOL at baseline and 3 months. Pain complaint was more important than anxiety and depressive symptoms in predicting changes in both physical and psychosocial domains of QOL. After controlling for the severity of pain, anxiety, and depression, Pain Catastrophizing Scale score was independently associated with QOL in MDD.Conclusion: The study supports the specific role of pain and pain-related cognition in predicting QOL in depressed patients. Further studies targeting pain-related cognition for improving the outcome of MDD are necessary.

Depressive dimensions and item response analysis of the Hamilton Depression Rating Scale–17 in eating disorders

2011-07-08

Abstract: Background: Most patients having eating disorders (EDs) experience depressive symptoms. To date, there have been few reports about the different depressive dimensions in EDs.Objective: The aim of this study was to investigate the dimensions of depressive symptoms and highlight the distribution of the symptoms. The psychometric properties of these measures were tested using item response theory methods.Methods: A total of 103 consecutively admitted inpatients and outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition, criteria for anorexia nervosa, bulimia nervosa, and EDs not otherwise specified were rated with the Hamilton Depression Rating Scale (HDRS-17). A factor analysis of the HDRS-17 was carried out with the Cf-varimax rotation.Results: Factor analysis showed 2 independent and clinically interpretable factors corresponding to “anxious depression” and “somatic complaints” that constituted the core of depression. For the HDRS-17, item response theory analyses revealed that most of the items were maximally related to the core concept of depression and provided a good functioning. The 17 items were distributed in almost the same way as in the factor analyses found by other authors with different clinical groups. We conclude therefore that for the sample of EDs, 2 factors constitute the core symptoms of depression and most of the items provided a good functioning.

Smoking for weight control and its associations with eating disorder symptomatology

Marney A. White — 2011-07-08

Abstract: Objective: This study examined interrelationships between cigarette smoking for weight control and eating disorder symptoms in a community sample of adult female smokers.Method: Participants were 107 female smokers who completed a battery of questionnaires, including the Eating Disorder Examination-Questionnaire (EDE-Q). Key items measured weight-control smoking, including smoking to prevent overeating, smoking to undo the effects of overeating, and smoking to feel less hungry. Smokers who endorsed smoking in an attempt to control weight were compared with those who denied such behaviors on EDE-Q scores and frequency of binge eating and purging.Results: A substantial proportion of participants reported weight-control smoking. Participants who endorsed weight-control smoking reported elevations on eating disorder symptoms as measured by the EDE-Q. Compensatory smoking was related to the frequency of binge eating.Discussion: The findings have implications for clinicians working with eating disorder patients; for some individuals, cigarette smoking may be used as an attempt to compensate for overeating.

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