Nature and Extent of Physical Comorbidities Among Korean Patients With Mental Illnesses: Pairwise and Network Analysis Based on Health Insurance Claims Data

Objective@#The nature of physical comorbidities in patients with mental illness may differ according to diagnosis and personal characteristics. We investigated this complexity by conventional logistic regression and network analysis. @*Methods@#A health insurance claims data in Korea was analyzed. For every combination of psychiatric and physical diagnoses, odds ratios were calculated adjusting age and sex. From the patient-diagnosis data, a network of diagnoses was constructed using Jaccard coefficient as the index of comorbidity. @*Results@#In 1,017,024 individuals, 77,447 (7.6%) were diagnosed with mental illnesses. The number of physical diagnoses among them was 11.2, which was 1.6 times higher than non-psychiatric groups. The most noticeable associations were 1) neurotic illnesses with gastrointestinal/pain disorders and 2) dementia with fracture, Parkinson’s disease, and cerebrovascular accidents. Unexpectedly, the diagnosis of metabolic syndrome was only scarcely found in patients with severe mental illnesses (SMIs). However, implicit associations between metabolic syndrome and SMIs were suggested in comorbidity networks. @*Conclusion@#Physical comorbidities in patients with mental illnesses were more extensive than those with other disease categories. However, the result raised questions as to whether the medical resources were being diverted to less serious conditions than more urgent conditions in patients with SMIs.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Challenges in Prescribing Clozapine in the Era of COVID-19:A Review Focused on Immunological Implications

The global COVID-19 pandemic has disrupted every aspect of the healthcare system. Apart from the issues surrounding COVID-19 itself, care for existing patients has met many challenges. One such challenge is caring for patients who are on clozapine treatment and have been confirmed positive for COVID-19. Schizophrenia has been considered to have a deep connection with the immune system, and clozapine can induce further changes in this system. COVID-19 can ravage the compromised immune system and aggravate tissue damage. The intricate relations between schizophrenia, clozapine, and COVID-19 make it difficult to predict the clinical course of COVID-19 in clozapine-treated patients. However, the rigid prohibition on using clozapine if COVID-19 is confirmed may harm patients. Patients who have to use clozapine are often refractory cases with no alternatives. Therefore, the decision to maintain or stop clozapine must be made after a comprehensive review of the patient’s unique situation. To do this, theoretical and practical issues surrounding the use of clozapine in COVID-19 should be reviewed and discussed. In this review, we gather useful information surrounding this issue and present an overview. Focusing on the immune system, various theoretical possibilities that could arise from schizophrenia, clozapine, and COVID-19 were carefully examined, and practical checklists for the care of these patients were explored. It is hoped that this review will convince many clinicians to pay attention to this momentous issue and facilitate more active sharing of clinical experiences.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Challenges in Prescribing Clozapine in the Era of COVID-19:A Review Focused on Immunological Implications

The global COVID-19 pandemic has disrupted every aspect of the healthcare system. Apart from the issues surrounding COVID-19 itself, care for existing patients has met many challenges. One such challenge is caring for patients who are on clozapine treatment and have been confirmed positive for COVID-19. Schizophrenia has been considered to have a deep connection with the immune system, and clozapine can induce further changes in this system. COVID-19 can ravage the compromised immune system and aggravate tissue damage. The intricate relations between schizophrenia, clozapine, and COVID-19 make it difficult to predict the clinical course of COVID-19 in clozapine-treated patients. However, the rigid prohibition on using clozapine if COVID-19 is confirmed may harm patients. Patients who have to use clozapine are often refractory cases with no alternatives. Therefore, the decision to maintain or stop clozapine must be made after a comprehensive review of the patient’s unique situation. To do this, theoretical and practical issues surrounding the use of clozapine in COVID-19 should be reviewed and discussed. In this review, we gather useful information surrounding this issue and present an overview. Focusing on the immune system, various theoretical possibilities that could arise from schizophrenia, clozapine, and COVID-19 were carefully examined, and practical checklists for the care of these patients were explored. It is hoped that this review will convince many clinicians to pay attention to this momentous issue and facilitate more active sharing of clinical experiences.

The Association between Excessive Internet Gaming Behavior and Immersive Tendency, Mediated by Attention Deficit/Hyperactivity Disorder Symptoms, in Korean Male University Students

Objective@#Problematic online gaming (POG) and problematic Internet use (PIU) have become a serious public mental health problem, with Internet gaming disorder (IGD) included in “Conditions for further study” section of DSM-5. Although higher immersive tendency is observed in people affected by POG, little is known about the simultaneous effect of immersive tendency and its highly comorbid mental disorder, attention deficit/hyperactivity disorder (ADHD). This study aimed to assess the relationship between immersive tendency, ADHD, and IGD. @*Methods@#Cross-sectional interview study was conducted in Seoul, Korea with 51 male undergraduate students; 23 active gamers and 28 controls. @*Results@#Current ADHD symptoms showed partial mediation effect on the path of immersive tendency on POG and PIU. The mediation model with inattention explained variance in both POG and PIU better than other current ADHD symptom models (R2=69.2 in POG; 69.3 in PIU). Childhood ADHD symptoms models demonstrated mediation effect on both POG and PIU which explained less variance than current ADHD symptom models (R2=53.7 in POG; 52.1 in PIU). Current ADHD symptoms, especially inattention, appear to mediate the effect of immersive tendency on POG/PIU. @*Conclusion@#Immersive tendencies may entail greater susceptibility to IGD, and comorbidity with ADHD may mediate the effect of immersive tendency on IGD.

The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson’s disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson’s disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

Initial Seizure Threshold in Brief-Pulse Bilateral Electroconvulsive Therapy in Patients with Schizophrenia or Schizoaffective Disorder

OBJECTIVE: The present study aimed to report the initial seizure threshold (IST) of a brief-pulse bilateral electroconvulsive therapy (BP-BL ECT) in Korean patients with schizophrenia/schizoaffective disorder and to identify IST predictors. METHODS: Among 67 patients who received ECT and diagnosed with schizophrenia/schizoaffective disorder based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, we included 56 patients who received 1-millisecond BP-BL ECT after anesthesia with sodium thiopental between March 2012 and June 2018. Demographic and clinical information was gathered from electronic medical records, and a multiple regression analysis was conducted to identify predictors of the IST. RESULTS: The mean age of the patients was 36.9±12.0 years and 30 (53.6%) patients were male. The mean and median IST were 105.9±54.5 and 96 millicoulombs (mC), respectively. The IST was predicted by age, gender, and dose (mg/kg) of sodium thiopental. Other physical and clinical variables were not associated with the IST. CONCLUSION: The present study demonstrated that the IST of 1-ms BP-BL ECT following sodium thiopental anesthesia in Korean patients was comparable to those reported in previous literature. The IST was associated with age, gender, and dose of sodium thiopental.

Long-Term Changes in Self-Report Auditory Verbal Hallucinations in Patients with Schizophrenia Using Clozapine

This study explored long-term changes in self-report auditory verbal hallucinations (AVHs) among patients with schizophrenia taking clozapine. Forty-four patients who were evaluated more than twice and were above the mild severity category on the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) were enrolled. The mean observation period was 492.5±350.1 days (median, 452 days). The mean total, physical, and emotional factor scores on the HPSVQ were significantly reduced from baseline to the final observations except for one item “interference with life,” which was not significantly reduced. Regarding the time-dependent longitudinal changes modeled using linear mixed-effect regression, the total and physical factor scores showed significant changes during the first year, but the emotional factor score did not satisfy a more stringent level of significance. Female gender was negatively associated with the reduction in total and physical factor scores. The duration of treatment with clozapine also had a negative relationship with the reductions in all three scores.

Antipsychotic-Induced Oculogyric Crisis and Paroxysmal Perceptual Alteration / 대한정신분열병학회지

During antipsychotic drug treatment, clinicians occasionally encounter sudden attacks of oculogyric crisis (OGC) and/or paroxysmal perceptual alteration (PPA) which occur mostly in the afternoon or early evening lasting for minutes to hours and are eventually remitted with rests or short sleep and/or medications such as benzodiazepines, anticholinergics and so forth. Moreover, these attacks are usually accompanied with psychiatric symptoms such as various modalities of hallucinations and illusions, delusions, obsessive thoughts, panic attacks, agitation as well as autonomic symptoms. These accompanying psychiatric symptoms can be perceived as a worsening of psychiatric symptoms if the clinician does not understand the symptoms due to the side effects of antipsychotic drugs, which may result in increasing the dosage of antipsychotics instead of reducing doses or switching to less offending drugs. On the other hand, patients could easily recognize the symptoms as the adverse effects of drugs. This literature review and case-series study is aimed to raise awareness of OGC and PPA by providing clinical cases and author's views with the literature reviews about concepts, recognitions and managements from the works of Japanese authors who first reported the clinical importance of these attacks, particularly PPA.

Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia

OBJECTIVE: This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. METHODS: Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. RESULTS: Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. CONCLUSION: Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.

Electroconvulsive Seizure Alters the Expression and Daily Oscillation of Circadian Genes in the Rat Frontal Cortex

OBJECTIVE: Electroconvulsive therapy (ECT) is the most effective treatment for mood disorders. Accumulating evidence has suggested the important role of circadian genes in mood disorders. However, the effects of ECT on circadian genes have not been systemically investigated. METHODS: We examined the expression and daily oscillation of major circadian genes in the rat frontal cortex after electroconvulsive seizure (ECS). RESULTS: Firstly, mRNA and protein level were investigated at 24 hr after single ECS (E1X) and repeated ECS treatements for 10 days (E10X), which showed more remarkable changes after E10X than E1X. mRNA expression of Rorα, Bmal1, Clock, Per1, and Cry1 was decreased, while Rev-erbα expression was increased at 24 hr after E10X compared to sham. The proteins showed similar pattern of changes. Next, the effects on oscillation and rhythm properties (mesor, amplitude, and acrophase) were examined, which also showed more prominent changes after E10X than E1X. After E10X, mesor of Rorα, Bmal1, and Cry1 was reduced, and that of Rev-erbα was increased. Five genes, Rev-erbα, Bmal1, Per1, Per2, and Cry2, showed earlier acrophase after E10X. CONCLUSION: The findings suggest that repeated ECS induces reduced expression and phase advance of major circadian genes in the in vivo rat frontal cortex.

Long-Term Evolution of Metabolic Status in Patients with Schizophrenia Stably Maintained on Second-Generation Antipsychotics

OBJECTIVE: Second-generation antipsychotics (SGAs) increase the risk of metabolic syndrome (MetS). Despite the risk of MetS, SGAs may have to be continued with change in some patients. The aim of this study was to trace the evolution of MetS in these patients. METHODS: Patients with schizophrenia who had been maintained on a fixed SGA regimen for more than a year were followed-up without changing the regimen. Metabolic indicators were evaluated at baseline and at follow-up. Prevalence, incidence and spontaneous normalization rate of MetS were estimated. Risk factors that might have influenced the evolution were scrutinized. RESULTS: A total of 151 subjects were included. During the mean observation period of 389.9±162.4 days, the prevalence of MetS was increased from 35.1 to 45.0%. The incidence rate was 29.6%, while the normalization rate was 26.4%, risk factors affecting incidence were age (OR=1.09, 95% CI: 1.03–1.17), baseline continuous values of metabolic syndrome risk scores (cMetS, OR=1.77, 95% CI:1.29–2.55) and baseline body weight (OR=1.06, 95% CI: 1.01–1.13). Normalization was influenced by age (OR=0.74, 95% CI: 0.57–0.89) and baseline body weight (OR=0.85, 95% CI: 0.72–0.95). CONCLUSION: The prevalence of MetS steadily increased with the continuous use of SGAs. However, individual difference was extensive and about a quarter of the patients were able to recover naturally without specific measurements.

A Case Study of a Machine-Learning Approach in Differential Diagnosis of Schizophrenia: The Predictive Capacity of WAIS-IV / 신경정신의학

OBJECTIVES: Machine learning (ML) encompasses a body of statistical approaches that can detect complex interaction patterns from multi-dimensional data. ML is gradually being adopted in medical science, for example, in treatment response prediction and diagnostic classification. Cognitive impairment is a prominent feature of schizophrenia, but is not routinely used in differential diagnosis. In this study, we investigated the predictive capacity of the Wechsler Adult Intelligence Scale IV (WAIS-IV) in differentiating schizophrenia from non-psychotic illnesses using the ML methodology. The purpose of this study was to illustrate the possibility of using ML as an aid in differential diagnosis. METHODS: The WAIS-IV test data for 434 psychiatric patients were curated from archived medical records. Using the final diagnoses based on DSM-IV as the target and the WAIS-IV scores as predictor variables, predictive diagnostic models were built using 1) linear 2) non-linear/non-parametric ML algorithms. The accuracy obtained was compared to that of the baseline model built without the WAIS-IV information. RESULTS: The performances of the various ML models were compared. The accuracy of the baseline model was 71.5%, but the best non-linear model showed an accuracy of 84.6%, which was significantly higher than that of non-informative random guessing (p=0.002). Overall, the models using the non-linear algorithms showed better accuracy than the linear ones. CONCLUSION: The high performance of the developed models demonstrated the predictive capacity of the WAIS-IV and justified the application of ML in psychiatric diagnosis. However, the practical application of ML models may need refinement and larger-scale data collection.

Association between the 5-HTTLPR Genotype and Childhood Characteristics in Mood Disorders

OBJECTIVE: The features of childhood attention deficit hyperactivity disorder (ADHD) are significantly associated with adult mood disorders. Some genetic factors may be common to both ADHD and mood disorders underlie the association between these two phenotypes. The present study aimed to determine whether a genetic role may be played by the serotonin transporter-linked polymorphic region (5-HTTLPR) in the childhood ADHD features of adult patients with mood disorders. METHODS: The present study included 232 patients with major depressive disorder (MDD), 154 patients with bipolar disorder (BPD), and 1,288 normal controls. Childhood ADHD features were assessed with the Korean version of the Wender Utah Rating Scale (WURS-K). The total score and the scores of three factors (impulsivity, inattention, and mood instability) from the WURS-K were analyzed to determine whether they were associated with the 5-HTTLPR genotype. RESULTS: In the BPD type II group, the 5-HTTLPR genotype was significantly associated with the total score (p=0.029) and the impulsivity factor (p=0.004) on the WURS-K. However, the inattention and mood instability factors were not associated with the 5-HTTLPR genotype. BPD type I, MDD and normal control groups did not exhibit any significant associations between the WURS-K scores and the 5-HTTLPR genotype. CONCLUSION: The findings suggest that the 5-HTTLPR genotype may play a role in the impulsivity component of childhood ADHD in patients with BPD type II. Because of a small sample size and a single candidate gene, further studies investigating other candidate genes using a larger sample are warranted to determine any common genetic links.

The Effects of Social Anxiety, Self-Esteem, and Depression on Suicidal Ideation in Korean Adolescents / 신경정신의학

OBJECTIVES: The purpose of this study was to investigate the manner by which social anxiety symptoms, self-esteem, and depression influence suicidal ideation in adolescents. METHODS: This study involved 1320 middle school students. All participants completed several self-assessment questionnaires. Correlations among variables were assessed, and multiple regression analysis was performed to evaluate the relationships between variables and suicidal ideation. Finally, a structural equation model was used to determine the pathways by which the tested variables can influence suicidal ideation. RESULTS: Symptoms of social anxiety were positively correlated with depression and suicidal ideation, but were negatively correlated with self-esteem. Additionally, multiple regression analysis revealed that social anxiety symptoms, depression, and self-esteem were significantly related to suicidal ideation. The influence of social anxiety symptoms on suicidal ideation was associated with an increase in depression, whereas self-esteem acted as an intermediary between social anxiety symptoms and depression. CONCLUSION: The results of the present study demonstrate that social anxiety symptoms can directly increase depression and lower self-esteem, which in turn can increase the risk of suicidal ideation. Thus, it may be possible to prevent depression and ultimately lower the risk of suicide in adolescents by pursuing programs designed for the early detection of social anxiety symptoms and by using intervention programs that improve self-esteem.

Conceptualization of Soliloquy in Patients with Schizophrenia / 신경정신의학

Soliloquy is a significant symptom in schizophrenia and is usually regarded as being related to auditory hallucination. Elucidation of the psychopathology of soliloquy is incomplete. Soliloquy is also a normal human behavior that has multidimensional functions such as guiding internal cognitive processes and managing social interaction. In the young, soliloquy appears as egocentric speech and arises before maturation of the third-person perspective. Soliloquy has been regarded as indicative of an intermediary stage during the transformation of social speech into internalized thinking. Every thought process retains a social dimension because language itself is based on intersubjectively shared meanings, and internal thinking originates from interpersonal communication. Thus, soliloquy can be seen as a kind of thought process that accentuates the social dimension. This approach may help in understanding soliloquy in normal and pathological situations. Soliloquy was actively discussed in the late nineteenth and early twentieth century in European psychiatry. Since then it has received less attention and has been neglected as an academic concern, except in child developmental theory. Recently however, soliloquy has attracted more attention among neuroscientific researchers. To attain an advanced understanding of soliloquy, it is necessary to integrate the early European perception of soliloquy with current developmental theory. In this paper, we review past literature on the conceptualization of soliloquy and integrate those concepts into an explanatory framework. In addition, a case series and a discussion of the applicability of the explanatory framework are presented. Our results may help provide an insight into the contemporary understanding of soliloquy.