Psychotic-like experiences are associated with suicidal feelings and deliberate self-harm behaviors in adolescents aged 12-15 years.

OBJECTIVE: Psychotic disorders are a significant risk factor for suicide, especially among young people. Psychotic-like experiences (PLEs) in the general population may share an etiological background with psychotic disorders. Therefore, the present study examined the association between PLEs and risk of suicide in a community sample of adolescents. METHOD: Psychotic-like experiences, suicidal feelings, and self-harm behaviors were studied using a self-report questionnaire administered to 5073 Japanese adolescents. Depression and anxiety were evaluated using the 12-item General Health Questionnaire (GHQ). RESULTS: The presence of PLEs was significantly associated with suicidal feelings (OR = 3.1, 95% CI = 2.2-4.5) and deliberate self-harm behaviors (OR = 3.1, 95% CI = 2.0-4.8) after controlling for the effects of age, gender, GHQ-12 score, victimization, and substance use. Suicidal feelings and behaviors were more prevalent in subjects with a greater number of PLEs. CONCLUSION: Psychotic-like experiences may increase the risk of suicidal problems among adolescents.

Voxel-based analysis of MRI reveals anterior cingulate gray-matter volume reduction in posttraumatic stress disorder due to terrorism.

MRI studies using the manual tracing method have shown a smaller-than-normal hippocampal volume in patients with posttraumatic stress disorder (PTSD). However, these studies have yielded inconsistent results, and brain structures other than the hippocampus have not been well investigated. A recently developed, fully automated method called voxel-based morphometry enables an exploration of structural changes throughout the brain by applying statistical parametric mapping to high-resolution MRI. Here we first used this technology in patients with PTSD. Participants were 9 victims of the Tokyo subway sarin attack with PTSD and 16 matched victims of the same traumatic event without PTSD. The voxel-based morphometry showed a significant gray-matter volume reduction in the left anterior cingulate cortex (ACC) in trauma survivors with PTSD compared with those without PTSD. The severity of the disorder was negatively correlated with the gray-matter volume of the left ACC in PTSD subjects. There were no significant differences in other gray-matter regions or any of the white-matter regions between two groups. The present study demonstrates evidence for structural abnormalities of ACC in patients with PTSD. Together with previous functional neuroimaging studies showing a dysfunction of this region, the present findings provide further support for the important role of ACC, which is pivotally involved in attention, emotional regulation, and conditioned fear, in the pathology of PTSD.

Effects of sarin on the nervous system in rescue team staff members and police officers 3 years after the Tokyo subway sarin attack.

Although the clinical manifestations of acute sarin poisoning have been reported in detail, no comprehensive study of the chronic physical and psychiatric effects of acute sarin poisoning has been carried out. To clarify the chronic effects of sarin on the nervous system, a cross-sectional epidemiologic study was conducted 3 years after the Tokyo subway sarin attack. Subjects consisted of the rescue team staff members and police officers who had worked at the disaster site. Subjects consisted of 56 male exposed subjects and 52 referent subjects matched for age and occupation. A neurobehavioral test, stabilometry, and measurement of vibration perception thresholds were performed, as well as psychometric tests to assess traumatic stress symptoms. The exposed group performed less well in the backward digit span test than the referent group in a dose-effect manner. This result was the same after controlling for possible confounding factors and was independent of traumatic stress symptoms. In other tests of memory function, except for the Benton visual retention test (mean correct answers), effects related to exposure were also suggested, although they were not statistically significant. In contrast, the dose-effect relationships observed in the neurobehavioral tests (psychomotor function) were unclear. None of the stabilometry and vibration perception threshold parameters had any relation to exposure. Our findings suggest the chronic decline of memory function 2 years and 10 months to 3 years and 9 months after exposure to sarin in the Tokyo subway attack, and further study is needed.

The association between intravenous haloperidol and prolonged QT interval.

Although intravenous haloperidol (HAL) is an effective medication that is often prescribed to treat agitation, several instances of torsade de pointes or prolonged QT interval have been reported. To investigate the association between intravenous HAL and QT prolongation and between intravenous HAL and ventricular tachyarrhythmia, a cross-sectional cohort study was performed that included measuring corrected QT intervals (QTc) on an emergency basis before intravenous HAL and continuously monitoring electrocardiographic (ECG) findings after intravenous HAL. During a 2-month period, 47 patients received intravenous injections to control psychotic disruptive behavior. According to clinical practice, patients were divided as follows. The FZ-alone group was treated with intravenous flunitrazepam (FZ), and the FZ-plus-HAL group received intravenous FZ followed by intravenous HAL. Although the difference in the mean QTc immediately after intravenous FZ between the two groups was not significant, the mean QTc after 8 hours in the FZ-plus-HAL group was longer than that in the FZ-alone group (p < 0.001). Four patients in the FZ-plus-HAL group had a QTc of more than 500 msec after 8 hours. The change in QTc during 8 hours significantly differed between the two groups (t = 2.64, p > 0.05). Furthermore, the change in QTc was moderately correlated with the dose of intravenous HAL, as evidenced by a coefficient of correlation of 0.48 (p < 0.001). However, ventricular tachyarrhythmia was not detected among 307 patients within a 1-year period, although the ECG was continuously monitored for at least 8 hours after intravenous HAL. The modest nature of QTc prolongation and the apparent absence of ventricular tachyarrhythmia under continuous ECG monitoring indicate that QTc prolongation associated with intravenous HAL is not necessarily dangerous. However, in an emergency situation, clinicians cannot exclude patients predisposed to torsade de pointes, such as those with inherited ion channel disorders. Therefore, clinicians should be aware of the association between intravenous HAL and QT prolongation.

Suppression of cellular immunity in men with a past history of posttraumatic stress disorder.

OBJECTIVE: High rates of medical morbidity have been reported in subjects with posttraumatic stress disorder (PTSD). The authors examined immune function in subjects in remission from past PTSD. METHOD: The initial study group was composed of 1,550 Japanese male workers. Japanese versions of the Events Check List, the Impact of Event Scale-Revised, and the Diagnostic Interview Schedule for DSM-IV were used to identify subjects who had a past history of PTSD. Twelve of the workers were identified as having such a history. These men were matched in age and smoking habits, which affect immunity, to 48 comparison subjects who had similar stressful life experiences but no current or past history of PTSD. Natural killer (NK) cell activity, lymphocyte subset counts, and production of interferon gamma (IFN-gamma) and interleukin-4 (IL-4) were measured in the 60 men by means of phytohemagglutinin stimulation. RESULTS: The number of lymphocytes, number of T cells, NK cell activity, and total amounts of IFN-gamma and IL-4 were significantly lower in the 12 men with a past history of PTSD. CONCLUSIONS: PTSD leaves a long-lasting immunosuppression and has long-term implications for health.

Association of alexithymic characteristics and posttraumatic stress responses following medical treatment for children with refractory hematological diseases.

Recent research has examined posttraumatic stress disorder (PTSD) following medical treatment for children with refractory hematological diseases such as leukemia. However, much remains unknown. This study examined the association of alexithymic characteristics on the manifestation of posttraumatic stress responses in 33 children with refractory hematological diseases. Of 33 children, 27 (81.8%) exhibited posttraumatic stress responses following medical treatment for refractory hematological diseases. The frequency of posttraumatic stress responses was significantly higher than with children who experienced severe flood disaster. Also, the severity of posttraumatic stress responses was significantly stronger than for children who experienced severe flood disaster. Moreover, children with refractory hematological diseases were more likely to exhibit alexithymic characteristics. The alexithymic characteristics were significantly and positively correlated with avoidance and emotional numbing among posttraumatic stress responses. The results suggest the possibility that alexithymic characteristics may be predictive of the manifestation of avoidance and emotional numbing among posttraumatic stress responses following medical treatment for refractory hematological diseases.

[Effectiveness of home help service for psychiatric patients. The results of a model project in S city].

PURPOSE: The purpose of this study was to evaluate the effectiveness of a home help service project for psychiatric patients in S city. METHODS: To assess the effectiveness of the home help service, home help service providers at S city in 1997 were invited to hearings and the transcripts were examined qualitatively. Based on the results, interview questions were developed. We then interviewed 28 home help providers who were providing or had completed the service project, as well as care managers as of July 1998. Home help providers divided their patient stories retrospectively into three time frames: before starting home care, one month after starting providing care and at the present. Amount of care provided and patients' self care level were scored and averages ere compared for the three time frames. RESULTS: The analysis of the hearing data revealed parameters for the effectiveness of home help service for psychiatric patients to be as follows: 1) enhanced ability of daily living, such as taking meals, maintaining hygiene and shopping, (primary effectiveness: 5 items); and 2) developing social function, such as being motivated, maintaining personal relationship, extending social life, and decreasing family burden, (secondary effectiveness: 9 items). The amount of care needed was found to be significantly decreased and social function was significantly enhanced on comparisons between before starting home care and one month later, as well as between before starting home care and the present. DISCUSSION: Home help service for psychiatric patients is not only useful for enhancing patients' ability to succeed in daily living tasks, but also for developing their social functioning. Effectiveness was also identified in the level of patients' behavior. The results provide reasonable grounds for extended use of the home help service.

Laboratory findings in acute schizophrenia. Relevance to medical management on emergency admission.

This study documents the prevalence of abnormal laboratory findings in schizophrenic patients who were admitted, because of acute disease, to a psychiatric intensive care unit in Japan. Patient laboratory data were evaluated retrospectively prior to treatment. Of 259 male acute schizophrenic patients (ICD-10: F2 group), nearly 10% were dehydrated, 33% had hypokalemia and leukocytosis, and 66% showed elevated serum muscle enzymes. This prevalence was statistically significant compared with that of psychiatric outpatients (F1 group). In addition, these medical problems in the F2 group were as frequent as those in the F1 group, i.e., alcohol and/or psychoactive substance abusers (ICD-10), although the problems in the F2 group occurred less often than in the F1 group. Current medication, obvious complications, or the presence of alcohol and/or psychoactive substance abuse in the F2 group were not major causes of these results. The medical problems significantly improved after 8 hours of fluid therapy. These findings strongly suggest the significance of medical management for acute schizophrenic patients on emergency admission as well as for alcohol and/or psychoactive substance abusers.

Hypokalemia and agitation in acute psychotic patients.

Hypokalemia is caused partly by intensive exercise. Some evidence suggests that psychological distress may cause hypokalemia. The relationship between the decline of serum potassium concentration and the level of symptoms of acute agitation, which was defined as a total score on a subset of six categories on the 18-item Brief Psychiatric Rating Scale (anxiety, tension, mannerism and posturing, hostility, uncooperativeness, psychomotor excitement), was examined in 313 schizophrenic men, admitted on an emergency basis during a 24-month period. In addition, change in serum potassium concentration after sedation was investigated. Serum potassium concentration in the severely agitated group was lower than that in the mild group. There was a significant correlation between serum potassium concentration and the level of symptoms of acute agitation (r = -0.30, P < 0.0001). Although the decline of serum potassium concentration in the patients who were sufficiently sedated improved within 8 h, that in the patients showing high scores on the acute agitation subset even 8 h after emergency admission was prolonged. Results indicate that sedation improves acute agitation-induced hypokalemia. rights

Abnormal physiological conditions in acute schizophrenic patients on emergency admission: dehydration, hypokalemia, leukocytosis and elevated serum muscle enzymes.

This study investigated varieties and incidence of abnormal physiological conditions in acute schizophrenic patients on emergency. Laboratory data obtained prior to treatment from patients, admitted on an emergency basis during an 18-month period, were evaluated retrospectively, as well as demographics and clinical characteristics. Of 259 male acute schizophrenic patients (ICD-10: F2), 6.9% revealed dehydration, a third had hypokalemia and leukocytosis, and two thirds showed elevated serum muscle enzymes. These percentages were statistically significant compared with those of outpatients. In addition, the former three of these conditions in the F2 group were as frequent as those in alcohol and/or psychoactive substance abusers (ICD-10: F1) on emergency admission, although elevated serum muscle enzymes in the F2 group was less frequent than that in the F1 group. In order to prevent these abnormal physiological conditions from worsening and becoming life-threatening, one fourth of the F2 group [dehydration, 6.9%, severe hypokalemia (< 3.0 mEq/l), 2.3%, and markedly elevated serum muscle enzymes (creatine phosphokinase > 1000 IU/l), 16.5%] required medical management such as fluid therapy and various types of monitoring. In cases of a behavioral emergency, laboratory screening and monitoring of urinary output were essential. Due to their lack of cooperation, case history, physical examination, and initial vital signs did not contribute to detection of their medical condition.

Personality traits of Japanese patients in remission from an episode of primary unipolar depression.

Personality traits were assessed by means of the Munich Personality Test (MPT) in 75 Japanese subjects, 27 patients in remission from an episode of moderate to severe primary unipolar depression, with melancholic features during one episode or more of the disorder, in 24 patients in remission from other non-organic mental disorders and in 24 healthy controls. Compared with healthy controls, unipolar depressives displayed decreased Frustration Tolerance and elevated Rigidity as well as a stronger Orientation towards Social Norms. No significant difference was found between patients in remission from either unipolar depression or other mental disorders. However, the increase in Rigidity in comparison with healthy subjects was significant in the depressives only whereas the other patients, in contrast to the depressives, had significantly lower scores in Extraversion than the healthy subjects. Our results in Japanese patients are similar to findings of previous German studies, including two high risk studies, in which the same assessment instrument was used. This suggests that, beyond cultural differences, Rigidity, possibly in combination with a strong Orientation towards Social Norms and a reduced Frustration Tolerance, is a stable vulnerability marker for at least the more severe forms of primary unipolar depression.

Post-traumatic symptoms among younger and elderly evacuees in the early stages following the 1995 Hanshin-Awaji earthquake in Japan.

We assessed the frequency of short-term, post-traumatic symptoms among evacuees of the Hanshin-Awaji earthquake. A total of 67 younger subjects (under 60 years) and 75 elderly subjects (60 years or above) were interviewed during the third week after the earthquake, and 50 and 73 subjects, respectively, were interviewed during the eighth week. All subjects were assessed using the Post-Traumatic Symptom Scale. During the first assessment, subjects from both age groups experienced sleep disturbances, depression, hypersensitivity and irritability. During the second assessment, the percentage of younger subjects experiencing symptoms did not decrease, while elderly subjects showed a significant decrease in 8 of 10 symptoms. This may have been due to such factors as decreased psychological stress, extensive social networks, and previous disaster experiences in the case of the elderly subjects.

Suicide and mental disorders.

In Japan, there has not yet been a complete psychological autopsy study. The author conducted a retrospective study of failed suicides (quasi-completed suicides) admitted to an emergency critical care center. According to the lethality of suicide methods, 133 out of 265 subjects over 6 years (1986-1991) were classified as the absolutely dangerous (AD; the failed suicides) group. As a principal diagnosis, psychoses, endogenous depression, substance abuse were present in 75% of the AD group. The diagnostic distribution largely differed with depressive disorders being mainly in the older group (50+ years), and psychoses predominating in the younger group (< 30 years). This study suggested that the majority of suicide victims in Japan also had mental disorders, and suicide prevention should be confronted with this clinical fact.

[Mental disorder as a risk factor of suicide; a clinical study of failed suicides].

This is a clinical study of failed suicides, in order to contribute to the explanation of completed suicides. 423 suicidal patients were admitted to the emergency critical care unit of a metropolitan municipal hospital during 6 years. The catchment area of the unit is the east four wards of Tokyo. Almost all patients who attempted suicide and four who later on completed suicide were interviewed by consultating psychiatrists. The total number of cases thus investigated was 265. Medical and psychiatric charts were retrospectively evaluated for the study. According to the lethality of respective suicidal methods, the 265 cases were divided to the ABSOLUTELY DANGEROUS GROUP (133 patients) and the RELATIVELY DANGEROUS GROUP (132 patients). The former, except for the few patients who later on died, could be considered as "failed suicides"; 75% of these patients were mentally disordered (psychoses, depressive disorders or psychoactive substance use disorders), whereas in the latter group the respective figure was 48%. The rates of each disorder were different in the age classes: younger (below 30), middle aged (30-49), and older (50 and over). In the younger group, psychoses (F2 cord of ICD-10 draft) were the main cause (52%). By contrast, endogenous major depression was the main cause in the older group (48%). The rate of psychoactive substance use disorders was highest (22%) in the middle aged among the three classes. There were 1562 officially recorded completed suicides in the catchment area during the same 6 years. From the distribution of diagnoses in each of the three age classes of the ABSOLUTELY DANGEROUS GROUP and the distribution of age classes in 1562 completed suicides, the rates of mental disorders amongst the completed suicides were estimated as roughly 26% psychoses, 46% depressive disorders and 18% substance use disorders. The total figure was 90% and quite similar to the results of previous studies by psychological autopsies in the western countries. For an attempt to decrease the rates of suicide, the most important point seems to be the prevention of suicides by the mentally disordered. Depression is most prevalent among elderly suicidal patients. In contrast to previous studies, the author found psychoses most often in younger patients. Psychotic symptoms of schizophrenic and of alcoholic suicidal patients were analysed in detail. None of them nor any other patient could be considered as a "rational suicide" case.