Prenatal tobacco smoke exposure, risk of schizophrenia, and severity of positive/negative symptoms.

Prenatal exposure to cigarette smoke causes chronic fetal hypoxia, dysregulation of endocrine equilibrium, and disruption of fetal neurodevelopment associated with brain malfunction, all of which potentially could induce vulnerability to schizophrenia. A total of 212 schizophrenia patients aged 14-30years, and 212 matched controls were studied. Prenatal tobacco smoke exposure of the schizophrenia patients was compared to that of the normal controls by applying logistic regression analysis and controlling for several confounding factors. The outcomes of interest were comparison of the frequency of maternal and paternal smoking between patients and controls, as well as the severity of positive and negative symptoms between the offspring of smoking and nonsmoking parents. Among the mothers of schizophrenia patients and controls, 92 (43.4%) and 46 (21.7%) smoked, respectively. Maternal smoking during pregnancy had a significant unique contribution on increasing the risk for development of schizophrenia (p=0.001), and a greater severity of negative symptoms (p=0.023). Paternal smoking did not have a significant effect on the risk of schizophrenia, or severity of negative symptoms. The findings suggest that maternal smoking during pregnancy puts offspring at an increased risk for later schizophrenia, with increased severity of negative symptoms. Given the wide practice of smoking during pregnancy, fetal exposure to tobacco smoke could be a major preventable neurodevelopmental factor that increases vulnerability to schizophrenia.

Bodily manifestations in the psychoanalytic process.

The broadening scope of psychoanalysis has brought to the fore patients whose unconscious conflicts tend to be literally played out on the stage of the body. In these cases, the body seems to be predominantly used in a concrete, not symbolic, way in order to express underlying conflicts. In a similar vein, transference and countertransference can be manifested via the body. The authors briefly discuss some of the literature on body-mind issues, and then present an extended case report to illustrate bodily manifestations in the psychoanalytic process.

Assessment of sexual function in patients with cancer undergoing radiotherapy--a single centre prospective study.

AIM: The main objective was to delineate the rates and clinical course of sexual function and depression in cancer patients undergoing radiotherapy. PATIENTS AND METHODS: Forty-eight male and 90 female radiotherapy-naive outpatients with breast or pelvic cancer completed the International Index of Erectile Function (IIEF) or the Female Sexual Function Index (FSFI), and the Hamilton Depression Scale (HDS) prior to (phase 1), at the end of (phase 2) and 12 months after radiotherapy (phase 3). RESULTS: Overall, the majority of patients (93.8% of males and 80% of females) experienced intense sexual dysfunction. At presentation, males reported severe erectile dysfunction that was significantly associated with age. However, only in sexual desire was the difference between baseline and phase 3 significant. In females, an improvement was observed in all parameters of FSFI between phase 1 and 3. Females with stage III disease achieved lower scores in almost all parameters of FSFI than those with stage II. Finally, although a quarter of patients reported elevated depression scores, depression was not related to sexual function. CONCLUSION: A significant proportion of cancer patients experience intense levels of sexual dysfunction and depression throughout radiotherapy and the subsequent year. Pelvic radiotherapy affected sexual function to a higher degree than did breast radiotherapy.

Repression and splitting in the psychoanalytic process.

The authors examine the concepts of repression and splitting and their interplay during the psychoanalytic process. Initially, repression was introduced by the clinical phenomenon of resistance, leading to the formulation of the association between intrapsychic conflicts and neurotic symptoms. Later, repression was linked to normal development and to personality organization. Splitting, on the other hand, has been defined in quite diverse ways. The two main definitions are of splitting within the ego, and splitting of representations of the self, and of internal and external objects. Repression and splitting are compared developmentally, dynamically, and with respect to their relationship to psychic functioning and energic conditions. Clinical material is presented from the analysis of a patient who presented with borderline personality organization and narcissistic features. During the initial phase of analysis, splitting associated with projection, projective identification and idealization were the main defence mechanisms. As the analysis progressed and the themes of omnipotence and mourning were explored with the simultaneous working through of drive derivatives expressed in the transference, repression gained ground over the more primitive defence mechanisms. The evolution of the case showed a gradual shift from splitting to repression and the association of repression with a more advanced psychic organization. This development reflected the dynamic movement from borderline to hysterical organization in psychoanalytic nosology.

Suicidality in the "prodromal" phase of schizophrenia.

OBJECTIVES: Patients with schizophrenia are at high risk for suicide ideation, attempts, and completed suicide. However, suicidal behavior during the prodromal phase of schizophrenia and a possible association between prodromal suicidal behavior and suicidality after the onset of overt psychosis are not studied. METHODS: One hundred six consecutively admitted schizophrenia patients with recent onset were evaluated retrospectively for prodromal symptoms and suicidality during the prodromal phase and after the onset of frank psychosis. In addition, 106 matched control subjects from the general population were evaluated for suicidality during the same age period of the prodromal phase of the corresponding patient. RESULTS: Suicide ideation and attempt during the prodromal period were reported in 25.5% and 7.5% of the patients, which are 3.8- and 8-fold greater than in the controls, respectively. Patients with suicidal behavior experienced a greater number of prodromal symptoms than those without. Prodromal depressive mood, marked impairment in role functioning, and tobacco smoking exerted an independent effect on suicide ideation, whereas depressive mood was the symptom significantly more frequent in patients with suicide attempt. Suicide attempts were associated with an earlier onset of prodromal symptoms and frank psychosis. All patients with prodromal suicide attempts were cigarette smokers. Suicide ideation during the prodromal phase was strongly associated with lifetime suicidality after the onset of frank psychosis. CONCLUSIONS: Suicidal behavior is quite common during the prodromal period. The association of smoking, depressive mood, impaired functioning, and a large number of prodromal symptoms, particularly in patients with an early onset of symptomatology, carries a substantially increased risk for suicide ideation. Particular care is needed in patients with prodromal suicide ideation after the onset of frank psychosis because the risk to attempt suicide is high.

Sex differences in prepsychotic "prodromal" symptomatology and its association with Positive and Negative Syndrome Scale active phase psychopathology in male and female patients.

BACKGROUND: A wide spectrum of prodromal symptoms has been reported, but their association with the severity of the active phase psychopathology in relationship to sex is unknown. METHOD: Seventy-three (47 male) Diganostic and Statistical Manual (DSM) schizophrenia patients were subjected to the structured clinical interview for Positive and Negative Syndrome Scale (PANSS). Prodromal symptoms were recorded retrospectively after psychotic phase had subsided. RESULTS: Thirty-eight prodromal symptoms were identified. All symptoms appeared in both sexes. However, there was a significantly greater frequency of 3 symptoms (odd beliefs/magical thinking, over elaborate speech, hyperacusia) in female patients and of 2 symptoms (marked peculiar behavior, aggressiveness) in male patients. In the female patients, 9 symptoms were associated with an increased risk for severe total and components of the PANSS psychopathology in the psychotic phase; 2 symptoms were associated with a mild negative subscale psychopathology. In the male patients, 6 symptoms were associated with the severity of the PANSS psychopathology; 5 carried an increase risk for severe and 1 was associated with mild psychopathology. Also, the risk for severe PANSS positive, general, and total psychopathology increased with the increasing number of total and less specific symptoms in the female but not in the male patients. CONCLUSIONS: Sex differences in schizophrenia are extended into the prepsychotic stage. Also, the presence of certain prodromal symptoms, different in men and women, and the number of symptoms in female patients are associated with the severity of the psychotic phase psychopathology. Evaluation of early therapeutic interventions in prodromal phase should consider sex and spectrum of prodromal symptoms.

Cortical motor neurophysiology of patients with schizophrenia: a study using transcranial magnetic stimulation.

Trancranial magnetic stimulation (TMS) provides a non-invasive means for exploring physiological alterations of central motor control in a variety of neuropsychiatric diseases. The present study aimed to assess the neurophysiological profile of muscle evoked responses to a standard TMS procedure in 51 medicated patients with schizophrenia and 51 age- and sex-matched healthy subjects. Motor evoked potentials (MEPs) from the abductor pollicis brevis muscle were elicited by stimulation of the contralateral motor cortex with a circular coil. The hot spot was marked, and the resting motor threshold (RMTh), the stimulus intensity for maximum MEP (SI-max), the post-stimulus silent period of voluntary muscle activity, and MEP latency and amplitude were measured. The main findings were the significantly higher than normal values for RMTh and SI-max, which are both indices of neuronal excitability. In particular, patients who had ziprasidone in their therapeutic regimen demonstrated the highest SI-max for both hemispheres, and the highest RMTh for the left hemisphere, patients receiving olanzapine demonstrated the lowest RMTh for the left hemisphere, and those on quetiapine showed intermediate values. The silent period was longer in the patients than in the controls when a RMTh-related SI was used and did not differ between the two groups when a fixed SI was used. We concluded that the observed TMS changes could be interpreted as primary alterations of intracortical motor excitability followed by defects of cortical inhibition and should be attributed to schizophrenia, antipsychotic medication or the interaction between the two factors.

Relationship of "prodromal" symptoms with severity and type of psychopathology in the active phase of schizophrenia.

BACKGROUND: Both retrospective and prospective studies have identified a broad spectrum of "prodromal" symptoms, but their relationship to those of frank psychosis remains largely unexplored. METHOD: In 73 successive hospitalized patients with schizophrenia in the first or second psychotic episode and with duration of illness 3 years or less from the onset of psychosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Axis I diagnoses were made. In addition, within the first 5 days from the psychotic episode's onset, symptom severity was assessed with the Positive and Negative Syndrome Scale (PANSS). RESULTS: Stepwise regression analyses showed that 8 prodromal symptoms carried an increased risk for high total PANSS and the components of the PANSS scores, independently of sex; 1 symptom was associated with mild psychopathology. However, the categories of negative- and positive-disorganization prodromal symptoms were not associated with the corresponding PANSS components. Similar findings were observed in the nonparanoid patients, whereas in the paranoid, only 2 nonspecific symptoms were associated with high PANSS psychopathology. In addition, there were significant associations between number of prodromal symptoms and total PANSS and the subscales positive and general scores in the patients with the nonparanoid subtypes, but there were not such associations in those with the paranoid. CONCLUSIONS: Several prodromal symptoms, as well as the number of symptoms, are associated with the severity of the psychopathology of frank psychosis. In the nonparanoid subtypes there is a continuance in the transition from the prepsychotic to the psychotic stage, whereas in the paranoid, the transition appears to be disrupted.

Persistent suppression of postexercise facilitation of motor evoked potentials during alternate phases of bipolar disorder.

The current study sought to longitudinally evaluate the postexercise facilitation of motor evoked potentials (MEP) in two patients during different phases of short-circle depressive-manic disorder. Each study included 50 baseline MEP elicited by transcranial magnetic stimulation, followed by 50 MEP immediately after nonfatiguing exercise of the examined muscle. Postexercise MEP facilitation, expressed as percentage of baseline value, varied from 71% to 119% and from 99% to 107% in each patient, respectively, being significantly lower than our mean normal control value (268%). No differences in MEP facilitation between phases of short-circle depressive-manic disorder were revealed. Reduced postexercise facilitation was independent of the bipolar disorder phases, suggesting an invariable underlying association of the psychiatric pathophysiological mechanisms to impaired cortical excitability.

Smoking, psychosocial factors, psychopathologic behavior, and other related conditions in hospitalized youth suicide attempters.

BACKGROUND: Comorbidity of suicidal behavior with various risk factors has been reported. This study examines the combined effect and the interactions of the most prominent risk factors in hospitalized suicide attempters. METHOD: Seventy-six successive hospitalized suicide attempters and 76 matched control subjects, 9 to 20 years old, were subjected to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I and Axis II diagnoses and were interviewed for the use of licit and illicit substances. Also, 18 control subjects with the same psychiatric disorders diagnosed in the attempters were examined. Logistic regression analysis was applied to determine the independent effect of the risk factors to suicide attempts. RESULTS: The findings showed an 18-fold greater frequency of psychiatric disorders, a 14-fold greater frequency of other conditions that may be a focus of clinical attention (mainly relational problems), a 9.7-fold greater frequency of smoking, and a 4.7-fold greater frequency of psychosocial and environmental problems in the attempters than in the control subjects. The independent association of these factors with increased suicide risk persisted after adjusting for the effect of other factors. CONCLUSIONS: Psychopathologic behavior, psychosocial factors, and smoking are independently associated with increased risk for serious suicide attempts.

Quetiapine successfully treating oculogyric crisis induced by antipsychotic drugs.

We report two patients who developed persistent oculogyric crisis, obsessional thoughts and psychiatric symptoms after prolonged treatment with typical and atypical antipsychotics. Both our patients did not improve after withdrawal of these antipsychotics, but rather after quetiapine was administered.

Association of cigarette smoking and depressive symptoms in a forensic population.

The link between mental health issues and smoking has been an important area of investigation. However, little is known about this association in a general adult, male forensic population. The aim of this study was to identify demographic and clinical (depression and anxiety) variables that predict smoking in a forensic population. A large cohort of 353 inmates in a high-security prison underwent a psychiatric interview, including administration of the Montgomery-Asberg Rating Scale for Depression (MADRS) and Hamilton's Rating Scale for Anxiety (HAM-A). Multiple regression analysis suggested that younger age and higher depression scores might predict the amount of daily smoking in this population. In contrast, anxiety symptoms were not an independent predictor for smoking in our study. These findings support the need for additional research to focus on those factors associated with smoking in forensic populations. Psychiatric screening for younger male individuals in forensic settings and targeted cognitive-behavioral interventions to treat depressed smokers may ameliorate the smoking abstinence rate in prisons.

Suicidal ideation in prisoners: risk factors and relevance to suicidal behaviour. A prospective case-control study.

OBJECTIVE: To investigate risk factors for suicidal ideation (SI) in prisoners, as well as the prediction of suicidal behaviour by SI. METHOD: Participants were recruited from the all-male,adults', high security prison of Patras, Greece. Sixty-seven prisoners who expressed SI were evaluated using a structured interview, Hamilton's Rating Scale for Anxiety (HAMA) and the Montgomery-Asberg Rating Scale for Depression (MADRS). Sixty-seven control prisoners without SI, matched for age, nationality and penal status were evaluated using the same structured interview and rating scales. All participants were followed-up prospectively for 12 months after their initial assessment and any acts of self-destructive behaviour were recorded. RESULTS: Independent significant risk factors for SI in prisoners were the family history of suicidal behaviour (OR = 56.34, 95% CI = 4.23-750.1, p < 0.002), history of psychiatric hospitalisation (OR = 7.18, 95% CI = 1.83-28.16, p < 0.005), and higher scores in the MADRS (p < 0.03) and HAMA (p < 0.03) scales. During the follow-up period, suicidal behaviour (suicide attempt or self-mutilation) was observed in 12 (17.9%) inmates with SI, as opposed to none of the controls (p < 0.0001). CONCLUSION: A family history of suicidal behaviour, history of psychiatric hospitalisation and symptoms of anxiety or depression were independent risk factors for SI in prisoners. Inmates with SI had a higher risk for self-destructive acts at follow-up. Inmates with SI are a high-risk group for future self-destructive acts, so special precautions designed to reduce this risk are warranted.

Quetiapine in the treatment of focal tardive dystonia induced by other atypical antipsychotics: a report of 2 cases.

The authors report 2 patients with schizophrenia who developed focal tardive dystonia secondary to treatment with atypical antipsychotics (risperidone, olanzapine). When quetiapine was gradually introduced and other antipsychotics were discontinued, these patients experienced remarkable and sustained improvement of their dystonic symptoms, without loss of psychotic symptom control. The mechanism by which quetiapine may improve tardive dystonia caused by other atypical antipsychotics is unclear. Due to its receptor and pharmacologic profile, quetiapine is the atypical antipsychotic that is most similar to clozapine (without its hematologic side effects), which leads the authors to consider it for the treatment of tardive movement disorders.

Major depression and risk of depressive symptomatology associated with short-term and low-dose interferon-alpha treatment.

OBJECTIVE: The objective of this study is to identify early patients who are at-risk for major depression (MD) induced by interferon-alpha (IFN-alpha) and evaluate the response of depressive symptoms to antidepressants. METHODS: Thirty-six consecutive patients were treated with IFN-alpha. Psychiatric evaluations were performed prior to, and at 1 and 2 months after onset of therapy and upon completion of the study. Diagnoses were made according to DSM-IV criteria, and the severity of depressive symptoms was determined by the Hamilton Depression Rating Scale score (HDRSS). RESULTS: Of the 36 patients studied, 7 (19%) had MD before IFN-alpha treatment, 6 of which manifested a worsening of the depressive symptomatology during treatment. Of the remaining 29 patients, 9 (31%) developed MD during treatment. The median time required for the appearance or worsening of the depressive symptoms was 15 days (range 7-25). The median HDRSS before IFN-alpha in the 36 patients was 3 (range 1-20), whereas after 1 month of therapy, it was 10 (range 1-24; P=.000004). There was a strong positive correlation in the HDRSS before and 1 month after the initiation of treatment (r=.863). Of the 14 patients with a HDRSS of 1-2 before IFN-alpha treatment, only 1 (7%) developed MD, whereas of the 15 patients with a score >3, 8 (53%) developed MD. Antidepressants resulted in a decrease of the HDRSS to the IFN-alpha pretreatment values. CONCLUSION: One third of those treated with IFN-alpha developed MD. The HDRSS before treatment reveals the high- and low-risk patients for developing MD. Psychiatric evaluation should be performed prior to IFN-alpha treatment.

Induction of the rabbit syndrome following coadministration of paroxetine, perphenazine, and amitriptyline.

The authors present a case of paroxetine-induced rabbit syndrome in a 65-year-old white woman. To their knowledge, this is the first report in the literature describing rabbit syndrome induced by the administration of a selective serotonin reuptake inhibitor-specifically, paroxetine in combination with perphenazine and amitriptyline.

Psychopathology and behavioural trends of children with accidental poisoning.

OBJECTIVE: To study the psychopathology of both young children with accidental poisoning and their mothers, measure the poisoned children's trends of behaviour and explore whether there is an association between parental smoking and poisoning in children. METHODS: The psychopathology of 150 poisoned and 150 matched control young children, and their mothers was studied according to DSM-IV criteria. Children's perceptions of behaviour were examined by a measure assessing internalizing and externalizing behaviour. RESULTS: Psychiatric disorders were by 4.3-fold more frequent in the poisoned than in the control children. Also, the study children exhibited higher levels in all aspects of behaviour. In the poisoned children's mothers the frequency of psychiatric disorders was threefold greater than in the control. Also, "parent-child relational problem" and "psychosocial and environmental problems" were more frequent in the study than the control groups. Smoking was more frequent in both parents of the poisoned than of the control children. CONCLUSIONS: Findings show that risk factors for accidental poisoning are localized on the children, their parents or may have a psychosocial-environmental origin. The presence of certain psychiatric disorders in young children (attention-deficit and disruptive behaviour disorders) or their mothers (anxiety, personality and mood disorders) requires the implementation of early measures for reducing the risk of poisoning.

Characteristics of inmates receiving prescribed benzodiazepines in a high-security Greek prison.

The aim of the current study was to investigate the characteristics of Greek inmates that were taking regularly benzodiazepines (BZDs) at therapeutic doses, in the high-security prison of Patras, Greece. Three hundred eighty-four prisoners were included in the study. BZD users (BUs, n = 192), compared with non-BZD users (NBUs, n = 192), were significantly more often unemployed before imprisonment; were significantly more often single, divorced, or widowed; were significantly more often on remand; were taking in significantly greater proportions antidepressant and antipsychotic medications; had significantly more often a history of psychiatric hospitalization; and had significantly more often a history of illicit intravenous (IV) drug use. BUs were significantly more often positive on serum antibodies to hepatitis C (anti-HCV), and scored significantly higher on Hamilton's Rating Scale for Anxiety (HAM-A) and Zung's Self-Rating Depression Scale (SDS). Multivariable logistic regression analysis showed that the history of psychiatric hospitalization, history of illicit drug use, history of unemployment, symptoms of anxiety, and anti-HCV positivity were independently associated with BZD use in this prison. Medical and psychiatric interventions focusing on anxiety problems, depression, drug addiction, and HCV in this group of BUs are warranted.

Suicide attempts in high-dose benzodiazepine users.

Substance use disorders are associated with increased suicidal behavior. The suicidal behavior in patients without a history of illegal substance abuse, who consume benzodiazepines (BZDs) regularly in doses higher than those recommended, has not been previously studied. The aim of this study was to investigate the factors associated with the past history of suicide attempts in high-dose regular BZD users (HDRUs). Fifty-five HDRUs were recruited from inpatient and outpatient psychiatric services, and were compared to 55 psychiatric controls, matched for demographic characteristics and psychiatric diagnoses to HDRUs (Controls A), and to 55 psychiatric controls matched only for demographic characteristics to HDRUs (Controls B). Both control groups were non-BZD users. Patients with previous or current use of illegal substances were excluded. There was a statistically significant difference in the history of suicide attempts, comparing HDRUs (17 attempters, 30.9%) with Controls B (two attempters, 3.6%), while the difference was not significant comparing HDRUs with Controls A (10 attempters, 18.2%). Using logistic regression analysis, it was found that only comorbid borderline personality disorder (BPD), not high-dose BZD use, was independently associated with a history of suicide attempt. The percentage of patients with a history of suicide attempt was significantly higher in HDRUs with comorbid BPD, compared to HDRUs without BPD.

Effect of exercise on motor evoked potentials elicited by transcranial magnetic stimulation in psychiatric patients.

SUMMARY: Under normal conditions, motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation increase in amplitude if the subject exercises the examined muscle immediately before recording. The authors examined the effect of nonfatiguing exercise on the amplitude of MEPs on 42 psychiatric, medicated inpatients (14 with depression, 14 with schizophrenia, and 14 with mania) compared with 14 healthy control subjects. For each subject, a total of 50 baseline and 50 postexercise MEPs were recorded. The mean (+/- standard deviation) postexercise MEP facilitation, expressed as a percentage of mean baseline values, was significantly lower (p