[Acute psychotic productivity in cerebral imaging]. / Akute psychotische Produktivität in der zerebralen Bildgebung1.

Regional cerebral blood flow (rCBF) was analysed in 24 neuroleptically never treated schizophrenics by 99m-Tc-HMPAO-SPECT. Psychopathological symptoms (PANSS) were correlated with rCBF-measures using multidimensional scaling (MDS). Highest degrees of correlation were found for ideas of grandiosity and formal thought disorders compared to different regions of interest (ROIs). An adynamic cluster was defined by basic symptoms which showed signs of deficiency. This cluster was by the highest degree correlated with a cluster defined by rCBF compared to four different clusters of basic symptoms. A fMRI-study was performed in schizophrenic patients with auditive hallucinations in comparison to healthy controls. We offered simple acoustic stimuli perceived as coming from the outside versus inside. For the outside condition, controls activated the medial temporal gyrus on the left side and the rightsided precuneus and postcentral gyrus which represent the auditive source locating and the stimulus processing systems, for inside, they activated the left insula. Hallucinating schizophrenic neither activated the one nor the other system. We discussed the findings as a possible explanation of the schizophrenics' tendency to misinterpret hallucinations as real perceptions.

[Personality and personality disorders I. Universality and sensitivity of dimensional personality models as diagnostic systems for personality disorders]. / Persönlichkeit und Persönlichkeitsstörungen I -- Zur Universalität und Sensitivität dimensionaler Beschreibungssysteme (hierarchische Persönlichkeitsmodelle) für Persönlichkeitsstörungen.

OBJECTIVE: A dimensional diagnostic system for personality disorders (PD) postulates continuous transitions from normal to disordered personalities (continuity hypothesis) and universal validity of basic personality dimensions (universal hypothesis). In the present study three dimensional personality models that claim to provide a systematic representation of the overall domain of personality disorders were compared: the Big-Five model proposed by Costa and McCrae, the psychobiological model proposed by Cloninger and colleagues, and the "Dimensional Assessment of Personal Pathology (DAPP)" model proposed by Livesley and colleagues. METHOD: The "Six Factor Test" (SFT) measuring the Big-Five factors of personality, the "Temperament and Character Inventory (TCI)" measuring 4 temperament and 3 character dimensions, and the DAPP measuring 18 basic traits and 4 second ordered factors were administered to general population subjects (n = 156), and a clinical sample (n = 220) including a subsample of 69 patients with at least one diagnosis of DSM-IV PD. Group comparisons, regression analyses, and facet theoretical analyses were conducted. RESULTS: The nonmetric similarity analyses of the three personality models show a nearly identical radex-representation of the second ordered factors in the non-clinical and clinical sample reflecting an universal validity of 4 basic personality dimensions and confirming the universal hypothesis. In comparison with the BIG-Five concept and the psychobiological model the DAPP model seems to be more sensitive to differentiate PD patients from controls with a reclassification rate of 94.5 %. CONCLUSIONS: The Big-Five model, the DAPP and the TCI represent a substantially similar domain despite their different conceptualization. However, the DAPP was more sensitive to differences between PD patients and controls, offered a more comprehensive account of PD, and could differentiate the two groups more effectively.

[Personality and personality disorders II. The Specificity of the DAPP-model as a diagnostic system for personality disorders]. / Persönlichkeit und Persönlichkeitsstörungen II -- Zur Spezifität des DAPP-Ansatzes als differenzielles Beschreibungssystem von Persönlichkeitsstörungen.

The 'Dimensional Assessment of Personality Pathology - Basic Questionnaire' (DAPP) measures 18 traits to provide a systematic representation of the overall domain of personality disorders (PD). The present study investigated the relationships between DAPP personality profiles and dimensional assessments of DSM-IV PD in general population subjects (n = 156), and a sample of 220 nonpsychotic psychiatric patients (including n = 67 PD patients). Using nonmetric multidimensional scaling models the similarities between the 18 DAPP-factors and the dimensional scores of the 12 DSM-IV PD (inclusive appendix) were graphically represented in a 2-dimensional similarity-system. Here each DSM-IV PD dimension could be described by a distinct profile of DAPP-factors. Overall results support the assumption that PD can be represented by a dimensional system of personality traits with sufficient sensitivity and specificity.

[Personality, accentuated traits and personality disorders. A contribution to dimensional diagnosis of personality disorders]. / Persönlichkeit, akzentuierte Wesenszüge und Persönlichkeitsstörungen. Ein Beitrag zur dimensionalen Diagnostik von Persönlichkeitsstörungen.

A dimensional diagnostic system for personality disorders (PD) postulates continuous transition from normal to disordered personalities (continuity hypothesis) and universal validity of basic personality dimensions (universal hypothesis). The present study investigates the validity of Leonhard's concept of attenuated personalities that define a conceptual link between normal personality dimensions and PD. Nine possible continuous transitions between three conceptual levels (Big Five personality factors, nine attenuated personality traits, nine PD) were tested by questionnaire data obtained from a mentally healthy (n = 166) and a clinical sample (n = 78). Both samples differed significantly in nearly all variables. However, they showed substantial similarity concerning the (in)validity of single continua and the complex structure of all variables as analyzed by multidimensional scaling. The concept of attenuated personalities could be validated for six out of nine tested continua and can be recommended for application in dimensional models of personality and personality disorders.

Diagnosing schizophrenia in the initial prodromal phase.

BACKGROUND: In schizophrenia research, early detection in the initial prodrome before first psychotic episodes is a major topic. Therefore, the prognostic accuracy of initial prodromal symptoms was examined prospectively. METHODS: The study sample was composed of patients referred to outpatient departments of German psychiatric university departments, because of diagnostic problems, between 1987 and 1991. They were examined with the Bonn Scale for the Assessment of Basic Symptoms and the Ninth Version of the Present State Examination to detect an incipient schizophrenic disorder. Of 385 patients showing no schizophrenia-characteristic symptoms, between 1995 and 1998, 110 with and 50 without initial prodromal symptoms were followed up and reexamined with the same instruments for a transition to schizophrenia. RESULTS: During a mean follow-up period of 9.6 years, 79 (49.4%) of the 160 patients had transited to schizophrenia. The absence of prodromal symptoms excluded a subsequent schizophrenia with a probability of 96% (sensitivity: 0.98; false-negative predictions: 1.3%), whereas their presence predicted schizophrenia with a probability of 70% (specificity: 0.59; false-positive predictions: 20%). Certain disturbances, such as thought interference, disturbances of receptive language, or visual distortions, predicted schizophrenia, even with a probability up to 91% (specificity: 0.85-0.91; false-positive predictions: 1.9%-7.5%). CONCLUSIONS: The Bonn Scale for the Assessment of Basic Symptoms operationalization of prodromal symptoms performed well in the early detection of schizophrenia. It therefore might be useful for the prediction of the disorder, especially if it is further refined to select those items with particularly high prognostic accuracy.

[Impulse control and affect regulation in personality disorders]. / Impulskontrolle und Affektregulation bei Persönlichkeitsstörungen.

In borderline and antisocial personality disorder there is a close interaction between affect dysregulation and impulse control disorder. Different approaches are presented that focus on affective responses to experimental stimuli in these personality disorders. Results suggest that in borderline personality disorder intense emotional responses occur in the context of specific stressors, in particular fear of being abandoned. Evidence for a general emotional hyperreactivity was not found; on the contrary, female borderline subjects rather showed reduced emotional arousal. Regarding the psychopathic subtype of antisocial personality disorder, results provided strong support for the theory of emotional detachment, which may predispose to violence through a lack of feeling of fear or also of compassion which could counteract violent impulses. Consequences for psychotherapy in BPD are considered.

Circumplex models for the similarity relationships between higher-order factors of personality and personality disorders: an empirical analysis.

Similarity relationships between personality factors and personality disorders (PDs) are usually described within the conceptual framework of the "big five" model. Recently, two-dimensional circumplex models have been suggested as alternatives, such as the interpersonal circle, the multifacet circumplex, and the circumplex of premorbid personality types. The present study is an empirical investigation of the similarity relationships between the big five, the 11 DSM-III-R personality disorders and four subaffective disorders. This was performed in a sample of 165 psychiatric inpatients. We tested the extent to which the relationships could be adequately represented in two dimensions and which circumplex model can be supported by the empirical configuration. Results obtained by principal-components analysis (PCA) strongly confirm the circumplex of premorbid personality, and to some extent the multifacet circumplex. However, the interpersonal circle cannot be confirmed.

Quality of life in psychiatry: a systematic contribution to construct validation and the development of the integrative assessment tool "modular system for quality of life".

The aim of the present study is to contribute to an ongoing validation process of the Quality of Life (QoL) construct in the clinical field by investigating its internal structure. Eight (inter)nationally validated questionnaires have been analyzed by an integrative approach in a multicenter study. Data has been collected in a mentally healthy (n = 479), a depressed (n = 171) and a schizophrenic (n = 139) sample. Apart from conventional psychometric criteria a similarity structure analysis (SSA) within a facet analytic methodology has been applied. A dimensional structure of the resulting integrative questionnaire "Modular System for Quality of Life" (MSQoL) could be generated that consists of one "G-factor" (life in general) and six specific dimensions (physical health, vitality, psychosocial relationships, material resources, affect, leisure time). This basic structure represents a core module measured by 47 items which is sufficiently valid for all three samples. The empirical structures of healthy, depressed and schizophrenic samples fulfill the first law of attitude and share a common variance of 95%. In addition, there are four specific modules (demography, family, partnership, profession). No specific modules could be identified for the psychopathological subgroups. The conclusion can be drawn that QoL is construed very similar by all three investigated populations which is the base for searching for quantitative differences and profiles. The MSQoL integrates the non-redundant components of eight QoL-instruments, is psychometrically able to assess the basic structure and can be completed within a cumulative research design by items specific for a particular setting.

[Aspects of cerebral connnectivity in schizophrenia. A comparative CBF study on treated schizophrenics before and after medication]. / Aspekte zerebraler Konnektivität bei Schizophrenie. Eine vergleichende rCBF-Studie von nie behandelten Schizophrenen vor und nach Medikation.

INTRODUCTION: The hypothesis of prefrontal-temporolimbic disconnectivity, considered to be relevant to the pathogenesis of schizophrenia, has been tested in 29 drug-naive schizophrenic patients, comparing the active with the remitted state. METHOD: A pre-post-treatment design was applied to 29 drug-naive schizophrenic inpatients, 18 male, mean age 32 years, 11 female, mean age 32 years, mean duration of illness 29 months. Psychopathological symptoms were assessed using PANSS, regional cerebral blood (rCBF) was measured by HMPAO-SPECT. RCBF values were calculated for 21 regions of interest after normalization to cerebellum, and plotted by Euklidean diagrams using the ordinal, nonmetric, multidimensional scaling method. These diagrams represent similarity correlations visualized as spatial distances. High correlation levels as indicated by small Euklidean distances have been interpreted as functional connectivity. RESULTS: In active schizophrenia, functional disconnectivity was observed between prefrontal and temporal cortex. After remission, connectivity was improved between temporolimbic and frontal cortex. CONCLUSION: Comparing active with remitted schizophrenia, a frontotemporal disconnectivity appears. Temporolimbic as well as frontolimbic connections restitute parallel to psychopathological improvement.

Active and remitted schizophrenia: psychopathological and regional cerebral blood flow findings.

Single photon emission computed tomography with technetium-99m-d,l-hexamethylpropyleneamine oxime (99mTc-HMPAO) was used to assess regional cerebral blood flow (rCBF) during both florid and remitted stages of schizophrenia. Forty schizophrenic patients in an active phase of illness (diagnosis by DSM-III-R) were examined in two clinical states (ill vs. improved). At study entry, 24 patients were drug-naive, five were currently drug-free, and 11 were being treated with antipsychotic medication. Twenty medical patients who suffered from non-specific headaches but were free of neurological and psychiatric symptoms served as control subjects. At initial examination during the active phase of illness, cerebral perfusion patterns in the schizophrenic patients were characterized by both hypofrontality and hypotemporality. After remission, hypofrontality was no longer apparent in two of four frontal regions, and hypotemporality disappeared completely. As assessed with the Positive and Negative Syndrome Scale (PANSS), formal thought disorders, hallucinations, and ideas of grandiosity correlated with rCBF in the active phase of illness, but not after remission. In the remitted but not in the florid state, blunted affect, difficulties in abstract thinking, lack of spontaneity, and stereotyped thoughts correlated with rCBF. Correlations of five symptoms with rCBF changed significantly from first to second examination. The present study suggests that correlations between single psychotic symptoms and rCBF differ significantly in florid vs. remitted phases of schizophrenia.

[Quality of life. Construct validation and the development of a modular system]. / Das Konstrukt Lebensqualität. Metaanalytische Validierung und die Entwicklung eines modularen Erhebungssystems.

The construct Quality of Life (QoL) is investigated by metaanalysis of eight (inter)nationally validated questionnaires in a multicenter study. Data have been collected in a mentally healthy (n = 479), a depressed (n = 171) and a schizophrenic (n = 139) sample. Conventional psychometric criteria and a facet analytical methodology have been applied. The resulting questionnaire "Modular System for Quality of Life" (MSQoL) consists of a core module with 47 items (one "G-factor" and six subdimensions), which is sufficiently valid for all three samples. Additionally, there are four specific modules (demography, family, partnership, profession). No specific modules can be identified for the psychopathological subgroups. The validated radex structure for subjective QoL offers the opportunity for a cumulative research design and for adaptations to the actual setting.

Special feature: personality and personality disorders. A facet theoretical analysis of the similarity relationships.

Categorical and dimensional models of personality, and personality disorders and their interrelationships, are discussed. A facet theoretical analysis of the structural relationships between personality factors and disorders is described. It is hypothesized that higher-order personality traits organize the personality of both the psychically healthy and the psychically ill, and that personality disorders represent maladaptive variants of traits that are evident in all persons to varying degrees. Data were collected from a clinical (n = 165) and a nonclinical sample (n = 100). Results show that the two classes of variables (personality factors and disorders) have similar relationships to each other, and can be structured in the form of a radex in both samples. Finally, the compatibility of the radex structure with other models is examined, comparing facet theory with factor analytical techniques. The results of the facet theoretical analysis further support the hypothesis of a universal personality model, and a continuous transition from normal personalities to personality disorders.

[Experimental detection of inadequate affect regulation in patients with self-mutilating behavior]. / Experimenteller Nachweis mangelnder Affektregulation bei Patientinnen mit selbstschädigendem Verhalten.

According to DSM-IV affective instability in borderline personality disorder is due to marked reactions to environmental events. The aim of this study was to investigate affective responsiveness of abnormal personalities with self-harming impulsive behaviors by means of an affect-stimulation design. The first experiment was based on the presentation of a short story that allowed affective responses to various stimuli to be assessed in regard to quality, intensity, and alterations over time. The second one presented a typical frustration design, which provoked specific feelings of anger and disappointment. Impulsive personalities showed an affective hyperreactivity that was characterized by a decreased threshold for affective responses, as well as by intensive, rapidly changing affects. Furthermore, affect experiences turned out to be qualitatively diffuse and undifferentiated. Results support that affective instability of patients with borderline personality disorder should be differentiated from the autonomous deviations of mood typical of affective disorders. Their affective hyperreactivity is a crucial part of impulsive personality functioning.

Psychopathological and SPECT findings in never-treated schizophrenia.

A total of 24 never-treated (i.e. drug-naive) actively psychotic schizophrenic patients, operationalized according to DSM-III-R, were examined in a pre-post-treatment design using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and 99mTc-HMPAO-single photon emission computed tomography (SPECT) to assess regional cerebral blood flow (rCBF). The control subjects were 20 patients free of neurological and psychiatric symptoms. Before treatment there was only a slight hypofrontality, and hypoperfusion was observed in the left temporal superior region. After treatment, hypofrontality was reduced to one region and temporal hypoperfusion disappeared. Formal thought disorders were accompanied by increased rCBF in the bilateral frontal interior and left temporal superior regions. Delusions were associated with hypoperfusion in the anterior cingulate cortex. Negative symptoms showed no linkage to hypofrontality, either before or after treatment. Factor analysis showed delusions and hallucinations loading on different dimensions. The disorganized dimension correlated positively with all regions of interest, whereas these were negatively correlated with reality distortion.

Affective instability and impulsivity in personality disorder. Results of an experimental study.

Affective instability in borderline personality disorder is due to a marked reactivity to environmental events. The present study focused on the relationship between affective instability and impulsivity in personality disorder. It used an experimental approach in the form of an affect-stimulation design based on the presentation of a short story which allowed for an analysis of affective responses in regard to quality, intensity, and alterations over time. Impulsive personalities showed a strong intensity of affective responses us well as a tendency towards rapid affect alterations supporting the theory of poor affect regulation in subjects with impulsive self-harming behaviour. Results suggest that affective instability is a crucial part of impulsive personality functioning.

Early self-experienced neuropsychological deficits and subsequent schizophrenic diseases: an 8-year average follow-up prospective study.

The aim of the present study was to investigate the potential predictive value of early self-experienced neuropsychological deficits for the subsequent development of schizophrenia. A total of 96 patients with DSM-III-R diagnoses of personality disorders (formerly called 'neurotic disorders') who had been examined for the presence of such subjective experiences of deficits with standardized instruments were re-examined for the possible development of schizophrenic symptoms. After an average follow-up period of about 8 years, more than 50% of the patients had developed schizophrenia according to DSM-III-R criteria. In 77% of cases the outcome 'schizophrenia vs. no schizophrenia' was correctly predicted by the earlier presence or absence of self-experienced disturbances of thought, speech, memory, perception and action. These findings suggest that certain self-experienced neuropsychological deficits are able to indicate susceptibility to psychosis.

[Are self-perceivable neuropsychological deficits in patients with neuroses or personality disorder diagnoses indicative of later schizophrenia?]. / Sind selbst wahrnehmbare neuropsychologische Defizite bei Patienten mit Neurose- oder Persönlichkeitsstörungsdiagnosen für spätere schizophrene Erkrankungen prädiktiv?

For the first time, the present study assessed the achievable predictive value of early self-experienced neuropsychological deficits for the fater development of schizophrenia. Ninety-six patients with DSM-III-R diagnoses mainly of the formerly neurotic or personality disordered field, of whom 81% had shown such basic disorders at the time of the index examination and therefore were classified as persons at high risk of developing schizophrenia, were re-examined for schizophrenia. After an average follow-up period of about 8 years, more than half of the re-examined sample had developed a schizophrenic disorder according to DSM-III-R. The outcome of schizophrenia versus no schizophrenia was predicted correctly in 77% of cases by the presence or absence of self-experienced disturbances of perception, thought, speech or action.

Regional cerebral blood flow and negative/positive symptoms in 24 drug-naive schizophrenics.

UNLABELLED: SPECT/PET studies in schizophrenia revealed inconsistent changes of regional cerebral blood flow (rCBF). Frontal hyperperfusion as well as hypoperfusion are described. This study was undertaken to investigate the relations between rCBF, psychopathology according to PANSS and effects of neuroleptic therapy. METHODS: Twenty-four drug-naive acute patients with a first manifestation of schizophrenia were examined with 99mTc-HMPAO brain SPECT and assessed according to PANSS. Of these, 22 were controlled again after neuroleptic treatment. Following attenuation correction, region-to-cerebellar count ratios were obtained from 98 irregular regions of interest drawn in all slices (6.25 mm). The ratios were compared to 20 control subjects, and changes lying outside of 2 s.d. were considered abnormal. RESULTS: In different drug-naive patients, hyperperfusion as well as hypoperfused patterns were found. In drug-naive patients, the seven subscores of positive symptoms (pos 1-7) in PANSS showed different correlations to rCBF: Formal thought disorders (pos 2) and grandiosity (pos 5) were positively correlated to bifrontal and bitemporal rCBF (r = +0.59 to +0.70). Delusional ideas (pos 1), hallucinatory behavior (pos 3) and suspiciousness (pos 6) demonstrated a negative correlation to bifrontal, cingulate, left temporal and left thalamic rCBF (r = -0.59 to -0.66). Stereotyped ideas (neg 7) as a negative symptom showed a negative correlation to left frontal, left temporal and left parietal rCBF (r = -0.59 to -0.65). No correlations were found between residual positive symptoms and rCBF after neuroleptic treatment and clinical improvement, but all negative symptoms (neg 1-7) had a negative correlation to bifrontal, bitemporal, cingulate, basal ganglia and thalamic rCBF (r = -0.59 to -0.74). CONCLUSION: Our results illustrate that different positive symptoms are accompanied by different rCBF values: some induce hyperperfusion, others hypoperfusion. After therapy (and reduction of positive symptoms), only negative symptoms correlate exclusively to hypoperfusion. This may be the crucial factor in explaining inconsistencies of past results in perfusion pattern in drug-naive schizophrenic patients.

Phenomenology of simple partial seizures.

Based on a sample of 325 inpatients we present the subjective experiences during simple partial seizures. In a majority of cases, auras comprised composed forms of different symptomatic qualities. We describe rules which seem to govern sequences of aura phenomena. Autonomous and vestibular sensations were shown to have preceding positions related to others, olfactory and gustatory sensations preferred a following position. The tentative explanation of the findings favours the idea of heterogeneity rather than the concept of a focal discharge in a simple partial seizures.