Correlations between cortical gyrification and schizophrenia symptoms with and without comorbid hostility symptoms.

Introduction: Interest in identifying the clinical implications of the neuropathophysiological background of schizophrenia is rising, including changes in cortical gyrification that may be due to neurodevelopmental abnormalities. Inpatients with schizophrenia can show abnormal gyrification of cortical regions correlated with the symptom severity. Methods: Our study included 36 patients that suffered an acute episode of schizophrenia and have undergone structural magnetic resonance imaging (MRI) to calculate the local gyrification index (LGI). Results: In the whole sample, the severity of symptoms significantly correlated with higher LGI in different cortical areas, including bilateral frontal, cingulate, parietal, temporal cortices, and right occipital cortex. Among these areas, patients with low hostility symptoms (LHS) compared to patients with high hostility symptoms (HHS) showed significantly lower LGI related to the severity of symptoms in bilateral frontal and temporal lobes. Discussion: The severity of psychopathology correlated with higher LGI in large portions of the cerebral cortex, possibly expressing abnormal neural development in schizophrenia. These findings could pave the way for further studies and future tailored diagnostic and therapeutic strategies.

Are Demoralization and Insight Involved in Suicide Risk? An Observational Study on Psychiatric Inpatients.

INTRODUCTION: Several features contribute to determining suicide risk. This study was designed with the aim of evaluating whether insight into illness and demoralization are involved in suicide risk (active suicidal ideation or behavior). METHODS: For this purpose, in a sample of 100 adult psychiatric inpatients, we used the Columbia Suicide Severity Rating Scale to assess suicide risk, the Demoralization Scale for demoralization symptoms, and the Insight Scale to assess illness insight. We also investigated several demographic and clinical features, including gender, age, duration of untreated illness, previous suicide attempts, and nonsuicidal self-injurious behavior. RESULTS: The results demonstrated that patients with higher scores on the insight-high dimension had 1.35 greater odds of having a higher suicide risk, and those with lifetime suicide attempts had 7.45 greater odds of having a higher suicide risk. Among the various clinical factors, the study indicated that only nonsuicidal self-harm behaviors in the last 3 months was a risk factor for suicide risk. CONCLUSIONS: The results indicated that greater illness insight is involved in suicide risk regardless of demoralization.

Mediators in the Association Between Affective Temperaments and Suicide Risk Among Psychiatric Inpatients.

BACKGROUND: Affective temperaments have been shown to be related to psychiatric disorders and suicidal behaviors. Less is known about the potential contributory role of affective temperaments on suicide risk factors. In the present study, we investigated whether the effect of affective temperaments on suicide risk was mediated by other variables, such as hopelessness, mentalization deficits, dissociation, psychological pain, and depressive symptoms. METHODS: Several assessment instruments, including the Mini International Neuropsychiatric Interview (MINI); the Temperament Evaluation of Memphis, Pisa, and San Diego Autoquestionnaire (TEMPS-A); the Beck Hopelessness Scale (BHS); the Gotland Male Depression Scale (GMDS); the Dissociative Experiences Scale (DES); the Psychological Pain Assessment Scale (PPAS); and the Mentalization Questionnaire (MZQ), were administered to 189 psychiatrically hospitalized patients (103 women, 86 men) in Rome, Italy. RESULTS: In single-mediator models, hopelessness, depressive symptoms, and mentalization, but not psychological pain or dissociation, were significant mediators in the association between prevalent temperament and suicide risk. In a multiple-mediator model, a significant indirect effect was found only for depression. Results demonstrated that patients with negative temperaments reported higher suicide risk, psychological pain, hopelessness, and depression, and less mentalization than patients with no prevalent temperament or hyperthymic temperaments. CONCLUSIONS: Hopelessness, depression, and mentalization are all factors that mediate the relation between affective temperaments and suicide risk. Identifying factors that mediate the effects of affective temperamental makeup on suicide risk should enhance screening and intervention efforts.

Combined NMDA Inhibitor Use in a Patient With Multisubstance-induced Psychotic Disorder.

: Novel psychoactive substance use is a major social concern. Their use may elicit or uncover unpredictably as yet undescribed clinical pictures. We aimed to illustrate a multisubstance use case indistinguishable from paranoid schizophrenia, so to alert clinicians on possibly misdiagnosing substance-induced psychotic disorders. CASE REPORT: We describe a case of a 32-year-old man who started at 18 years with cannabinoids and ketamine, and is currently using N-methyl-D-aspartate (NMDA) antagonists. At age 23, he developed social withdrawal after being assaulted by a stranger, but did not consult psychiatrists until age 26; during this period, he was using internet-purchased methoxetamine and ketamine, and was persecutory, irritable, suspicious, and insomniac and discontinued all received medical prescriptions. He added dextromethorphan to his list of used substances. At age 31, while using phencyclidine, and, for the first time, methoxphenidine, he developed a religious delusion, involving God calling him to reach Him, and the near-death experiences ensured by NMDA antagonists backed his purpose. He received Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnosis of multisubstance-induced psychotic disorder and was hospitalized 8 times, 6 of which after visiting the emergency room due to the development of extreme anguish, verbal and physical aggression, and paranoia. He reportedly used methoxphenidine, methoxyphencyclidine, ethylnorketamine, norketamine, and deschlorketamine, to achieve near-death experiences, and eventually to reach God in heavens. CONCLUSIONS: This case points to the need for better control of drugs sold on the internet. It also illustrates that people using NMDA antagonists may present clinical pictures indistinguishable from those of major psychoses and are likely to be misdiagnosed.

Genetic association analysis of serotonin and signal transduction pathways in suicide attempters from an Italian sample of psychiatric patients.

Genetic factors have been reported to contribute to the liability of suicide. We aimed to investigate functional polymorphisms in eight genes (serotonin transporter, SLC6A4; receptors, 5HTR1A, 1B, 5HTR2A; Tryptophan Hydroxylase, TPH1, TPH2; Monoamine Oxidase, MAOA and G Protein Subunit Beta 3, GNB3) to investigate their predictive value for suicide. The possible confounding effects of gender and phenotypic patients dissection were also valued. A sample of 111 consecutive psychiatric inpatients was recruited and assessed using specific psychometric instruments. Genomic DNA was isolated from peripheral white blood cell samples and polymorphisms were genotyped by pyrosequencing technology. Although no differences were observed between allele and genotype frequencies for all polymorphisms and suicide attempt (SA), a polygenic risk score was detected for three genes HTR2A (A-1438G), TPH1 and TPH2 increasing the prediction of SA risk (Thresh=0.43, p=0.038, R2=0.053). Moreover some nominal associations were obtained after gender and phenotypic dissection stratification (TEMPS-A, TEMPs-H, GSMD, SHSS, GAF, CGI) for SLC6A4 (5-HTTLPR), HTR1A (C-1019G), HTR2A (A-1438G), TPH1 (A799C) and GNB3 (C825T) genes, that were lost after Bonferroni correction. This is a first evidence that specific additive combinations of genes could increase the prediction of SA risk and that gender and phenotypic dissection could influence the association of the genes with SA. This could represent a further study also for future meta-analyses on larger samples.

Use of benzylglycinamide by a HIV-seropositive polysubstance user: The changing pattern of novel psychoactive substance use among youths.

A 24-year old woman with multisubstance use since the age of 13, including opioids and cocaine, and long-standing HIV/HCV seropositivity status, presented with psychosis, agitation, and insomnia at the emergency department of a university hospital. She had been abusive and physically aggressive frequently without specific reasons and was involved in criminal legal cases. She was hospitalized twice. During her first hospital stay she experienced a brief episode of detachment from her environment, similar to episodes reportedly suffered at home. Psychosis had developed following heavy polysubstance abuse. Her mother provided sachets containing benzylglycinamide, a substance with no known psychotropic effects, which were also present in the patient's urine. She was occasionally positive for cannabinoids. She used to buy various novel psychoactive substances (NPSs) from the internet and used experimentally various substances freely made available to her by drug suppliers/dealers. She was unable to explain clearly why she was taking any of the identified NPS. She stated she was taking benzylglycinamide to calm her when smoking synthetic cannabinoids. While it appears that benzylglycinamide is not likely to constitute a novel drug of abuse, her polysubstance use exemplifies trends in NPS use patterns among the youths in the Western world and should alert mental health workers as to the possible dangers of such behavior and its reflection on social behavior and psychopathology.

Development of Hiccup in Male Patients Hospitalized in a Psychiatric Ward: Is it Specifically Related to the Aripiprazole-Benzodiazepine Combination?

OBJECTIVES: The aim of this study was to identify hiccup cases among patients hospitalized in a psychiatric ward and focus on their treatment, so to establish intervention risk. METHODS: We reviewed records of 354 consecutively admitted patients during the year 2013 to identify hiccup cases. RESULTS: Hiccup occurred in 7 patients on both aripiprazole and benzodiazepines and in one on delorazepam. No patient on aripiprazole alone developed hiccup. No patient on drugs other than aripiprazole or benzodiazepines developed hiccup. The symptom subsided in 3 cases upon discontinuing aripiprazole and in 5 cases after discontinuing the benzodiazepine (including the case on delorazepam alone); in 2 cases of persistent hiccup, the symptom resolved after adding the calcium channel blocker, pregabalin. All patients developing hiccup were male. There was a 70-fold increase in the risk for developing hiccup in the aripiprazole/benzodiazepine intake condition versus all other conditions, and it further increased if limiting to the male sex. LIMITATIONS: The retrospective nature of the study was its limitation. CONCLUSIONS: Hospitalized psychiatric patients on both aripiprazole and benzodiazepines may be at significant risk of hiccup. This clinical awareness could lead to antipsychotic and/or benzodiazepine discontinuation or switch or to the addition of calcium channel blocker inhibitors.

White matter microstructure in ultra-high risk and first episode schizophrenia: A prospective study.

There is increasing evidence of white matter (WM) pathology in schizophrenia, but its role at the very early stage of the disorder remains unclear. In an exploration of WM microstructure in ultra-high risk (UHR) subjects and first episode schizophrenia (FES), 34 FES, 27 UHR and 26 healthy control (HC) subjects underwent a magnetic resonance imaging (MRI) tract based spatial statistics (TBSS) investigation. Whole brain fractional anisotropy (FA), mean diffusivity (MD), radial (RD) and axial diffusivity (AD) values were extracted. UHR subjects who later developed psychosis showed lower FA compared with HC in the corpus callosum (CC), the left superior and inferior longitudinal fasciculus, the left inferior fronto-occipital fasciculs (IFO), and the forceps; RD was significantly higher in the CC, the forceps, the anterior thalamic radiation bilaterally, and the cingulum bundle. FES, compared to HC, showed a significant FA reduction of the CC, the superior and inferior longitudinal fasciculi bilaterally, the IFO bilaterally, the corona radiate bilaterally, and the forceps; while RD was found to be significantly increased in the left superior longitudinal fasciculus. UHR who later developed psychosis had WM abnormalities affecting brain pathways that are crucial for intra- and inter-hemispheric connections.

Neurocognition in schizophrenia: from prodrome to multi-episode illness.

Individuals with schizophrenia present a neuropsychological deficit throughout the course of the disorder. Few studies have addressed the progression of the deficit since the prodromal phase of the disorder. This investigation explored neurocognition in accordance with the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus recommendations. The aim of the study was to explore the presence of neurocognitive impairment in ultra-high-risk individuals and the stage of this impairment in samples at different phases of illness. Thirty-six individuals with a prodromal syndrome, 53 first-episode and 44 multi-episode schizophrenia patients were assessed to examine neuropsychological performance. ANCOVA analysis adjusted for possible confounder factors and planned contrasts with healthy controls were undertaken. The results revealed deficits in speed-of-processing, visual-learning and social-cognition in prodromal individuals, and of all other neuropsychological domains in both first-episode and multi-episode patients. Furthermore impairment was found in the first-episode and in the multi-episode group, respectively on working-memory and attention. Within the framework of the neurodevelopmental model of schizophrenia, our results suggest the presence of neuropsychological impairment before the onset of full-blown psychosis. Moreover, the deficits are larger in the more chronic groups, according to the theory of an ongoing neurodevelopmental alteration.

Facial emotion recognition impairment is related to disorganisation in multi-episode schizophrenia.

The present investigation explores the relationship between facial emotion recognition (FER) and symptom domains in three groups of schizophrenia spectrum patients (43 ultra-high-risk, 50 first episode and 44 multi-episode patients) in which the existence of FER impairment has already been demonstrated. Regression analysis showed that symptoms and FER impairment are related in multi-episode patients, regardless of the illness duration. We suggest that the link between symptoms and FER impairment is involved in the progression of the disease.

Response to intravenous antidepressant treatment by suicidal vs. nonsuicidal depressed patients.

BACKGROUND: As effects of suicidal status on antidepressant responses remain uncertain, we compared responses to treatment in suicidal and nonsuicidal depressed patients. METHODS: We evaluated treatment response and covariates in 82 depressed patients diagnosed with DSM-IV major depressive (n=50) or bipolar disorders (n=32) treated initially in a day-hospital for 2 weeks, followed by 4 weeks of outpatient treatment, using citalopram given intravenously and then orally, with or without a mood-stabilizer. Suicidal status was based on an intake score of > or = 3 on item-3 of the 17-item Hamilton Depression Rating Scale, verified by clinical assessment. Morbidity and clinical change were assessed with the remaining 16 items (HDRS(16)). RESULTS: Suicidal (n=31) and nonsuicidal subjects (n=51) were similar in baseline ratings of depressive symptom-severity but were depressed longer and more likely to abuse substances. Suicidal ratings improved by 36% during 6 weeks of treatment among initially suicidal patients, but other depressive symptoms (HDRS(16)) improved half as much as in nonsuicidal subjects (13.4 vs. 25.1 points), independent of diagnosis, initial illness-severity, and treatment, and half as many patients improved by > or = 20%. In multivariate modeling, only being suicidal predicted poor response. CONCLUSIONS: Being suicidal may limit response to treatment in depressed major affective disorder patients, independent of diagnosis or overall symptomatic severity.

Completed suicide in schizophrenia: evidence from a case-control study.

Suicide is the single major cause of death among patients with schizophrenia. Despite great efforts in the prevention of such deaths, suicide rates have remained alarming, pointing to the need for a better understanding of the phenomenon. The present sample comprised 20 male patients with schizophrenia who committed suicide and who were investigated retrospectively for a large number of characteristics. Controls were 20 living patients with schizophrenia. The results suggest that suicide attempts, hopelessness and self-devaluation were the three variables most strongly associated with completed suicide. However, a number of variables were identified which may constitute risk factors, some of which have not been identified in the past: agitation and motor restlessness (OR = 3.66; 95%CI = 0.95/14.02), self-devaluation (OR = 28.49; 95%CI = 3.15/257.40), hopelessness (OR = 51.00; 95%CI = 7.56-343.72), insomnia (OR = 12.66; 95%CI = 0.95/14.02), mental disintegration (OR = 3.66; 95%CI = 0.95/14.02), and suicide attempt (OR = 3.66; 95%CI = 1.40/114.41). Poor adherence to medications was also predictive of completed suicide in our sample of schizophrenia patients, primarily because the suicide victims showed very low adherence.

Quality of life and suicide risk in patients with diabetes mellitus.

BACKGROUND: Diabetes mellitus may have profound effects on physical and emotional health and quality of life. OBJECTIVE: The authors evaluated the perceived quality of life and its association with suicide risk in Italian patients with diabetes mellitus. METHOD: Authors evaluated 100 patients with type 1 and type 2 diabetes. Patients completed the Beck Hopelessness Scale, the Suicide Score Scale, the SF-36 Health Survey Questionnaire, and the General Self-Efficacy Scale. RESULTS: Patients with diabetes showed greater hopelessness and suicide ideation than internal-medicine outpatients. Poor quality of life was related to low self-efficacy, high hopelessness, and suicidality. A stepwise multiple regression found that polytherapy and older age predicted suicidality. CONCLUSION: It would be useful in future research to follow up patient samples to determine how many and which patients engage in fatal and nonfatal suicidal behavior and the relationship of these parameters with quality of life.

Suicide risk and exposure to mobbing.

The aim of this study was to study suicide risk in subjects exposed to mobbing, that is, systematic psychological harassment in the workplace. Such psychological harassment, unique to the workplace, threatens both the emotional well-being and professional ability of its victims. The items of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) that assess suicide risk were studied in 102 individuals who were exposed to mobbing. The results indicated that individuals exposed to mobbing had clear differences on the MMPI-2 from normative samples. In addition, those who appeared to be at risk for suicide differed in their scores from those not at risk. Implications for psychopathology and suicide preventions are discussed.

Suicide risk in depression and bipolar disorder: Do impulsiveness-aggressiveness and pharmacotherapy predict suicidal intent?

The aims of the present study were to examine clinical, personality, and sociodemographic predictors of suicide risk in a sample of inpatients affected by major affective disorders. The participants were 74 inpatients affected by major depressive disorder or bipolar disorder-I. Patients completed a semi-structured interview, the Beck Hopelessness Scale, the Aggression Questionnaire, the Barratt Impulsiveness Scale, and the Hamilton scales for depression and anxiety. Over 52% of the patients were high suicide risks. Those at risk reported more severe depressive-anxious symptomatology, more impulsivity and more hostility. Impulsivity, the use of antidepressants, anxiety/somatization, and the use of mood stabilizers (a negative predictor) resulted in accurate predicting of suicide intent. Impulsivity and antidepressant use were the strongest predictors even after controlling for several sociodemographic and clinical variables.

Temperament and personality dimensions in suicidal and nonsuicidal psychiatric inpatients.

BACKGROUND: Suicide is a serious public health problem. In the international literature there is evidence to support the notion that certain temperaments and personality traits are often associated with suicidal behavior. SAMPLING AND METHODS: In this study, 150 psychiatric inpatients were investigated using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire, the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Beck Hopelessness Scale and evaluated for suicide risk by means of the critical items of the Mini International Neuropsychiatric Interview. RESULTS: Statistical analysis, including logistic regression analysis and multiple regression analysis, showed that suicide risk contributed to the prediction of hopelessness. Among the temperaments, only the hyperthymic temperament, as a protective factor, and the dysthymic/cyclothymic/anxious temperament contributed significantly to the prediction of hopelessness. Irritable temperament and social introversion were predictive factors for suicidal risk. Hopelessness and depression were associated with higher suicidal behavior and ideation, but, unexpectedly, depression as measured by the MMPI did not contribute significantly to the multiple regressions. CONCLUSIONS: The present study indicated that, although suicidal psychiatric patients have MMPI-2 profiles in the pathological range, they exhibit several differences from nonsuicidal patients. Patients at risk of suicide have specific temperaments as well as personality and defense mechanism profiles. They are more socially introverted, depressed and psychasthenic, and use hysterical and schizoid mechanisms more often. Generalizability of the findings was limited by the small sample size and the mix of bipolar disorder I, bipolar disorder II, major depressive disorder and psychotic disorder patients.

Periventricular white matter hyperintensities as predictors of suicide attempts in bipolar disorders and unipolar depression.

The aim of this study was to evaluate whether deep white matter hyperintensities (DWMH) and periventricular white matter hyperintensities (PVH) are associated with suicidal behavior in patients with major affective disorders. Subjects were 99 consecutively admitted inpatients (42 men; 57 women; mean age: 46.5 years [SD=15.2; Min./Max.=19/79]) with a diagnosis of major affective disorder (bipolar disorder type I, bipolar disorder type-II and unipolar major depressive disorder). 44.4% of the participants had made at least one previous suicide attempt. T2-weighted brain magnetic resonance images were rated for the presence and extension of WMH using the modified Fazekas scale. Patients were interviewed for clinical data on average 5 days after admission. Bivariate analyses, corrected for multiple-testing, and logistic regression analysis were used to test the association between suicide attempts and clinical variables. Attempters and nonattempters differed only in the presence of PVH--the former were more likely to have PVH. The logistic regression indicated that the presence of PVH was robustly associated with suicidal behaviors after controlling for age (OR: 8.08). In conclusion, neuroimaging measures may be markers of risk for suicidal attempts in patients with major affective disorders.

Surviving the suicides of significant others: a case study.

Psychological pain has been reported to be major contributing factor for completed suicide, and classical suicidology based its wisdom on this construct. In this paper we report the case of a patient whose family experienced a high number of suicides apparently due to an escalation of psychological pain in the family members after the successive suicides. We also briefly discuss the problem of helping survivors after the suicide of loved one.