Preventing progression to first-episode psychosis in early initial prodromal states.

BACKGROUND: Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred. AIMS: To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS. METHOD: A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up. RESULTS: A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019). CONCLUSIONS: Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

Quality of life profiles and changes in the course of maintenance treatment among 1,015 patients with severe opioid dependence.

INTRODUCTION: Studies indicate that different areas of mental, physical, social and daily life functioning need to be considered in order to improve intervention outcomes in substance user patients. The aim of the study was to assess health-related quality of life (HRQOL) in patients diagnosed with opioid dependence as compared to healthy controls and patients diagnosed with depression and schizophrenia. METHODS: A total of 1,015 outpatients diagnosed with opioid dependence were investigated during 12 months of maintenance treatment. HRQOL (MSQoL), addiction (EUROP-ASI), and sociodemographic characteristics were assessed. RESULTS: HRQOL in opioid dependence improved significantly (p < .001), but was lower as compared to that of healthy controls and patients diagnosed with schizophrenia. HRQOL in opioid dependence comprises addiction-specific aspects, most importantly low material satisfaction, physical health, and social stability. CONCLUSIONS: HRQOL measurement provides valuable information for course and outcome in opioid dependence treatment.

Perceived parental rearing in subjects with obsessive-compulsive disorder and their siblings.

OBJECTIVE: Perceived parenting in patients suffering from obsessive-compulsive disorder (OCD) is examined. We attempted to overcome some methodological limitations of prior studies by taking age of onset, parental OCD and comorbid depression into consideration. In addition, we included data from unaffected siblings to corroborate information on parental rearing. METHOD: One hundred and twenty-two cases with OCD and 41 of their siblings as well as 59 healthy controls and 45 of their siblings completed the German short-version of the EMBU (FEE). RESULTS: Obsessive-compulsive disorder cases reported less parental warmth and more parental rejection and control. Further analyses indicated that parenting is also associated with OCD in cases with late onset and cases without parents affected by OCD. OCD cases with comorbid depression described their parents particularly negatively. Data from siblings indicated good validity of perceived parenting in OCD. CONCLUSION: This study provides further evidence for dysfunctional child rearing being relevant to the development of OCD and depression.

Reduced subjective quality of life in persons at risk for psychosis.

OBJECTIVE: Subjective quality of life (sQoL) and potentially contributing factors were investigated in individuals putatively in an early (EIPS) or late initial prodromal state (LIPS) and healthy controls (HC). METHOD: Participants comprised 58 EIPS individuals, 157 LIPS individuals and 87 HC individuals. sQoL was assessed together with locus of control (LoC), coping, demography and psychopathology. RESULTS: Putatively prodromal groups exhibited markedly lower sQoL than HC (all domains P < 0.00001). EIPS and LIPS individuals did not differ significantly. Depression was the most consistent explaining variable of sQoL in EIPS and LIPS individuals. In EIPS individuals, LoC emerged as an additional predictor. CONCLUSION: Individuals at risk for psychosis experienced a marked impairment of sQoL across all domains. This was evident even in the early state, showed no significant further deterioration during the late state and was predominantly explained by non-specific symptoms.

Impulsiveness in obsessive-compulsive disorder: results from a family study.

OBJECTIVE: Although obsessive-compulsive disorder (OCD) is usually conceptualized as an anxiety disorder some studies suggested it to be a deficit of impulse control. The purpose of this study was to assess impulsiveness in OCD families and compare it to control families. METHOD: Seventy cases and their 139 relatives were compared with 70 controls and their 134 relatives from a German family study on OCD (German Epidemiologic Network for OCD Studies). All subjects were interviewed and diagnosed according DSM-IV criteria and were administered the Barratt Impulsiveness Scale (BIS) and PADUA-Inventory to assess obsessive-compulsive symptoms. RESULTS: OCD subjects had significantly higher scores of cognitive impulsiveness. However, first-degree relatives of OCD cases and of controls had comparable BIS-11 scores. Significant associations of aggressive obsessions and checking with cognitive impulsiveness were found. CONCLUSION: OCD is a severe mental disorder that is characterized by a lack of cognitive inhibition. However, impulsiveness does not represent a familial trait in families of OCD subjects.

[Measuring fatigue in patients with multiple sclerosis with standardized methods in German speaking areas]. / Messbarkeit von Fatigue bei multipler Sklerose mithilfe standardisierter Methoden im deutschsprachigen Raum.

Fatigue describes the presence of a pronounced and advanced state of weariness. People with fatigue need more energy and it takes more effort to perform different activities than expected when compared to the patients disability. Fatigue can be observed in up to 92 % of patients suffering from multiple sclerosis. In the presented study, the German fatigue severity scale (dFSS) was established following the English "Fatigue Severity Scale". We enrolled 20 patients suffering from a primary relapsing multiple sclerosis and compared them to 20 healthy controls. Fatigue was detected if at least 4 points were reached in the dFSS. The dFSS demonstrated high validity and reliability. The dFSS is able to differentiate patients with fatigue from healthy controls. As consequence, the dFSS can be used to evaluate fatigue in German speaking individuals. The presented data demonstrated a good internal consistence. The scale is able to measure fatigue in an economic and rapid fashion. Therefore, it can be used in clinical situations for measuring fatigue in German speaking individuals.

Cognitive function remains unchanged after endarterectomy of unilateral internal carotid artery stenosis under local anaesthesia.

OBJECTIVE: To assess changes in cognitive function and affective state following carotid endarterectomy (CEA) for high-degree unilateral internal carotid artery stenosis. METHODS: In 33 patients, a CEA was performed under local anaesthesia for a high-grade unilateral stenosis of the internal carotid artery (group A). Twenty-five patients underwent surgery for peripheral arterial occlusive disease under regional anaesthesia served as controls (group B). Patients with neurological deficits due to previous strokes or dementia were excluded. Intelligence level was assessed preoperatively. Cognitive tests were applied preoperatively and postoperatively (3-5 days after surgery) and after 4 months follow-up. Confounding factors, including anxiety and depression, were checked through questionnaires and interviews. RESULTS: No perioperative neurological complication occurred following CEA. Patients in group A showed a significant postoperative deterioration only in one sub-test. There was no significant change in anxiety and depression during follow up. The control group B had no significant changes in cognitive test performance. Anxiety improved significantly postoperatively, but increased again at the end of the study. There was no significant difference between the groups over time. CONCLUSION: Cognitive function does not change following CEA of a unilateral internal carotid stenosis.

No effect of intravenous immunoglobulins on cytokine-producing lymphocytes in secondary progressive multiple sclerosis.

Intravenous immunoglobulins (IVIG) have been effective in reducing multiple sclerosis (MS) disease activity and improving disability scores. However, the mechanism by which this beneficial effect is achieved remains unclear. An effect of IVIG on pro- and anti-inflammatory cytokines which are thought to play a role in the disease process - has been postulated in a number of animal and ex vivo studies. Hence, we performed a study on 34 patients with secondary progressive (SP) MS being treated with monthly IVIG or placebo for two years according to the protocol of the ESIMS study. Clinical outcome measures and cytokine production (interferon gamma, tumour necrosis factor alpha, interleukin-4 and -10) were recorded in all patients and compared with respect to the treatment group. Against our expectations, IVIG did not reduce the relapse rate or the progression of disability or cytokine production. Our data argue against an enduring immunomodulating effect of IVIG, at least in SPMS.

A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in acute patients with schizophrenia: outcome at 24 months.

OBJECTIVE: We compared the effects of a brief group cognitive-behavioural therapy (CBT) and a group psychoeducational (PE) programme in acute patients with schizophrenia 2 years after treatment. At 6-month follow-up, the CBT group had shown significantly less re-hospitalization rates and on a descriptive level higher compliance with medication. METHOD: Eighty-eight in-patients with acute schizophrenia were randomized to receive a therapy envelope of 8 weeks including either 16 sessions of CBT or eight sessions of PE. RESULTS: From the initial sample, 43 patients (48.9%) completed the 24-month follow-up. There were no significant group differences regarding re-admission, symptoms or compliance with medication. However, on a descriptive level patients who received CBT on average experienced 21.8% less re-hospitalizations, 71 days less in hospital and higher compliance ratings at the 24-month follow-up. CONCLUSION: The significant advantages of CBT at short-term follow-up were lost at long-term follow-up. However, on a descriptive level some advantages for CBT remained after 2 years.

[Pathways to care: help-seeking behavior in first-episode psychosis]. / Wege in die Behandlung: Hilfesuchverhalten schizophrener Ersterkrankter.

Several studies on first episode schizophrenia suggest that a longer duration of untreated psychosis (DUP) results in poorer clinical outcome. The same is expected for the duration of untreated illness (DUI). It is therefore important to expose people at risk of schizophrenia to adequate treatment early on. The improvement of pathways to adequate treatment within the health care system might well be helpful. Therefore, an analysis of the pathways to care is necessary. Thus, in this present study 80 in-patients with first episode psychosis were investigated using the semi-structured interview IRAOS ("Interview for the Retrospective Assessment of the Onset of Schizophrenia") and data about the pathways to care before psychiatric admission were collected. The results indicate that patients contact on average three carers. Contact to a psychiatrist or a psychotherapist was only made two and a half years after onset of illness; general practitioners were only contacted after more than five years. However, there was a significant time lapse between first contact to psychiatrist/ psychotherapist and psychiatric admission. Only 31 % of patients sought help in the prodromal phase of the illness. Two strategies for a public campaign can be derived from these results: firstly, a public awareness campaign has to be implemented to shorten the interval from onset of illness to first help-seeking behaviour and secondly, professionals need to have more knowledge and better awareness of prodromal signs in order to reduce the time between diagnosis and adequate treatment.

A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia.

OBJECTIVE: Although the efficacy of cognitive-behavioural therapy (CBT) in schizophrenia has been established in a number of studies, no information is available on the differential efficacy of CBT in comparison with patient psychoeducation (PE). METHOD: Eighty-eight in-patients with schizophrenia were randomized to receive a therapy envelope of 8 weeks including either 16 sessions group CBT or eight [correction] sessions group PE treatment. Assessments took place at baseline, post-treatment and 6 month follow-up. RESULTS: Patients, who received CBT were significantly less rehospitalized than patients in the PE group during the follow-up period. On a descriptive level, CBT resulted in lower relapse rates and higher compliance ratings at post-treatment and at follow-up than PE. Both forms of therapy led to significant psychopathological improvement at post-treatment and at follow-up. CONCLUSION: The brief group CBT intervention showed some superiority to the PE programme, which could be of considerable clinical and economical importance.

Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures.

OBJECTIVES: To determine whether patients with psychogenic non-epileptic seizures (PNES) have evidence of maladaptive personality, and whether they have a single or several different typical pathological personality profiles. METHODS: Patients were recruited from the department of epileptology, Bonn, Germany. In all, 85 patients with PNES and 63 with epilepsy completed a postal questionnaire including the dimensional assessment of personality pathology - basic questionnaire (DAPP-BQ). The DAPP-BQ was also completed by 100 healthy volunteers. The groups were compared and the PNES group was subjected to cluster analysis. RESULTS: Patients with PNES had a greater degree of personality abnormality than clinical and non-clinical controls. There were several clusters of personality pathology. The profile of the largest cluster (n = 43) resembled that found in borderline personality disorder, that of the second largest (n = 37) was characterised by an overly controlled personality, that of the third (n = 4) was similar to the profile in avoidant personality disorder. Outcome differed between clusters. CONCLUSIONS: Maladaptive personality is common in patients with PNES. PNES are associated with several distinct profiles of pathological personality. This is relevant because outcome differed between profiles.

[Early course of illness in first episode schizophrenia with long duration of untreated illness - a comparative study]. / Frühverlauf schizophrener Ersterkrankungen mit langer Dauer der unbehandelten Erkrankung - eine vergleichende Studie.

When a long duration of untreated illness (DUI) is correlated with an unfavourable progression of schizophrenia in the same way as that of a long duration of untreated psychosis (DUP), the characteristics of patients with a long DUI are of particular interest for early recognition and early intervention programmes. With this background, demographic data and early symptoms were collected from 82 first time in-patients with schizophrenia using the IRAOS (Interview for the Retrospective Assessment of the Onset of Schizophrenia). In the total sample, the average DUI was almost 5.9 years. On the basis of the DUI median (5.2 yrs), the random sample was divided into two groups: one with long (n = 41) and one with short (n = 41) DUI. When comparing both groups in terms of socio-demographic data, no significant differences could be found (with the exception of age at first admission: 28 - 32 yrs). On a psychopathological level, patients with long DUI were prone to depressive moods, anxiety, compulsive symptoms and showed early signs of disturbances in bodily perception. An educational campaign should sensitize both employees working in primary care and experts who diagnose and treat psychological illnesses, to the fact that these symptoms could point to a prodrome even when the patient has passed the typical age of being at risk from schizophrenia.

Low interleukin-10 production is associated with higher disability and MRI lesion load in secondary progressive multiple sclerosis.

Abnormalities in T-cell-derived cytokine production are a well-known phenomenon in multiple sclerosis (MS). An association between disability and the production of interferon gamma has been demonstrated recently. The present study investigated associations between disability, cytokine production in stimulated blood lymphocytes and magnetic resonance imaging data in 37 patients with the secondary progressive course in the stable phase of the disease. Patients with high interleukin-10 (IL-10) production had significantly lower disability scores (p=0.009) and lower T2 lesion load (p=0.03). Interleukin-10 might not only play a role in the pathological process of multiple sclerosis but has an impact on disease outcome as well.

[Subjective quality of life. Critical look at a modern construct]. / Subjektive Lebensqualität. Kritische Betrachtung eines modernen Konstrukts.

The scientific usefulness of the popular construct "subjective quality of life"(QoL) is critically investigated in a psychiatric context. Six problem areas were chosen: QoL is rooted in different scientific traditions (area I) and characterized by definitional uncertainty (area II). It is conceptually and empirically confounded with several other psychosocial constructs and lacks clear causal specificity (area III). The operationalization of QoL comprises a great number of heterogeneous instruments (area IV), and there are additional problems created by methodological and statistical issues (area V).Finally, there is no integrative, theoretical model that can be tested empirically in a systematic way (area VI). These problems support the conclusion that subjective QoL is a preparadigmatic or scientifically immature concept which should be applied with caution and under strict methodological standards when used to answer clinically relevant questions.

Low interferon gamma producers are better treatment responders: a two-year follow-up of interferon beta-treated multiple sclerosis patients.

As response to interferon beta (IFNB) treatment, a 50% reduction of the mean relapse rate compared to pretreatment values has been reported. However, individual responses vary considerably, ranging from no reduction in exacerbation frequency to complete suppression of relapses for at least two years. At the moment, valid predictors for IFNB response are lacking. Here we present a prospective evaluation of 33 patients with primary relapsing multiple sclerosis who were followed for two years of IFNB treatment A low interferon gamma (IFG) production before treatment predicted a two-year term without exacerbations in 68.8% of cases correctly, whereas a high pretreatment IFG production implied the risk of at least one relapse in the first two years in 70.6%. These preliminary results encourage further evaluation of IFG as predictor of an IFNB treatment response.

[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.

Remembering or knowing: electrophysiological evidence for an episodic memory deficit in schizophrenia.

BACKGROUND: In schizophrenia, impaired conscious retrieval of past events and facts may represent a selective cognitive deficit of declarative memory against a background of a generalized neuropsychological impairment. We aimed to disentangle the neural subprocesses leading to this deficit applying the 'Remember/Know procedure'. METHOD: Event-related potentials (ERPs) were recorded as 14 schizophrenic patients and 14 controls recognized an equal mixture of previously presented old and new words. For recognized old words, participants were required to judge whether recognition was associated with recollection ('Remember') or familiarity ('Know'), either reflecting episodic or semantic memory. RESULTS: Patients showed a lack of 'Remember responses', which led to more opportunities to make 'Know responses'. ERPs for 'Remember' compared to 'New responses' differed consistently in controls over left temporo-parietal and right frontal electrode sites. Although schizophrenic patients showed the same topography for this Remember old/new effect, it was apparent over temporoparietal sites for only 800 ms and over right frontal sites for 1100 ms post-stimulus. For controls, the Know old/new effect was elicited over temporo-parietal sites between 500 and 800 ms. For patients, it showed a widespread maximum over frontal sites between 500 and 1100 ms. CONCLUSIONS: The shorter time course of the left temporo-parietal Remember old/new effect suggests that the patients' episodic memory impairment was possibly mediated by a dysfunction of the mediotemporal regions. The more widespread frontal Know old/new effect in the patients suggests that the prefrontly mediated processes associated with retrieval of semantic memory may be enhanced compensatorily.