The effect of attention/information processing impairment of tardive dyskinesia and neuroleptics in chronic schizophrenics.

In this article we report the results of a test of the hypothesis that a form of attention/information processing dysfunction, attentional set impairment, is exacerbated by facial-oral tardive dyskinesia in schizophrenics. This hypothesis was tested in the context of a study that was aimed at determining whether the Reaction Time Crossover Effect, a well-established form of attentional set impairment in schizophrenia, was "affected" by neuroleptic treatment. Our results indicate that the crossover effect is resistant to modification by neuroleptics, but that it is exacerbated by facial-oral tardive dyskinesia. We speculate that neurophysiological mechanisms underlying tardive dyskinesia interact with or are similar to those underlying attentional set impairment.

Assessing need for extended psychiatric hospitalization.

The authors developed a set of rating scales to assess a wide range of variables believed by clinicians to influence the optimal length of hospital stay. They report the results of interrater reliability studies, a factor analysis of the scales, and a correlational study of the factors with actual length of stay. They describe the potential applications of the scales to clinical practice and research.

Effects of extended hospitalization: a one-year follow-up study.

The C. F. Menninger Memorial Hospital is conducting an ongoing follow-up study of the effects of extended hospitalization. The authors report key indicators of outcome at one year postdischarge for 110 patients hospitalized on extended care units for at least 180 days. Outcome is determined by postdischarge rates of rehospitalization, postdischarge suicide attempts, and occupational functioning at the time of the one-year follow-up interview. After comparing these areas with preadmission levels of symptomatology and functioning, the authors report significant improvement in each category at the time of follow-up.

Outcome at discharge for patients in an ongoing follow-up study of hospital treatment.

Methodological and practical difficulties have limited the growth of knowledge about outcome of psychiatric hospital treatment. The authors report on outcome at hospital discharge for 103 long-term and 93 short-term patients treated at the C. F. Menninger Memorial Hospital, part of an ongoing follow-up study of hospital treatment. Discharge outcome is based mainly on ratings of symptoms, global functioning, and therapeutic alliance as well as on patients' reports of satisfaction. At discharge both long- and short-term patients were found to have low levels of symptoms (based on the Brief Psychiatric Rating Scale) and a relatively adequate level of functioning (in the 51-to-60 range on the Global Assessment Scale) and to have been highly satisfied with treatment.

Relation of neuroleptic and anticholinergic medication to cognitive functions in schizophrenia.

In this article, we review research designed to examine the influence of neuroleptic and anticholinergic drugs on cognitive processes in schizophrenia. The review is motivated by the recognition that pharmacotherapy is an important factor in psychological research on schizophrenia, given that the great majority of patients studied in investigations of cognition receive both of these drugs. We find that neuroleptic treatment is associated with limited normalization on many psychological measures, whereas anticholinergics appear to disrupt some aspects of memory. Subject selection criteria, research designs, and drug measurement methods important in the evaluation of possible drug effects in psychological studies are discussed.

Skin-conductance orienting response in chronic schizophrenics: the role of neuroleptics.

The primary aim of this study was to determine whether there is an association between neuroleptic treatment and skin-conductance orienting response (SCOR) nonresponding in chronic schizophrenics. In a design adapted to this purpose, we were unable to demonstrate a relationship between neuroleptics and nonresponding. Although inability to prove the null hypothesis precludes a claim that neuroleptic treatment and SCOR nonresponding are unrelated, internal evidence and prior studies strongly suggest that such a dissociation exists in most chronic schizophrenic nonresponders. We also found stable nonspecific and toxic skin conductance activity differences between SCOR "responders" and "nonresponders" on three occasions of testing. We interpret our results as bearing on state and trait issues in chronic schizophrenics.

The effect of neuroleptics and tardive dyskinesia on smooth-pursuit eye movement in chronic schizophrenics.

We sought to determine whether such state-related factors as neuroleptic treatment and facio-oral tardive dyskinesia (TD) influence smooth-pursuit eye movement (SPEM) in chronic schizophrenics. The design involved 100 schizophrenics, 64 of whom showed "abnormal" eye tracking. Experimentally drug-withdrawn patients, some of whom were clinically relapsed, were compared with control patients who continued taking medication in prewithdrawal and postwithdrawal SPEM tests. All groups showed a slight worsening in eye-tracking performance on two postwithdrawal tests, but significant group-by-test session "interactions" were not demonstrable. We also determined that patients with TD tend to substitute large, nontracking saccades for SPEM to a significantly greater extent than nondyskinetic patients. Our findings strengthen the supposition that impaired SPEM is a trait in many schizophrenics but suggest that patients with TD be excluded in future studies of SPEM addressed to trait issues.

Topographic evoked potentials during backward masking in schizophrenics, patient controls and normal controls.

1. A backward masking task with simultaneous measurement of topographically mapped evoked potentials was performed by normal, schizophrenic, and patient control subjects. 2. Behavioral results replicated previous studies demonstrating schizophrenic deficit and to a lesser extent patient control deficit in this task. 3. Two competing theories of (A) defects in "gating" mechanisms or (B) failure in early stimulus "registration" processes were tested. 4. Topographical evoked response maps indicated a significant absence of a negative going wave in the 70-100 msec epoch in the schizophrenic group relative to both control groups. 5. As the 70-100 msec negativitity attenuation occurred during target presentation, and well before mask onset, it was concluded that schizophrenic deficit in this task consists of a failure in initial stimulus "registration" processes within the time allowed for stimulus availability. 6. Such defective mechanisms may be significant in the pathogenesis of schizophrenia.

Problems to anticipate in treating difficult patients in a long-term psychiatric hospital.

In a previous report, the authors identified four dimensions of patient pathology associated with treatment difficulty: withdrawn psychoticism, character pathology, violence-agitation and suicidal-depressed behavior. In a subsequent study, they linked these dimensions to patterns of countertransference. The present research extends the two prior reports by examining the relations of the patient pathology dimensions to staff members' dissatisfaction with four areas of treatment: interpersonal approaches, structure and control, quality of teamwork, and medication. The major findings are: withdrawn psychoticism primarily relates to dissatisfaction with interpersonal treatment approaches; character pathology entails dissatisfaction with the level of structure and control; violence-agitation poses particular problems for teamwork; and suicidal-depressed behavior is unrelated to dissatisfaction with any dimension of treatment. The authors propose that these various problems in treatment are, in part, mediated by patterns of countertransference which they described in the prior paper. These findings should help staff members to focus their attention on areas of treatment in which problems are bound to arise in work with different types of difficult patients.

An innovative approach to assessing outcome of long-term psychiatric hospitalization.

The failure of research on long-term hospital treatment to show consistent relationships between length of stay and treatment outcome may reflect a need for more refined measures to evaluate long-term treatment. The authors developed an individualized method of assessing improvement in patients' major areas of impairment over the course of treatment. Using the new approach and two more traditional methods, the authors evaluated the outcome of 37 discharged long-term patients of a private psychiatric hospital who had been rated at admission and discharge on 21 variables related to ego function; affective symptoms; risk of suicide, self-destructiveness, and violence; substance abuse; level of treatment alliance; and, at discharge only, on overall level of improvement. Although the traditional methods failed to show a correlation between length of stay and most of the variables, the individualized approach found that a longer hospital stay was related to greater improvement in areas of most impaired functioning.

Thought disorder in schizophrenia: cognitive and neuroscience approaches.

Research with schizophrenics is reviewed in the areas of the startle reflex, subject-initiated evoked potentials, and two-stimulus evoked potentials. A hypothesis of an early (pre-100 ms) information-processing deficit is posited and further refined by results presented from brain evoked potentials during a backward-masking experiment. The implications of these findings for the speech component of schizophrenic thought disorder are speculated upon, with specific reference to failures of temporal sequencing control that may underlie schizophrenic speech dysfunction and may be attributable to defective thalamic control. Recent neuroanatomical findings of abnormalities in the hippocampus and thalamus of schizophrenics are presented, and considered as likely contributors to the early information-processing deficits posited.

Episodic and residual thought pathology in chronic schizophrenics: effect of neuroleptics.

We sought to determine the effect of neuroleptic treatment on thought disorder in chronic schizophrenics, using the Thought Disorder Index (TDI). We were able to demonstrate that high levels of thought disorder are found in chronic schizophrenic and schizoaffective patients, while in both bipolar patients and normal controls thought pathology is minimal. Moreover, the TDI appears to be particularly well suited to the characterization of thought disorder in chronic schizophrenics. For total scores on the TDI, we were unable to demonstrate a significant reduction in thought pathology, although it was evident that thought disorder as reflected in the Conceptual Disorganization and Unusual Thought Content subscales of the Brief Psychiatric Rating Scale is significantly reduced by neuroleptics. In analyses of subscores of the TDI reflecting four levels of severity, we were able to show that more severe forms of thought pathology are normalized by neuroleptics, while less severe pathology is largely unaffected. Our results suggest that neuroleptic treatment reduces thought pathology associated with acute episodes, but that somewhat milder, though still disabling, residual thought pathology persists after clinical remission has been attained.

Relation of neuroleptic dose and tardive dyskinesia to attention, information-processing, and psychophysiology in medicated schizophrenics.

Relationships of neuroleptic dosage and tardive dyskinesia with measures of attentional, information-processing, and psychophysiological dysfunctions in medicated chronic schizophrenics were explored by correlational and stepwise multiple-regression analysis. High neuroleptic dosage was found to be associated with increased reaction time, reduced span of apprehension, low basal skin conductance level, and reduced skin conductance reactivity. Severe abnormal involuntary movements were associated with increased eye-tracking dysfunction, increased scanning eye-movement rate, increased reaction time, and reduced skin conductance reactivity. These findings led to the hypothesis that neuroleptic dosage and tardive dyskinesia may be sources of error variance in the measurement of attentional, information-processing, and psychophysiological functions in schizophrenics.

A research design to predict required length of psychiatric hospital stay.

It is often an important clinical task to predict how long a given patient will need to be hospitalized, but past research efforts to provide an empirical basis for such predictions have not been highly successful. The authors propose a conceptual model for predicting length of stay that goes beyond previous research; they not only include a range of traditionally employed patient characteristics but also take into account the nature of the treatment goals and the availability of post-hospital treatment resources. The model forms the basis for an objective prediction procedure which will be tested in a large-scale research project on long-term hospital treatment outcome.

Is eye tracking dysfunction specific to schizophrenia?

Based on eye tracking studies in psychiatric patients, normal controls, and first-degree relatives of patients, Holzman, Proctor, and Levy et al. (1974) state that eye tracking dysfunction (ETD) is specific to schizophrenia and may be a genetic marker of that disorder. A review of numerous subsequent studies, however, suggests that ETD is not specific to schizophrenia, but is restricted to functional psychosis. Evidence that ETD is a genetic marker of functional psychosis is, as yet, inconclusive.

Social dysfunction and treatment failure in schizophrenia.

Recent evaluation of a 20-year-old experimental ward resocialization program for chronic schizophrenics indicates that the general level of activity, much of it social, was disruptive to the psychological functioning of patients, particularly sicker ones. Antipsychotic drugs positively affected psychological functioning and also decreased social behavior. A review of other studies indicates that we are not unique in finding that intensive socioenvironmental therapies have adverse effects on schizophrenics. Furthermore, a wide range of studies indicates that schizophrenics are prone to avoid social interaction and show a decrement in functioning as the intensity of such interactions increases. Unfortunately, although various hypotheses seem feasible, little is known about the reasons for schizophrenics' social dysfunction and little research is presently being done. Given the recent findings that neuroleptic drug treatment by itself is insufficient to keep many patients out of the hospital and that those that stay in the community show an increase in withdrawal, the development of successful treatment programs for schizophrenia may hinge upon our learning more about the nature of and reasons for the schizophrenic's social dysfunction.