The varying impact of type, timing and frequency of exposure to childhood adversity on its association with adult psychotic disorder

BACKGROUND: Childhood adversity has been associated with onset of psychosis in adulthood but these studies have used only general definitions of this environmental risk indicator. Therefore, we sought to explore the prevalence of more specific adverse childhood experiences amongst those with and without psychotic disorders using detailed assessments in a large epidemiological case-control sample (AESOP). METHOD: Data were collected on 182 first-presentation psychosis cases and 246 geographically matched controls in two UK centres. Information relating to the timing and frequency of exposure to different types of childhood adversity (neglect, antipathy, physical and sexual abuse, local authority care, disrupted living arrangements and lack of supportive figure) was obtained using the Childhood Experience of Care and Abuse Questionnaire. RESULTS: Psychosis cases were three times more likely to report severe physical abuse from the mother that commenced prior to 12 years of age, even after adjustment for other significant forms of adversity and demographic confounders. A non-significant trend was also evident for greater prevalence of reported severe maternal antipathy amongst those with psychosis. Associations with maternal neglect and childhood sexual abuse disappeared after adjusting for maternal physical abuse and antipathy. Paternal maltreatment and other forms of adversity were not associated with psychosis nor was there evidence of a dose-response effect. CONCLUSIONS: These findings suggest that only specific adverse childhood experiences are associated with psychotic disorders and only in a minority of cases. If replicated, this greater precision will ensure that research into the mechanisms underlying the pathway from childhood adversity to psychosis is more fruitful.

Differing patterns of brain structural abnormalities between black and white patients with their first episode of psychosis

BACKGROUND: African-Caribbean and black African people living in the UK are reported to have a higher incidence of diagnosed psychosis compared with white British people. It has been argued that this may be a consequence of misdiagnosis. If this is true they might be less likely to show the patterns of structural brain abnormalities reported in white British patients. The aim of this study therefore was to investigate whether there are differences in the prevalence of structural brain abnormalities in white and black first-episode psychosis patients. METHOD: We obtained dual-echo (proton density/T2-weighted) images from a sample of 75 first-episode psychosis patients and 68 healthy controls. We used high resolution magnetic resonance imaging and voxel-based methods of image analysis. Two separate analyses were conducted: (1) 34 white British patients were compared with 33 white British controls; (2) 41 African-Caribbean and black African patients were compared with 35 African-Caribbean and black African controls. RESULTS: White British patients and African-Caribbean/black African patients had ventricular enlargement and increased lenticular nucleus volume compared with their respective ethnic controls. The African-Caribbean/black African patients also showed reduced global grey matter and increased lingual gyrus grey-matter volume. The white British patients had no regional or global grey-matter loss compared with their normal ethnic counterparts but showed increased grey matter in the left superior temporal lobe and right parahippocampal gyrus. CONCLUSIONS: We found no evidence in support of our hypothesis. Indeed, the finding of reduced global grey-matter volume in the African-Caribbean/black African patients but not in the white British patients was contrary to our prediction.

Migration, ethnicity, and psychosis: toward a sociodevelopmental model

There is consistent and strong evidence that the incidence of all psychoses is higher in many migrant and minority ethnic populations in a number of countries. The reasons for this are, however, unclear and a wide range of explanations have been proposed, from genetic to neurodevelopmental to psychosocial. In this article, we describe and evaluate the available evidence for and against each of these. What this shows is that: (1) there are few studies that have directly investigated specific risk factors in migrant and minority ethnic populations, with often only 1 or 2 studies of any relevance to specific explanations and (2) what limited research there has been tends to implicate a diverse range of social factors (including childhood separation from parents, discrimination and, at an area level, ethnic density) as being of potential importance. In an attempt to synthesize these disparate findings and provide a basis for future research, we go on to propose an integrated model--of a sociodevelopmental pathway to psychosis--to account for the reported high rates in migrant and minority ethnic populations. Aspects of this model will be directly tested in a new Europe-wide incidence and case-control study that we will conduct over the next 3 years, as part of the European Network of National Schizophrenia Networks studying Gene-Environment Interactions programme.

Letter to the editor: prevention is better than cure: a reply to McKenzie, March et al. and Selten & Cantor-Graae

We are grateful to the commentators for their constructive observations on our review. We agree with Kwame McKenzie (2009) that consensus needs to be built ; the key point we attempted to make is that, to gain such a consensus, the problem of high rates of psychosis in migrant and minority ethnic populations needs to be de-coupled from the no less important issue of service provision for minority ethnic patients. In the same way that improving customer services for insurance claimants following an accident is irrelevant to reducing the rate at which such accidents occur, so reforming mental health services (important as this no doubt is) will have no impact on population rates of disorder.

Neurological abnormalities and cognitive ability in first-episode psychosis.

BACKGROUND: It remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis. AIMS: To investigate whether an excess of neurological soft signs is independent of diagnosis (schizophrenia v. affective psychosis) and cognitive ability (IQ). METHOD: Evaluation of types of neurological soft signs in a prospective cohort of all individuals presenting with psychoses over 2 years (n=310), and in a control group from the general population (n=239). RESULTS: Primary (P<0.001), motor coordination (P<0.001), and motor sequencing (P<0.001) sign scores were significantly higher in people with any psychosis than in the control group. However, only primary and motor coordination scores remained higher when individuals with psychosis and controls were matched for premorbid and current IQ. CONCLUSIONS: Higher rates of primary and motor coordination signs are not associated with lower cognitive ability, and are specific to the presence of psychosis.

Perceptions of disadvantage, ethnicity and psychosis.

BACKGROUND: People from Black ethnic groups (African-Caribbean and Black African) are more prone to develop psychosis in Western countries. This excess might be explained by perceptions of disadvantage. AIMS: To investigate whether the higher incidence of psychosis in Black people is mediated by perceptions of disadvantage. METHOD: A population-based incidence and case-control study of first-episode psychosis (Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP)). A total of 482 participants answered questions about perceived disadvantage. RESULTS: Black ethnic groups had a higher incidence of psychosis (OR= 4.7, 95 per cent CI 3.1-7.2). After controlling for religious affiliation, social class and unemployment, the association of ethnicity with psychosis was attenuated (OR=3.0, 95 per cent CI 1.6-5.4) by perceptions of disadvantage. Participants in the Black non-psychosis group often attributed their disadvantage to racism, whereas Black people in the psychosis group attributed it to their own situation. CONCLUSIONS: Perceived disadvantage is partly associated with the excess of psychosis among Black people living in the UK. This may have implications for primary prevention.

Grey matter abnormalities in first-episode schizophrenia and affective psychosis.

BACKGROUND: Grey matter and other structural brain abnormalities are consistently reported in first-onset schizophrenia, but less is known about the extent of neuroanatomical changes in first-onset affective psychosis. AIMS: To determine which brain abnormalities are specific to (a) schizophrenia and (b) affective psychosis. METHOD: We obtained dual-echo (proton density/T2-weighted) magnetic resonance images and carried out voxel-based analysis on the images of 73 patients with first-episode psychosis (schizophrenia n=44, affective psychosis n=29) and 58 healthy controls. RESULTS: Both patients with schizophrenia and patients with affective psychosis had enlarged lateral and third ventricle volumes. Regional cortical grey matter reductions (including bilateral anterior cingulate gyrus, left insula and left fusiform gyrus) were evident in affective psychosis but not in schizophrenia, although patients with schizophrenia displayed decreased hippocampal grey matter and increased striatal grey matter at a more liberal statistical threshold. CONCLUSIONS: Both schizophrenia and affective psychosis are associated with volumetric abnormalities at the onset of frank psychosis, with some of these evident in common brain areas.

Grey matter correlates of minor physical anomalies in the AESOP first-episode psychosis study

BACKGROUND: Minor physical anomaliesare more prevalent among people withpsychosis. This supports aneurodevelopmental aetiology forpsychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association. AIMS: To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis. METHOD: Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients. RESULTS: The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus. CONCLUSIONS: Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regionalgrey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Urban environment and schizophrenia

Selten et al (2005) cite two reasons for the increased risk of schizophrenia in Surinamese immigrants to The Netherlands. These are an increased base rate in the Surinamese population and exposure to an urban competitive Dutch society. These findings are of particular interest to researchers in Trinidad and Tobago because both countries share a similar mix of African and East Indian population and historically were simultaneously but independently developed by British and Dutch colonisers.

Different effects of typical and atypical antipsychotics on grey matter in first episode psychosis: the AESOP study

Typical antipsychotic drugs act on the dopaminergic system, blocking the dopamine type 2 (D2) receptors. Atypical antipsychotics have lower affinity and occupancy for the dopaminergic receptors, and a high degree of occupancy of the serotoninergic receptors 5-HT2A. Whether these different pharmacological actions produce different effects on brain structure remains unclear. We explored the effects of different types of antipsychotic treatment on brain structure in an epidemiologically based, nonrandomized sample of patients at the first psychotic episode. Subjects were recruited as part of a large epidemiological study (’SOP: aetiology and ethnicity in schizophrenia and other psychoses). We evaluated 22 drug-free patients, 32 on treatment with typical antipsychotics and 30 with atypical antipsychotics. We used high-resolution MRI and voxel-based methods of image analysis. The MRI analysis suggested that both typical and atypical antipsychotics are associated with brain changes. However, typicals seem to affect more extensively the basal ganglia (enlargement of the putamen) and cortical areas (reductions of lobulus paracentralis, anterior cingulate gyrus, superior and medial frontal gyri, superior and middle temporal gyri, insula, and precuneus), while atypical antipsychotics seem particularly associated with enlargement of the thalami. These changes are likely to reflect the effect of antipsychotics on the brain, as there were no differences in duration of illness, total symptoms scores, and length of treatment among the groups. In conclusion, we would like to suggest that even after short-term treatment, typical and atypical antipsychotics may affect brain structure differently.

Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission.

Background Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African–Caribbean and Black African patients with a psychotic illness. Aims To establish whether African–Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres. Method All patients with a firstepisode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (ÆSOP)study. For this analysis we included all White British, other White, African–Caribbean and Black African patients from the ÆSOP sampling frame. Clinical, socio-demographic and pathways to care data were collected frompatients, relatives and case notes. Results African–Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African–Caribbean men were the most likely to be compulsorily admitted. Conclusions These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African–Caribbean and Black African patients.

The structural brain correlates of neurological soft signs in AESOP first-episode psychoses study

Patients with schizophrenia and related psychoses have an excess of minor neurological abnormalities (neurological soft signs of unclear neuropathological origin. These include poor motor coordination, sensory perceptual difficulties and difficulties in sequencing complex motor tasks. Neurological soft signs seem not to reflect primary tract or nuclear pathology. It still has to be established whether neurological soft signs result from specific or diffuse brain structural abnormalities. Studying their anatomical correlates can provide not only a better understanding of the aetiopathogenesis of soft signs, but also of the pathophysiology of schizophrenia. Suprisingly few studies have investigated the brain correlates of neurological soft signs. In the present study, we investigated the relationship between brain structure and neurological soft signs in an epidemiologically based sample of 77 first-episode psychosis patients. We used the Neurological Evaluation Scale for neurological assessment and high-resolution MRI and voxel based methods of image analysis to investigate brain structure. Higher rates of soft neurological signs (both motor and sensory) were associated with a reduction of grey matter volume of subcortical structures (putamen, globus pallidus and thalamus). Signs of sensory integration deficits were additionally associated with volume reduction in the cerebral cortex, including the precentral, superior and middle temporal, and lingual gyri. Neurological soft signs and their associated brain changes were independent of antipsychotic exposure. We conclude that neurological soft signs are associated with regional grey matter volume changes and that they may represent a clinical sign of the perturbed cortical-subcortical connectivity that putatively underlies psychotic disorders(AU)

Delusional parasitosis [abstract]

Delusional parasitosis is a rare psychiatric syndrome in which the patient believes that he/she is infested with parasites despite clear evidence to the contrary. It was first described in the literature about 100 years ago when it was referred to as psychogenic parasitosis. It can occur in the form of a delusional disorder of the somatic type (DSM IV) but it has also been reported in schizophrenia, affective or organic psychosis or induced psychosis. Patients with delusional parasitosis generally think that mites, lice or other insects have invaded their skin and most frequently seek treatment from dermatologists or family practitioners. It is a chronic disorder that may occur at any age but is more common in the elderly, particularly in females. The patient may try to pick the parasites out of the skin causing cutaneous lesions. Treatment is based on antipsychotic agents, psychotherapy and cooperation between dermatologist and psychiatrist. A case of delusional disorder of the somatic type (DSM IV) in a 55-year-old male is described. The patient sought medical attention because he strongly believed that his skin was infested with mites for three years. He tried to pick mites out of the skin of his face, neck, abdomen and back and this caused severe keloid formation. He was first seen by a dermatologist whose clinical and laboratory investigations for parasitic infestations were negative. After investigation, the patient was referred to the psychiatrist. Haloperidol was prescribed and there was good response to antipsychotic treatment. The delusional symptoms improved over the first three months and then a full recovery was observed. The patient maintained the recovery at one-year follow-up. (AU)

Utilization of liaison psychiatric services in a general hospital in Jamaica [abstract]

OBJECTIVE: To identify the pattern and characteristics of Liaison Psychiatry refferals in the University Hospital of the West Indies over a six-month period. METHOD: A prospective cohort analysis was conducted on patients referred to the Liaison Psychiatry service between November 28, 2000 and May 28, 2001. Clinical and sociodemographic data were gathered by individual interviews and mental status examination and a DSM IV diagnosis made. RESULTS: Fifty-nine patients were referred with 28 (47.5 percent) males, and with a mean ñ Standard Deviation age of 39.42 ñ 15.92 years. Significantly more patients were referred from the medical wards (37, 62.5 percent) than from the surgical wards (14, 23.7 percent) or the gynaecological wards (8, 13.6 percent) (x2= 16.803, 2df, p<0.005). The main reason for referral was "strange behaviour" (31, 52.5 percent) and depression (13, 22 percent). There was no statistically significant difference between the referring wards and the reason for referral or diagnostic pattern. An equal number of patients were diagnosed with a psychotic disorder and unipolar depressive disorder (33.9 percent each). CONCLUSION: The medical wards of the University Hospital of the West Indies are the main agents of referral to the Liaison Psychiatric service with the majority of patients presenting with the majority of patients unipolar depressive or psychotic disorders. (AU)

Dual diagnosis among patients admitted to acute inpatient psychiatric treatment settings in two hospitals in Kingston, Jamaica, 1998-1999

A systematic sample of 174 psychiatric patients who were admitted to two urban acute inpatient psychiatric units between November 1998 and January 1999 was analyzed to determine the prevalence and characteristics of patients with dual diagnosis and to compare those patients with other patients without dual diagnosis. The diagnoses were ascertained with the Structured Clinical Interview for DSM-IV. 100 patients were from Bellevue Hospital and 74 from the University Hospital of the West Indies. The prevalence of dual diagnosis was 32 percent at Bellevue Hospital and 20 percent at University Hospital. Among those with dual diagnosis, schizophrenia and other psychoses (68 percent) was found to be the commonest axis I group disorder, followed by bipolar disorder (17 percent) and major depression (11 percent). Eight-nine percent of patients seen with dual diagnosis had cannabis related diagnosis. Dual diagnosis was more common among male patients (42/47, p<0.001) than among females. When compared to patients who did not have dual diagnosis, these men were found to be younger, in the age range 20-39 years (35/47). Such comparison, also showed that dually diagnosed patients were more likely to have had a previous or current criminal record with odds ratios of 3.67 and 7.44 respectively. The prevalence rates of dual diagnosis in this study are similar to those seen in other countries. Although there were some characterisitcs of the dually diagnosed patients which were similar to that found in studies done in various countries there were few differences. Although not a direct finding of this study, it has been established by previous studies that the fact of having dual diagnosis increases the likelihood of difficulties in diagnosis and treatment. This is further compounded by the absence in Jamaica of any programme to adequately treat these patients. To better inform such treatment planning, future research on dual diagnosis should utilize diverse clinical and functioning measures to make a more detailed needs assessment of these patients (AU)

Preferences for same race and same sex mental health workers in patients with diagnoses of psychotic illness

One hundred and forty nine patients (35 British, 114 non-white or non-British) with at least a two year history of psychotic illness, were recruited into a project designed to compare different levels of community care interventions. At recruitment into the study patients were allocated a case manager. Twelve months after recruitment patients were asked whether they had a preference for same race case managers and same race psychiatrists. Patients were also asked whether they had a preference for same sex case managers and same sex psychiatrists. Results indicate that 25.3 percent of the white British group have a preference for same race case managers, and 25.8 percent of the non-white or non-British group have a preference for same race case manager. When the non-white or non-British group is broken down it appears that second generation African-Caribbean patients are more likely than other ethnic groups to express a preference for same race case manager (p=.046). Results also indicate that 25 percent of the non-white or non-British sample have a preference for same race psychiatrist, this however, did not reach statistical significance. Although there was a trend for patients to express a preference for female case managers, this also did not reach statistical significance. Results will be discussed in terms of implications for service provision.(AU)

African Caribbean men remanded to Brixton prison: psychiatric and forensic characteristics and outcome of final court appearance

AIMS: This study aims to examine the influence of ethnic origin on the range of diagnoses, past psychiatric and forensic contacts, and outcome of final court appearance in a random sample of men remanded in Brixton prison health care centre for a psychiatric assessment. METHOD: 277 men were randomly sampled from all men to HMP Brixton and referred to prison health care centres for a psychiatric assessment over a one year period. Men were interviewed immediately after remand to establish their socio-demographic profiles, their psychiatric diagnoses, alcohol and substance misuse histories, criminality, seriousness of index offence and violence involved in their index offence, past psychiatric and forensic contacts and outcome after court appearance. CONCLUSIONS: In this sample, a greater percentage of black men who were remanded in custody had a diagnoses of schizophrenia. They were remanded despite more stable housing and fewer criminal convictions than the white group. Custodial remands could be avoided if community services (psychiatric diversion) were especially sensitive to the needs of black men with severe mental illness.(AU)

Life events and perceptions of racism in patients with diagnoses of psychotic illness

One hundred and forty nine patients (35 white British, 114 non-white or non British) with at least a two year history of psychotic illness, were recruited into a project designed to compare different levels of community care interventions. Patients were interviewed at recruitment into the study (baseline), 12 months later (Year 1) and 24 months after recruitment (Year 2). All patients were administered a Racial Life Event Questionnaire (RLEQ) as part of their assessment. The RLEQ lists 72 events divided into twelve sections covering different areas of life, eg. financial, health, employment. Each event was read aloud to the patient and s/he was asked to indicate whether they had experienced the event in the last three months. At the end of each section if the patients had responded positively to an event having occurred, they were asked whether they believed their ethnicity played a part in the occurrence of the event, ie. whether the event happened because of racial prejudice or discrimination. Results indicate that at baseline non-white and non-British patients believed assault, and housing events were significantly related to racial prejudice and at Year 1 assault and financial events were significantly related to racial prejudices. At Year 2 patients were asked whether "generally speaking" they believed members of their ethnic group were discriminated against and likely to have problems in the areas covered. Results indicate that non-white or non-British patients believe people from their own ethnic group are likely to be discriminated against in the areas of finance, assault, health, housing and legal events. (AU)

Is it necessary to distinguish between first and second generation African-Caribbean populaton in psychiatric research?

In attempting to identify factors responsible for the onset, course and prognosis of an illness, it is necessary to identify differences between generations in order to separate the effects of heritability and environment. Ethnicity and culture can also be examined in this way so that changes in culture occasioned by changes in environment can be assessed in terms of their impact on illness. In our work on the family history of psychoses among the African-Caribbean population in Britain we have found that for schrizophrenia, the relatives of first generation (those born in the Caribbean) and white psychotic patients share similiar risks while the risk is markedly increase in the relatives, particularly siblings of the second generation (those born in Britain to Caribbean parents) psychotic patients. For affective psychoses, we have found that the risk in the relatives of the first generation patients is significantly less than for both the white and the second generation relatives. These differences would have been much less noticeable if the separation between first and second generation patients had not been undertaken and would have been more difficult to interpret. Our findings do suggest that there are factors acting on the second generation making them more susceptible than their first generation counterparts to psychotic illness. This therefore diminishes the likelihood that the increased risk of illness in the second generation is due to a genetic effect and is much more likely to be mediated by some selective environmental effects acting either specifically on those families already afflicted by the disease or more generally on the entire second generation population.(AU)

A study of the ethnicity and the aetiology of schizophrenia - background and objectives

High rates of schizophrenia have been repeatedly reported among the African-Caribbean population in Britain. There has been no satisfactory explanation for these increased rates and while migrants in general are thought to be at increased risk, the incidence of schizophrenia is especially raised among African-Caribbean population that was born in Britain (second generation). Preliminary data from the Caribbean also suggest that there is a specific pathological process occuring in Britain. The available evidence in Britain also suggest that there are environmental factors which are selectively affecting the African-Caribbean population in Britain that are making them more vulnerable to schizophrenia. The study of high risk groups can be very instrumental in the elucidation of the aetiology of disease and therefore the study of this population may shed light on the aetiology of schizophrenia as a whole. In addition, this increased incidence of schizopherenia places a heavy demand both on the families of an already disadvantaged group as well as on the psychiatric services, particularly in the inner cities where the majority of African Caribbean people live in Britain. An understanding of the determinants of this increased risk of schizophrenia would lead to appropriate intervention strategies especially in the areas of prevention and provision of effective care. The study will be a population based case control study of the first contact schizophrenia in African-Caribbeans and the remaining population in three British centres. The research hypotheses are that the African-Caribbeans psychotic patients will show more evidence of risk increasing social factors, in particular adverse life events and a marked discrepancy between expectations and achievement. Their siblings will also show a high risk for psychosis suggesting that certain families are more susceptible to the social adversity associated with migration. The study will combine two strategies; the first to determine the absolute risk of the disorder, and the other to identify the risk factors which mediate the onset and course of the illness. We will also carry out a one year outcome study to examine the needs for mental health care in the African-Caribbean population and the extent to which treatment is appropriate.(AU)