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.

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.

Factorial structure of the German version of the dimensional assessment of personality pathology-basic questionnaire in clinical and nonclinical samples.

The Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ) assesses 18 traits to provide a systematic representation of the overall domain of personality disorders. We tested the cross-cultural stability of the prediction that four higher-order factors (Emotional Dysregulation, Dissocial Behavior, Inhibitedness, and Compulsivity) underlie the 18 basic traits. A total of 81 patients who were primarily treated for an Axis II personality disorder and N = 166 healthy control patients completed the German version of the DAPP-BQ. Results clearly confirmed cross-cultural stability of the postulated four-factor structure in both samples, accounting for 74.7% (clinical sample), and 65.7% (nonclinical sample) of the total variance. All four higher-order factors showed specific correlational relationships with dimensional assessments of DSM-IV personality disorders.

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

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

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.

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.

[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.

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.

[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.

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

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

Central nervous system involvement in nocturnal enuresis: evidence of general neuromotor delay and specific brainstem dysfunction.

PURPOSE: To assess the involvement of central nervous system factors in the etiology of childhood nocturnal enuresis, an ongoing study of the fine neurology and neurophysiology has been instituted. MATERIALS AND METHODS: A total of 22 patients 8 to 14 years old were subcategorized sporadic and familial groups. Patients underwent a number of examinations, including a complete family pedigree; blood samples for linkage analyses; pediatric examination; urinalysis; uroflowmetry with pelvic floor electromyography; 24-hour flow charts; parental micturition questionnaire; child behavior checklist; intelligence test; standardized child psychiatric interview; acoustic, visual and event related late evoked potentials; Zurich Neuromotor Test Battery and the startle-blink paradigm. In this preliminary report only the results of the Zurich Neuromotor Test Battery and startle-blink paradigm are reported. RESULTS: In the Zurich Neuromotor Test Battery patients with enuresis had a longer timed performance but did not have more associated movements than the controls. In the startle-blink modulation paradigm inhibition of the electromyograph amplitudes was greatest following prestimulation with an interval of 120 milliseconds. This inhibition is known to be reduced among patients with enuresis compared to nonwetting children. The results indicated a general developmental (neuromotor) delay, in addition to specific dysfunction of the brain stem in patients with enuresis. The pre-pulse inhibition, as well as inhibition of bladder emptying at sleep, are regulated by brainstem centers in close anatomical proximity to the pontine micturition center and by analogous mechanisms. CONCLUSIONS: Reduced pre-pulse inhibition may represent a genetically transmitted trait indicative of nocturnal enuresis.

Interferon gamma production in blood lymphocytes correlates with disability score in multiple sclerosis patients.

The proinflammatory cytokine interferon gamma (IFG) is elevated in body fluids of multiple sclerosis patients but its variation range is broad. The reason for this wide scatter of IFG production is not yet known. We looked for the relation between clinical parameters such as disability, exacerbation frequency, disease duration, course of the disease and IFG producing blood lymphocytes. Forty-one consecutive, clinically stable multiple sclerosis patients with primary relapsing course of the disease and without immunomodulatory or immunosuppressive treatment in the last 3 months were investigated for IFG in blood lymphocytes by flow cytometry. A significant positive correlation between IFG production and disability (r = 0.45, P<0.01, Spearman's rho coefficient) was found. Pathophysiological implications and therapeutical relevance of this unexpected finding are discussed.

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

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

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.

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.

A new nephelometric assay for beta-trace protein (prostaglandin D synthase) as an indicator of liquorrhoea.

OBJECTIVES: To determine the sensitivity and specificity of a nephelometric beta-trace protein assay for the diagnosis of liquorrhoea. METHODS: One hundred and forty clinical samples with suspected liquorrhoea were analysed by a newly developed nephelometric assay. An established electroimmunoassay served as a reference method. The sensitivity and specificity of the beta-trace nephelometric assay were calculated by a 2x2 contingency table for 10 different versions of a dichotomised nephelometric variable. In 52 patients (79 samples), the nephelometric findings were validated by referring to the clinical diagnosis based on the course of the disease, imaging techniques, and surgical inspection. RESULTS: Given a specificity of 100%, a beta-trace protein concentration of 6 mg/l or higher in a sample indicated liquorrhoea with a sensitivity of 92% compared with the reference method and of 93% compared with the clinical evaluation. The relation between the electroimmunoassay and the nephelometric assay was highly significant (p<0.001). CONCLUSIONS: The nephelometric beta-trace protein assay is a simple and rapid method for the detection of liquorrhoea with high sensitivity and specificity and may facilitate the diagnosis of fistulas leaking CSF.