Evidence for geographical variations in the prevalence of schizophrenia in rural Ireland.

Geographical variations in the rate of occurrence of schizophrenia have been the subject of much speculation and controversy, but it has proved extremely difficult to establish the existence of the phenomenon within a given study area. Using current inpatient and outpatient records and information from key informants active in the community, this study sought to identify all cases of schizophrenia in 36 District Electoral Divisions, constituting a clinical catchment area of 25,178 persons in a rural Irish county. Though the overall prevalence rate (3.3 per 1000) was unremarkable, this obscured a substantial and significant variation in prevalence rates (from 0.0 to 14.3 per 1000) between District Electoral Divisions. Prevalence rates in five District Electoral Divisions made particular contributions to the overall deviation from a statistical model for random occurrences in space. The results indicate spatial inhomogeneity in the prevalence of schizophrenia in rural Ireland and imply geographical variation in environmental or genetic factor(s) of etiologic relevance.

Cognitive dysfunction, negative symptoms, and tardive dyskinesia in schizophrenia. Their association in relation to topography of involuntary movements and criterion of their abnormality.

Little is known of factors that, on an individual basis, confer vulnerability to the emergence of involuntary movements (tardive dyskinesia) during long-term neuroleptic treatment. In this study of 88 chronic schizophrenic inpatients, 22 variables (four demographic, 14 medication history, and four features of illness) were compared for any association(s) with the presence, by differing topographies and criteria of abnormality, and severity of involuntary movements. Irrespective of the criterion used, the presence of marked cognitive dysfunction-muteness bore a consistent and highly significant primary association with both the presence and the overall severity of orofacial dyskinesia; no such association was found in relation to the presence of limb-truncal dyskinesia. Flattening of affect was the only other variable consistently associated with the presence of orofacial movements. The reliability and prominence of the association between the presence of orofacial, but not of limb-truncal, movements and cognitive dysfunction-negative symptoms suggest that these varying topographies may not constitute a unitary syndrome. This strong association, not with indexes of neuroleptic exposure but rather with features of the illness for which that treatment was prescribed, suggests some neurologic process, more subtle than may previously have been appreciated, as a vulnerability factor of some importance. In schizophrenia it appears to be intimately related to the disease process.

Primitive (developmental) reflexes and diffuse cerebral dysfunction in schizophrenia and bipolar affective disorder: overrepresentation in patients with tardive dyskinesia.

Primitive (developmental) reflexes are present in fetal and infant life, but disappear in adulthood. Their elicitation in later life usually occurs in association with cortical or diffuse cerebral dysfunction and suggests a new approach to the issue of whether tardive dyskinesia is particularly likely to occur in patients with organic brain disorder(s). Sixty-six patients with schizophrenia (age range 50-86) and 18 with bipolar affective disorder (age range 40-77) were assessed for the presence of involuntary movements and for the release of the grasp, palmomental, snout, corneomandibular, and glabellar reflexes. In each diagnostic group, patients with involuntary movements showed a significant excess of primitive reflexes in comparison with otherwise indistinguishable patients without such movements. These results complement recent reports that similar patients with involuntary movements also show greater cognitive impairment and point anew to an association between the presence of tardive dyskinesia and of organic brain dysfunction. They raise again the issue of whether or not such dysfunction may be a consequence of neurodevelopmental abnormality rather than of neurodegenerative processes.

An unusual cluster of tardive dyskinesia in schizophrenia: association with cognitive dysfunction and negative symptoms.

Factors associated with the emergence or nonemergence of involuntary movements (tardive dyskinesia) during long-term neuroleptic treatment were investigated in an atypical, isolated population of 31 schizophrenic inpatients with an unusually high prevalence of this syndrome. Patients with involuntary movements could not be distinguished from those without such movements by general characteristics or conventional indices of neuroleptic or anticholinergic treatment. However, they were more likely to show either marked cognitive dysfunction or muteness. These findings support the proposal that, at least in schizophrenia, subtle organic changes may contribute to vulnerability to the emergence of involuntary movements.

Tardive dyskinesia in bipolar affective disorder: aging, cognitive dysfunction, course of illness, and exposure to neuroleptics and lithium.

Cognitive function, course of illness, and medication history were assessed in 42 bipolar patients evaluated for the presence of involuntary movements. Among the 25 patients 55 years old or older, the 16 with involuntary movements were not distinguished from the nine without involuntary movements by past or current exposure to neuroleptics, anticholinergics, or carbamazepine, but they showed poorer cognitive function, had fewer major depressive episodes, and had received briefer exposure to lithium. The association between involuntary movements and cognitive dysfunction parallels that found in schizophrenia, suggesting that similar neurological processes may contribute to vulnerability to involuntary movements in the major functional psychoses.

Association of intellectual impairment, negative symptoms, and aging with tardive dyskinesia: clinical and animal studies.

It is not known why some schizophrenic patients receiving long-term neuroleptic treatment develop abnormal involuntary orofacial movements, while others do not. Schizophrenic patients with orofacial dyskinesia were found to be more intellectually impaired, more likely to show negative symptoms, and older than those without such movements. These features are characteristic of the "defect state," wherein structural brain changes may be demonstrable. Prolonged long-term neuroleptic treatment of young rats was associated with late-onset orofacial movements; however, such movements occurred spontaneously in untreated senescent rats. Structural brain changes consequent to aging and disease processes may be associated with the emergence of orofacial dyskinesia, even in the absence of exposure to neuroleptics. These movements do not appear to have their basis in striatal dopamine receptor supersensitivity.

Initial 'schizophrenia-like' psychosis in Pick's disease: case study with neuroimaging and neuropathology, and implications for frontotemporal dysfunction in schizophrenia.

'Schizophrenia-like' psychosis has not been reported previously as a prodrome of Pick's disease, a dementia of frontotemporal pathology. A woman having a consistent clinical diagnosis of typical schizophrenia who developed increasing affectivity and cognitive deficits was examined by computed tomography and brain biopsy. This presentation was found to be associated with left frontotemporal atrophy, left sylvian fissure abnormalities and enlargement of the anterior and temporal horns of the left lateral ventricle. On biopsy, all the neuropathological hallmarks of Pick's disease were present. Unusually, some specific aspect of Pick's disease in this patient appears initially to have disturbed brain function in a manner reproducing some fundamental aspect(s) of schizophrenia itself; left frontotemporal dysfunction would appear to be a relevant common denominator.

Developmental trajectory and disease progression in schizophrenia: the conundrum, and insights from a 12-year prospective study in the Monaghan 101.

Though conceptualised originally as a deteriorating disorder, some contemporary studies have been interpreted as challenging these foundations; more radically, it has been proposed that schizophrenia may be a 'static encephalopathy' of neurodevelopmental origin. The argument offered here is that schizophrenia is indeed a neurodevelopmental disorder, but that this is not in itself antithetical to later disease progression. Rather, the onset of psychosis may reflect the maturationally-mediated triggering of an active disease process that is associated with progressive deterioration unless attenuated by antipsychotic drugs. A developmental trajectory is proposed to link first or early second trimester dysplasia to the chronic course of the illness; from this, it is argued that schizophrenia is inherently a progressive disorder but that antipsychotic drugs may act to ameliorate this progressive component and thus confer on the disease course some of the characteristics of a 'static encephalopathy'. The 'true' natural history of an illness cannot be determined from studies in treated populations.

Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset.

This study examined geographical variation in rate of occurrence of schizophrenia by place at birth vs place at onset, among a rural Irish catchment area population of unusual stability and socioeconomic homogeneity. Within a catchment area of 21,520 persons, all cases of schizophrenia were sought using current inpatient and outpatient records and key informants active in the community. Suspected cases were interviewed personally and diagnosed using DSM-III-R criteria. Place at birth and place at onset of psychosis were specified among the 32 District Electoral Divisions constituting the study region. For the 72 cases ascertained, an unremarkable overall prevalence rate/morbid risk obscured substantial and significant geographical variations therein between District Electoral Divisions. Particularly after controlling for high-density families, men demonstrated prominent geographical variation both by place at birth and by place at onset, with most men remaining unmarried and becoming ill at their place of birth; conversely, women demonstrated prominent variation by place at birth but more limited variation by place at onset, despite more frequent transitions from the parental home to the marital home before onset. Even when cases changed their location before the onset of psychosis, geographical variation in rate of occurrence of schizophrenia remained associated more strongly with factors related to the place of their birth.

Effects of ketoprofen on respiratory and circulatory changes in endotoxic shock.

OBJECTIVE: To study the effects of ketoprofen, a dual inhibitor of the arachidonic acid metabolism, on hemodynamic and respiratory changes during endotoxic shock. DESIGN: Prospective, randomised, controlled study using an established intact animal model of endotoxic shock in sheep. SETTING: An animal laboratory in a university hospital. INTERVENTIONS: 4 groups were studied (n = 7 in each). Group K received ketoprofen and group A received aspirin 30 min before start of endotoxin infusion. Group E received endotoxin, but no drug treatment. Group C received neither endotoxin nor drug treatment. All the animals were anaesthetised with ketamine, had controlled ventilation with FiO2 = 0.5 and received Ringer's lactate at an infusion rate that would keep the pulmonary capillary wedge pressure constant. RESULTS: Both ketoprofen and aspirin prevented the early rise in pulmonary arterial pressure that occurred in group E a few minutes after start of i.v. infusion of endotoxin. Furthermore, ketoprofen prevented any significant changes in arterial blood pressure, arterial oxygen tension, oxygen delivery index, oxygen extraction ratio, respiratory compliance, intrapulmonary shunt fraction, and platelet counts that occurred in group E. Aspirin, on the other hand, provided only partial and time limited (1-2 h) protection against these changes. Wet-to-dry weight ratios of the lungs were significantly lower in the ketoprofen treated than in the untreated shock controls and the aspirin treated animals. CONCLUSION: Ketoprofen completely prevented the changes in hemodynamics and respiratory function observed in control-endotoxin-treated animals.

Duration of neuroleptic treatment and relapse rate: a 5-year follow-up study with haloperidol decanoate.

The role of neuroleptic drugs in controlling acute psychotic symptoms and reducing relapse is well established. It is the clinical management of chronically disabled patients that has major implications for health care planning. Drug discontinuation studies have indicated that patients with chronic schizophrenia should receive maintenance drug therapy for some years. This was a 5-year follow-up study to assess the long-term effects of depot haloperidol decanoate vs. other neuroleptics in 62 psychotic patients treated in the community. The study indicates that there were more relapses and hospitalization for patients maintained on other neuroleptics than for patients maintained on haloperidol decanoate. The study indicates that haloperidol decanoate even in low dosage is effective maintenance therapy is preventing relapse. Indeed, some of the good responders to haloperidol therapy may have benefitted from lowering the dosage of the drug. It is our experience that haloperidol decanoate is of good value in the management of psychotic illnesses that require long-term treatment. A more controlled longer-term study is needed to confirm our results.

Psychotropic drugs in suicidal patients: a comparison of psychotropic medications in attempters and completed suicides.

The correlation between suicide rate and aspects of treatment have been little studied in suicidology in spite of medicalization of suicide. This study compares the medication of 30 patients who committed suicide during 1980-1989 from a catchment area in rural Ireland with 20 who attempted suicide in a neighbouring area where there were no suicides. More drugs had been given to patients who committed suicide and they received higher doses of neuroleptics and benzodiazepines than those who merely attempted suicide.

Characterization of abnormal respiratory movements in schizophrenic, bipolar and mentally handicapped patients with typical tardive dyskinesia.

A population of 76 patients with typical tardive orofacial dyskinesia, and from which cases of respiratory disease had been excluded, were evaluated for abnormal respiratory movements. Such abnormality was present in 34 patients (45%), and was unrelated to age, sex or smoking habits. However, patients with respiratory movement disorder showed more severe orofacial dyskinesia and higher blood pressure. Putative pathophysiological processes implicated in this often unappreciated component of the tardive dyskinesia syndrome are discussed.

Time to abandon electroconvulsion as a treatment in modern psychiatry.

This review examines the evidence for the current use of electroconvulsive therapy (ECT) in psychiatry. The history of ECT is discussed because ECT emerged with no scientific evidence, and the absence of other suitable therapy for psychiatric illness was decisive in its adoption as a treatment. Evidence for the current recommendation of ECT in psychiatry is reconsidered. We suggest that ECT is an unscientific treatment and a symbol of authority of the old psychiatry. ECT is not necessary as a treatment modality in the modern practice of psychiatry.

Lysine acetyl salicylic acid in acute renal pain.

The effect of repeated doses of 1.8 g lysine acetyl salicylic acid (LAS) i.v. on severe pain secondary to acute renal colic (ARC) was studied in 45 consecutive patients. Clinically acceptable analgesia was obtained in 65% of the cases. No additional pain relief was achieved with the combination of pethidine 100 mg i.v. + metoclopramide 10 mg, i.m. (narcotics). Pain relief occurred within five minutes in one third of the patients while in the rest within 30 minutes. Significant reduction of systolic blood pressure (mean +/- S.D.) 23.8 +/- 19.5, pulse rate (mean +/- S.D.) 19.5 +/- 10.1 and vomiting were noted in patients who had pain relief. The incidence of nausea has increased after LAS administration. No other side effects were observed. LAS might therefore be applied as a first-hand alternative to narcotics for the treatment of ARC.

Evidence for the existence of schizophrenia in medieval Islamic society.

It has been claimed that descriptions of schizophrenia-like disorders were rare before 1800 in the Western world. Historical evidence from medieval Islamic society shows that madness was common in that society. Despite the limitations of the evidence, we propose that medieval Islamic physicians probably diagnosed and treated many cases of schizophrenia.