Design and clinical characteristics of a homogeneous schizophrenia pedigree sample from Tamil Nadu, India.

OBJECTIVE: The genetic complexity of schizophrenia may be compounded by the diagnostic imprecision inherent in distinguishing schizophrenia from closely related mood and substance use disorders. Further complexity may arise from studying genetically and/or environmentally diverse ethnic groups. Reported here are the ascertainment, demographic features and clinical characteristics, of a diagnostically and ethnically homogeneous schizophrenia pedigree sample from Tamil Nadu, India. Also reported is the theoretical power to detect genetic linkage in the subset of affected sibling pairs. METHOD: Affected sibling pair and trio pedigrees were identified by caste/ethnicity. Affected probands and siblings fulfilled DSM-IV criteria for schizophrenia or schizoaffective disorder. RESULTS: The present sample consisted of 159 affected sibling pairs and 187 parent-offspring trios originating primarily from the Tamil Brahmin caste, but also incorporating pedigrees from genetically similar, geographically proximal caste groups. Consistent with previous studies in Tamil Nadu, a very low prevalence of affective psychoses such as schizoaffective disorder, was observed, with most affected individuals having schizophrenia (499/504). Also observed were extremely low rates of nicotine (12.4%), alcohol (1.1%) and illicit drug use (0%). Most affected individuals exhibited negative symptoms (>90%) and a severe, chronic course. All participants lived in the same geographic and climatic region and most affected individuals resided with close family members, increasing uniformity of the sociocultural environment. In affected sibling pairs, power to detect linkage to small-effect risk loci was modest, but this homogeneous sample may be enriched for loci of larger effect. CONCLUSIONS: This Indian schizophrenia sample exhibits diagnostic and ethnic homogeneity with high consistency of sociocultural environmental features. These characteristics should assist efforts to identify risk genes for schizophrenia.

Extrapyramidal symptoms in unmedicated schizophrenia.

Studies of spontaneous extrapyramidal symptoms, dyskinesia and parkinsonism, in unmedicated schizophrenia are of importance in understanding their underlying pathology and relation to the psychosis. This is a study of extrapyramidal symptoms using Abnormal Involuntary Movements Scale for dyskinesia and Simpson-Angus Scale for parkinsonism in 143 schizophrenia patients who never received antipsychotic medication. Psychopathology was measured using the Positive and Negative Syndrome Scale. Dyskinesia was present in 35% of patients and parkinsonism in 15%. The two disorders coexisted in 11 subjects. Orofacial dyskinesia, rigidity and tremor were common symptoms noted. There was no significant change in the rates and total scores of dyskinesia and parkinsonism with gender, age, duration of illness or age at onset of psychosis. Dyskinesia was unrelated to psychopathology. Parkinsonism score correlated positively with the motor symptom cluster of psychopathology. Dyskinesia and parkinsonism scores correlated positively with each other and parkinsonism score discriminated presence of dyskinesia. The associations between the spontaneous abnormal movements and other aspects of schizophrenia differed from those described in treated patients. Dyskinesia and parkinsonism are an integral part of the schizophrenia disease process whose relationship with other factors could be influenced by antipsychotic drug treatment.

Structural brain differences between never-treated patients with schizophrenia, with and without dyskinesia, and normal control subjects: a magnetic resonance imaging study.

BACKGROUND: In south India, abnormal movements indistinguishable from tardive dyskinesia have been observed in chronically ill patients with schizophrenia who have never received antipsychotic medication. The present study, using magnetic resonance imaging, examines brain structure in such patients, in those without dyskinesia, and in normal control subjects. METHODS: Chronically ill patients with schizophrenia with and without dyskinesia and controls were identified in villages south of Chennai, India (each group, n = 31). Patients' mental state was assessed by the Positive and Negative Syndrome Scale for schizophrenia, dyskinesia by the Abnormal Involuntary Movements Scale, and parkinsonism by the Simpson and Angus scale. In patients and controls, magnetic resonance imaging measured the volume of the caudate and lentiform nuclei and the lateral ventricle-hemisphere ratio. RESULTS: The left lentiform nucleus was significantly (11%) larger in patients with dyskinesia compared with controls, and the right lateral ventricle-hemisphere ratio was significantly (33%) larger in patients without dyskinesia compared with controls. In all 3 groups, there were significant positive correlations between age and ventricle-hemisphere ratio. In controls, but not in patients, there were significant negative correlations between age and the volume of the caudate and lentiform nuclei. CONCLUSIONS: Never-treated patients with dyskinesia may have striatal pathologic conditions and may represent a subgroup of patients with schizophrenia; in those without abnormal movements, cortical atrophy is more apparent. The schizophrenic process may interfere with normal age-related anatomical changes in the basal ganglia.

At issue: management of medication noncompliance in schizophrenia by families in India.

Noncompliance with medication during a symptomatic phase is a common problem in the treatment of schizophrenia patients. In India, a majority of patients live with their families and those families supervise patients' medication intake. In a study of patients attending an urban outpatient care center in India, it was noted that when the patients were acutely ill and refused to take medication, the families administered medication to them without patients' knowledge, under the supervision of the psychiatrist. This method had been practiced by families in half the cases of patient noncompliance. Many families felt that there was no other viable alternative under the circumstances. Only a minority of patients was aware of having received medication through this method, and many of them reacted negatively to it. However, the patients were subsequently taking treatment voluntarily following the reduction in the severity of the behavioral disorder with the involuntary treatment. The issues involved in this form of treatment are discussed with regard to the social and health care environment in the country.

Folie a Famille: delusional parasitosis affecting all the members of a family.

Delusional parasitosis (Ekbom syndrome) is an uncommon psychiatric disorder that presents with a delusion of being infested with parasites. Treatment of this condition is difficult as patients with this paranoid disorder reject psychiatric diagnosis and treatment and often consult a dermatologist. Sharing the delusional beliefs of the paranoid patient by other people living in close emotional bonding with him/her could occur. We report here the clinically interesting phenomenon of delusion of parasitosis occurring simultaneously in all the members of a family. There was a pathological bonding between the members of the family who all presented to the dermatologist and rejected treatment. Dermatologists need to be aware of this uncommon clinical picture.

Spontaneous dyskinesia in first-degree relatives of chronically ill, never-treated people with schizophrenia.

BACKGROUND: We have suggested recently that there may be a subgroup of schizophrenia, namely schizophrenia with dyskinesia and striatal pathology. Might movement disorders be more common in relatives of those with schizophrenia and dyskinesia than in relatives of those without dyskinesia? Aims To determine the prevalence of abnormal movements in first-degree relatives of people with schizophrenia who themselves do or do not have abnormal movements. METHOD: Chronically ill, never-treated people with schizophrenia in south India (n=70) and their first-degree relatives (n=181) were examined for dyskinesia using the Abnormal Involuntary Movements Scale (AIMS) and for parkinsonism by the Simpson and Angus scale. RESULTS: Of all relatives, 25 (14%) had dyskinetic movements in at least one body area and 6 (3%) had parkinsonism. Siblings of people with schizophrenia and dyskinesia, compared with siblings of people without dyskinesia, had a higher total AIMS score and more had mild dyskinetic movements in at least one area (5/15 v. 3/34, P=0.04). There were no between-group differences in parkinsonism. CONCLUSIONS: Dyskinesia but not parkinsonism is more common in siblings of people with schizophrenia who have the corresponding movement disorder.