Prognostic implications of six alternative definitions of schizophrenia.

The ability of six different operational definitions of schizophrenia to identify prospectively patients whose eventual prognosis would be poor was studied using data from a six-year follow-up of a series of 134 patients with functional psychoses. All six definitions were more successful at predicting a poor symptomatic outcome than a poor social outcome. Spitzer's Research Diagnostic Criteria, Carpenter's flexible criteria, and Langfeldt's criteria predicted a poor outcome as well as the original clinical diagnoses and were considerably better than the New Haven criteria, Schneider's first rank symptoms, or the computer program Catego.

Contribution of the six-month criterion to the predictive validity of the DSM-III definition of schizophrenia.

To test the contribution of the criterion of six months of illness to the predictive usefulness of the DSM-III diagnosis of schizophrenia, we compared, from a sample of 121 patients with functional psychosis, those who had been ill for six months or more at index but did not meet the nontemporal DSM-III criteria and those who met the full criteria. We found that while the six-month criterion is an important component, it is not the sole reason for the predictive power of these criteria. Many who met only this criterion had relatively good outcomes, and, as a group, their outcomes were only slightly worse than for the entire series of psychotic patients. Those who met the full criteria had a significantly poorer outcome in terms of both continued psychopathology and social functioning.

Predictive validity of DSM-III and Feighner definitions of schizophrenia. A comparison with research diagnosis criteria and CATEGO.

The new DSM-III and the Feighner criteria give definitions of schizophrenia that are restrictive in that they require six months of illness before the diagnosis can be made. The definitions are compared with definitions of schizophrenia in the Research Diagnosis Criteria and CATEGO in terms of predictive validity using a cohort of 125 psychotic patients from the United States-United Kingdom Diagnostic Project. The results showed that while the DSM-III and Feighner definitions were more restrictive, they also had a higher degree of predictive specificity than the other two definitions. No patient diagnosed by DSM-III or Feighner criteria showed a change in diagnosis over time, and these patients were more likely to have persistent schizophrenic symptoms and to have social handicap. The appropriateness of the requirement of six months of illness and the practicality of using outcome as a validity measure are discussed.

Puerperal Psychosis. Phenomena and diagnosis.

Fifty-eight psychoses beginning within two weeks of childbirth are compared with 52 episodes of nonpuerperal psychotic illness occurring in young women. A clinical approach based on the use of multiple information sources and integrated assessment was used. Statistically significant differences between the two groups of patients were found in 52 of 214 psychopathological variables. Postpartum patients had more manic symptoms and "confusion," while nonpuerperal patients had more schizophrenic symptoms. The Research Diagnostic Criteria (RDC) showed an excess of schizoaffective (manic) puerperal patients and schizoaffective (depressed) or schizophrenic nonpuerperal patients. Only five of 58 puerperal episodes met RDC for schizophrenia. The relative lack of schizophrenic symptoms in the puerperal group was confirmed by self-ratings. The results are interpreted as supporting a link between puerperal psychosis and manic-depressive disease.

A comparison of clinical and diagnostic interview schedule diagnoses. Physician reexamination of lay-interviewed cases in the general population.

We examined the level of agreement between diagnoses derived from data gathered by lay interviewers using the Diagnostic Interview Schedule (DIS) in a general population survey (the Epidemiologic Catchment Area project) and both DIS and clinical diagnoses made by psychiatrists. Overall percent agreement between the lay DIS and the psychiatrists clinical impression ranged from 79% to 96%. The chance-corrected concordance was .60 or better for eight of the 11 diagnoses. Specificities were all 90% or better. Sensitivities were lower, but lay results showed a bias for only two diagnoses: major depression was significantly underdiagnosed and obsessive illness was overdiagnosed. We compared the present results with those of previous studies from clinical settings. We explored possible reasons for disagreement and discussed the implications of the findings for psychiatric epidemiologic research.

Definitions of mania: concordance and prediction of outcome.

The authors compare several definitions of mania in three series of patients. All the definitions were successful in selecting patients with a favorable outcome, but there were large differences in the number of patients diagnosed, ranging from 17 to 55. The Research Diagnostic Criteria (RDC) distinction between mania and schizoaffective mania proved useful in that the schizoaffective patients continued to show schizophrenic and paranoid symptoms, had more manic episodes, and had a poorer social outcome. The DSM-III tripartite division into nonpsychotic mania and two subgroups of psychotic mania did not appear to have a clear advantage over the RDC dichotomy in the prediction of outcome.

Definitions of depression: concordance and prediction of outcome.

Using patient samples in London hospitals, the authors compared three methods of diagnosing and subdividing depressive illness in terms of their ability to predict outcome. The Catego class D+ selected patients who continued to suffer from episodes of psychotic depression. The Research Diagnostic Criteria selected patients with schizoaffective depressions whose outcome a completely different from that of major depressive disorder. DSM-III had advantages over the other systems, since it divides depression into three subtypes that differ from each other and from schizophrenia. Patients with a DSM-III diagnosis of mood-incongruent psychotic depression had persistent schizophrenic psychopathology, but their outcome differed from that of both schizophrenic and manic-depressive patients.

Documenting an episode of psychiatric illness: need for multiple information sources, multiple raters, and narrative.

It is argued that the structured psychiatric interview, which has become the foundation of much modern clinical research, is not a sufficient method of documenting an episode of psychotic illness. This valuable resource needs to be supplemented by a high standard of recorded observation throughout hospitalization by all staff in contact with the patient. The conversion of observations into ratings can involve considerable error and should be left to at least two highly trained research workers. The only data worthy of this effort are the entire body of clinical information obtained from all sources. This requires detailed written records. The advantages of a narrative record, in addition to numerical ratings, is that it can be reinterpreted at any time using different systems of psychopathological or nosological ideas.

Clinical clues to the aetiology of puerperal psychosis.

Recent case reports of postpartum psychosis are reviewed, which suggest hypotheses for the aetiology of this disease. The main themes are: The relationship to manic depression. Premenstrual relapse. Prepartum onset. Onset after miscarriage or evacuation of a trophoblastic tumour. Onset after bromocriptine treatment. Attempts to treat this and related psychoses by progesterone. Apomorphine growth hormone challenge tests.

Prepartum psychosis.

Four patients are described who suffered from postpartum psychosis, and also from similar episodes starting in late pregnancy. It is argued that these patients provide evidence for the prepartum onset of postpartum psychosis in a small minority of patients. The relevance of this to the aetiology of puerperal psychosis is discussed.

The clinical picture of the depressed form of puerperal psychosis.

The clinical features of 104 patients admitted to a mother and baby unit over a 5-year period with RDC diagnoses of depression or schizoaffective depression were studied by self-ratings, measurements of non-verbal behaviour from standardised videotaped interviews, and observer ratings based on multiple information sources. The hypothesis was tested that they included a large subset which represented the depressed form of a bipolar puerperal psychosis. It was deduced that these illnesses would start early in the puerperium, and would have some specific clinical features. A comparison of patients with onset of depression within 2 weeks of delivery with those with onset during pregnancy or much later in the postnatal period showed a number of significant differences. A discriminant function analysis using serial reclassification of atypical patients refined the early-onset group by the exclusion of about one third of the patients who had an atypical clinical picture; the patients who remained, who are considered to represent the depressed form of puerperal psychosis, showed less anger, less self-rated emotion and more animation than the other depressed patients.

Premenstrual relapse of puerperal psychosis.

Eight patients suffering from puerperal psychosis rapidly recovered, then relapsed shortly before the onset of their first menstrual period; five of them had repeated premenstrual relapses. This clinical observation supports a hormonal aetiology for post-partum psychosis.

Psycho-social stress and puerperal depression.

This study assessed the role of psycho-social stress in the development of psychiatric disorder during pregnancy and after childbirth. The samples were a consecutive series of women admitted to a psychiatric Mother and Baby Unit with a depressive illness and a random sample of women who had recently given birth. Whereas prepartum-onset disturbances were found to be overwhelmingly stress-related, women with a postpartum onset of depression were considerably less likely to have experienced a recent stress event or difficulty before onset. The relative lack of psycho-social antecedents among women who became ill within 2-3 weeks of giving birth strengthens the argument that puerperal depression may have a distinct, possibly biological aetiology.

Nigerian 'heart muscle disease': the late stages of untreated hypertensive heart failure?

Evidence for the hypertensive origin of Nigerian 'heart muscle disease' is presented. Epidemiologically, clinically and pathologically it is similar to hypertensive failure and it is associated with hypertension. It is more severe than hypertensive failure as judged by its prognosis and the myocardial damage at necropsy. The radiographic aortic width and renal histology, but not the retinal arteries have evidence of chronic hypertension in some. Using renal histology and scores on a discriminant analysis it was estimated that 34/62 cases in the necropsy series had been hypertensive . Up to 28 cases had not suffered from chronic hypertension but this figure (3%) of cardiac necropsies does not justify the identification of a highly prevalent myocardial disease in Nigeria. The arguments could apply to South African cryptogenic 'heart disease' and 'Jamaican cardiomyopathy'. The study presents data on the natural history of hypertensive failure.

Fetal abuse.

The possible occurrence of fetal abuse in expectant mothers has received little attention in either clinical practice or in research. Five cases with reported fetal abuse are presented. Each case suffered from depression and four of the five women had unplanned pregnancies and had considered a termination of pregnancy. Other possible factors associated with fetal abuse included: denial of the pregnancy, ambivalence towards the pregnancy, previous postpartum depression, and relationship difficulties. Enquiry of possible fetal abuse in pregnant women should be made, particularly if a depressive illness is demonstrated. The relationship between fetal abuse and subsequent child abuse remains unclear.