Short-term functional outcome in psychotic patients: results of the Turku early psychosis study (TEPS).

BACKGROUND: Functional recovery of patients with clinical and subclinical psychosis is associated with clinical, neuropsychological and developmental factors. Less is known about how these factors predict functional outcomes in the same models. We investigated functional outcomes and their predictors in patients with first-episode psychosis (FEP) or a confirmed or nonconfirmed clinical high risk of psychosis (CHR-P vs. CHR-N). METHODS: Altogether, 130 patients with FEP, 60 patients with CHR-P and 47 patients with CHR-N were recruited and extensively examined at baseline (T0) and 9 (T1) and 18 (T2) months later. Global Assessment of Functioning (GAF) at T0, T1 and T2 and psychotic, depression, and anxiety symptoms at T1 and T2 were assessed. Functional outcomes were predicted using multivariate repeated ANOVA. RESULTS: During follow-up, the GAF score improved significantly in patients with FEP and CHR-P but not in patients with CHR-N. A single marital status, low basic education level, poor work situation, disorganization symptoms, perceptual deficits, and poor premorbid adjustment in patients with FEP, disorganization symptoms and poor premorbid adjustment in patients with CHR-P, and a low basic education level, poor work situation and general symptoms in patients with CHR-N predicted poor functional outcomes. Psychotic symptoms at T1 in patients with FEP and psychotic and depression symptoms at T1 and anxiety symptoms at T2 in patients with CHR-P were associated with poor functioning. CONCLUSIONS: In patients with FEP and CHR-P, poor premorbid adjustment and disorganization symptomatology are common predictors of the functional outcome, while a low education level and poor work situation predict worse functional outcomes in patients with FEP and CHR-N. Interventions aimed at improving the ability to work and study are most important in improving the functioning of patients with clinical or subclinical psychosis.

Childhood physical abuse and emotional neglect are specifically associated with adult mental disorders.

Background: Childhood adversities and trauma (CAT) are associated with adult mental disorders. Nevertheless, although CAT of different domains mostly co-occurs, and co-morbidity is common, the associations between CAT and mental disorders, when taking these interrelations into account, are not well known.Aims: We aimed to study differential associations between the five core domains of CAT and current axis-I disorders, taking into consideration their interrelations.Methods: Four hundred and fifteen outpatients attending adult primary (n = 255) and psychiatric care (n = 160) were assessed with the Trauma and Distress Scale (TADS) and the Mini International Neuropsychiatric Interview (MINI). Associations between CAT core domains and diagnostic categories were examined by path analyses.Results: At least some infrequent experience of CAT (83.6%), mostly of neglect, and current mental disorders (49.4%), mostly depression, was frequent, as were co-morbidities and co-occurrence of CAT domains. Considering these interrelations in a path model of excellent fit, physical abuse predicted depressive, manic, psychotic and anxiety disorders, whereas emotional neglect predicted depressive, anxiety and substance misuse disorders.Conclusions: Of all five CAT core domains, physical abuse and emotional neglect had the strongest association with adult psychiatric disorders and might have transmitted earlier reported main effects of other CAT domains onto mental disorders.

One-session cognitive behavior treatment for long-term frequent attenders in primary care: randomized controlled trial.

AIM: The aim of the study was to find out, if a single cognitive behavior treatment (CBT) session for long-term frequent attenders in primary care affects the attendance frequency and mental well-being of the patients. METHODS: Out of 193 long-term frequent attenders, 56 participated and were randomized to receive either a one-session CBT intervention or usual care. The groups were compared to each other regarding change in general practitioner visits and change in depressive symptoms, sense of coherence, somatoform symptoms and hypochondriacal anxiety at six months' follow-up. RESULTS: The attendance frequency decreased in both groups, but there was no difference between the groups. Changes in mental functioning did not differ between the groups. When patients with no mental health disorder were analyzed separately, the decrease in GP visits was significantly higher in the intervention group than in the control group (p = .004). CONCLUSION: A single session of CBT is not useful in reducing GP visits or improving mental well-being of long-term frequent attenders. Frequent attenders without a psychiatric disorder may benefit from this kind of intervention.

A study on the association of psychiatric diagnoses and childhood adversities with suicide risk.

BACKGROUND: In addition to psychiatric disorders, childhood adversities may increase the risk of suicidal behavior. In previous studies, the effects of clinical co-morbidity and overlap of childhood adversities has rarely been taken into account. AIM: The study aims to search associations of psychiatric diagnoses and childhood adversities and trauma (CAT) with suicide risk. METHODS: Altogether 415 adult patients attending primary and psychiatric outpatient care filled in the Trauma and Distress Scale, including assessment of five core CAT domains (emotional, physical and sexual abuse, and emotional and physical neglect). The study patients' current psychiatric disorders and suicide risk were assessed by the Mini International Neuropsychiatric Interview. RESULTS: Age, poor perceived health, poor social support, current psychiatric treatment, all psychiatric disorders, except hypomania, emotional and physical abuse, and emotional neglect did associate significantly with suicide risk. Number of psychiatric disorders and CAT domains had dose-dependent effects on suicide risk. In multivariate analysis, current psychiatric treatment, current and life-time major depression, social phobia, alcohol, and drug dependency, as well as emotional abuse had direct associations with suicide risk. In females, manic disorders and drug dependence, and in males, dysthymia, social phobia, and emotional abuse associated with suicide risk. CONCLUSIONS: Psychiatric disorders and most CAT domains associate with suicide risk. However, when the effect of co-morbidity and overlap of CAT domains is controlled, major depression, social phobia, alcohol, and drug dependency and emotional abuse seem to increase the risk of suicide. The risk profile varies between the genders.

Effect of childhood adversities on alcohol problems is mainly mediated by depression.

BACKGROUND AND OBJECTIVES: We aimed to study how five childhood adversities and trauma (CAT) core domains: emotional abuse (EmoAb), physical abuse (PhyAb), sexual abuse (SexAb), emotional neglect (EmoNeg), physical neglect (PhyNeg), associate with alcohol problems (APs), and whether there are any gender differences in these associations. METHODS: Altogether, 690 adult participants drawn from the general population completed a mailed questionnaire, including the trauma and distress scale, as an indicator of CAT, and questions concerning sociodemographic background, depressive symptoms, and APs. RESULTS: In univariate analyses, male gender, middle age, divorced/separated marital status and lower education, frequency of use of alcohol, previous treatment for mental problems, as well as depressive symptoms and CAT domain scores were associated with APs. Of the CAT domains, females reported more EmoAb and SexAb than males, but there was no gender difference in other CAT domains and depressive symptoms. In multivariate analyses, when the effects of background characteristics were controlled, CAT sum and all its domains had indirect effects via depressive symptoms on APs with no significant direct effect except in females, in whom PhyAb and SexAb associated directly with APs even when the effects of other CAT domains were taken into account. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: All CAT domains associate extensively with APs. Generally, their effect on APs is mainly mediated via depressive symptoms. In females, PhyAb and SexAb also have a considerable direct effect on APs. In treating individuals with CAT experiences and alcohol problems, treatment of depression is also important. (Am J Addict 2018;XX:1-9).

Effect of administrative information on visit rate of frequent attenders in primary health care: ten-year follow-up study.

BACKGROUND: Frequent attenders (FAs) use a disproportionately large share of the resources of general practitioners (GPs) working in primary healthcare centres. The aim of this study was to estimate the proportion of FAs among all patients in the primary health care centres of a medium-sized city in Finland, and to examine whether providing GPs with administrative information about their frequent attenders (names and numbers of visits per year) can reduce the number of FAs and the frequency of their visits. METHODS: Statistic data on all GP visits (n = 1.8 million) to 11 public healthcare centres in one city were collected from the electronic patient records covering the period from 2001 to 2010. A FA-patient was defined as a person who made10 or more visits to GPs during one year. The baseline situation in 2001 was compared with the situation in 2006 after administrative information had been provided three times to all GPs working in the healthcare centres. Poisson's regression analysis was used, and FA numbers and consultation rates in the years 2002-2005 were compared with the year 2006; figures for 2006 were also compared with those for the follow-up period 2007-2010. RESULTS: During the years 2001-2006, the proportion of visits of FA-patients fell overall from 9.1 to 8.5%, a decline of 0.6% (p < 0.0001). This reduction was equivalent to an annual work load of two GPs in the study center. The proportion of visits of FA patients increased again in the follow-up period (2007-2010), when administrative information was no longer provided. CONCLUSION: When GPs are provided with information on the number and names of their FA-patients, the annual rate of FA visits to GPs drops significantly. The method is simple and repeatable. However, without a control group of GPs who have not received such information, it is impossible to assess if the intervention was the only circumstance affecting the reduction in FA consultation rates.

Health-related quality of life during adjuvant radiotherapy in breast cancer.

OBJECTIVE: In this study, health- related quality of life (HRQoL) and its determinants were assessed in breast cancer patients undergoing postoperative adjuvant radiotherapy. The aim was to improve our understanding of patient's situation at the end of adjuvant treatment, as the return to every day life approaches after breast cancer surgery and adjuvant chemo- and radiotherapy. METHODS: Health- related quality of life was measured by the 15D instrument. Self-administered questionnaires were distributed to patients undergoing postoperative radiotherapy. Out of 389 consecutive breast cancer patients, 273 comprised the final study group. The results were compared to 15D results for an age-standardized sample of the female general population in Finland (n = 3,335). Determinants of HRQoL were assessed by a multivariate model. RESULTS: In patients <53 years, but not in older patients, the total 15D score was lower than in age-standardized controls. Both younger and older patients differed significantly from the controls on specific 15D dimensions of sleeping, depression, distress, vitality, and sexual activity. When clinical and treatment variables were assessed by a multivariate model, depressive symptoms had a negative effect on HRQoL. Further, having undergone breast conserving surgery instead of mastectomy was associated with poorer HRQoL. CONCLUSIONS: Impairment of HRQoL was observed during adjuvant radiotherapy in breast cancer. This finding calls for action to develop supportive and preventive means to smoothen the return to normal activities after completion of adjuvant treatment for breast cancer.

Psychosocial outcome in patients at clinical high risk of psychosis: a prospective follow-up.

PURPOSE: In patients at clinical high risk (CHR) of psychosis, transition to psychosis has been the focus of recent studies. Their broader outcome has received less attention. We studied psychosocial state and outcome in CHR patients. METHODS: In the European Prediction of Psychosis Study, 244 young help-seeking CHR patients were assessed with the Strauss and Carpenter Prognostic Scale (SCPS) at baseline, and 149 (61.1%) of them were assessed for the second time at the 18-month follow-up. The followed patients were classified into poor and good outcome groups. RESULTS: Female gender, ever-married/cohabitating relationship, and good working/studying situation were associated with good baseline SCPS scores. During follow-up, patients' SCPS scores improved significantly. Good follow-up SCPS scores were predicted by higher level of education, good working/studying status at baseline, and white ethnicity. One-third of the followed CHR patients had poor global outcome. Poor working/studying situation and lower level of education were associated with poor global outcome. Transition to psychosis was associated with baseline, but not with follow-up SCPS scores or with global outcome. CONCLUSION: The majority of CHR patients experience good short-term recovery, but one-third have poor psychosocial outcome. Good working situation is the major indicator of good outcome, while low level of education and non-white ethnicity seem to be associated with poor outcome. Transition to psychosis has little effect on psychosocial outcome in CHR patients. In treating CHR patients, clinicians should focus their attention on a broader outcome, and not only on preventing transition to psychosis.

The effects of interpersonal counselling on health-related quality of life after myocardial infarction.

AIM: To evaluate the effects of interpersonal counselling on health-related quality of life after myocardial infarction. BACKGROUND: Depression is a risk factor for poor health-related quality of life after myocardial infarction. Interpersonal counselling seems to reduce depressive symptoms and distress after myocardial infarction. METHODS: Myocardial infarction patients (n=103) were randomised into an intervention group (n=51) with 1-6 (mean 4·6) interpersonal counselling-sessions focusing on managing depressive symptoms and a control group (n=52). Health-related quality of life after myocardial infarction was measured with EuroQol-5D (EQ-5D) in hospital, at six and 18 months after discharge. RESULTS: No differences in the changes of health-related quality of life were found between the groups during follow-up. However, health-related quality of life improved significantly in the intervention group. In the group of patients under 60 years, the effect of interpersonal counselling was significant in the intervention group compared with the control group. CONCLUSIONS: Interpersonal counselling does not seem to improve health-related quality of life better than standard care after myocardial infarction in general, but it does seem to be beneficial with younger myocardial infarction patients. RELEVANCE TO CLINICAL PRACTICE: There is a need to study the effects of interpersonal counselling further with younger myocardial infarction patients and to develop the intervention further, before using it systematically as part of nursing practice.

Weak sense of coherence predicts depression: 1-year and 9-year follow-ups of the Finnish Outcomes of Depression International Network (ODIN) sample.

BACKGROUND: Previous studies show conflicting results on the role of weak sense of coherence (SOC) as a risk factor for depression. AIMS: The aim of this work was to study whether a weak SOC predicts depressive symptoms in a non-depressive population sample in the short or long perspective. METHOD: Participants without depressive symptoms (n = 1645) in the Finnish sample of the Outcomes of Depression International Network (ODIN) study were assessed at 1-year and 9-year follow-up. Depressive symptoms were assessed by the Beck Depression Inventory (BDI), and SOC by the 13-item Orientation to Life Questionnaire (SOC-13). Logistic regression analysis was used to test the association between baseline SOC and depressive symptoms measured at the follow-ups. RESULTS: In univariate analysis, there was a significant inverse association between baseline SOC and depressive symptoms at 1 year (p = 0.000) and at 9 years (p = 0.000). In multivariate analysis, weak SOC continued to predict depressive symptoms at 1 year (p = 0.022) and 9 years (p = 0.015). CONCLUSIONS: Weak SOC predicted depressive symptoms in the short and long perspective. It seems likely that a strong SOC represents a protective function, not only absence of current depression.

How GPs can Recognize Persistent Frequent Attenders at Finnish Primary Health Care Using Electronic Patient Records.

INTRODUCTION: The proportion of patients who are frequent attenders (FAs) varies from few percent to almost 30% of all patients. A small group of patients continued to visit GPs year after year. In previous studies, it has been reported that over 15% of all 1-year FAs were persistent frequent attenders (pFAs). OBJECTIVES: This study aimed to identify typical features of pFAs from the textual content in their medical entries, which could help GPs to recognize pFAs easily and facilitated treatment.Methods: A retrospective register study was done, using 10 years of electronic patient records. The data were collected from Finnish primary health care centers and used to analyze chronic symptoms and diagnoses of pFAs and to calculate the inverse document frequency weight (IDF) of words used in the patient records. IDF was used to determine which words, if any, are typical for pFAs. The study group consisted of the 5-year pFAs and control group of 1-year FAs. The main background variables were age, gender, occupation, smoking habits, use of alcohol, and BMI. RESULTS: Out of 4392 frequent attenders, 6.6% were pFAs for 3 years and 1.1% were pFAs for 5 years. Of the pFAs, 65% were female and 35% were male. The study group had significantly more depressive episodes (P = .004), heart failure (P = .019), asthma (P = .032), COPD (P = .036), epilepsy (P = .035), and lumbago (P = .046) compared to the control group. GPs described their 5-year pFAs by words related to lung and breathing issues, but there was no statistical difference to the 1-year FAs' descriptions. CONCLUSION: A typical pFA seems to be a woman, aged about 55 years with depressive episodes, asthma or COPD, and lower back pain. Physicians describe pFAs with ordinary words in patient records. It was not possible to differentiate pFAs from 1-year FAs in this way.

Alexithymia, human relationships, and mobile phone use.

Alexithymia is a personality trait associated with difficulties in identifying feelings, difficulties in describing feelings to other people, constricted imaginal processes, and an externally oriented cognitive style. It has been found to be associated with personality features that may cause interpersonally avoidant behavior and other interpersonal problems. The present study explored, in a sample of primary care patients (N = 491), whether alexithymia is associated with mobile phone usage, and whether the perceived quality and quantity of human relationships mediate its effect. Even controlling for sociodemographic variables and symptoms of depression, mania and psychoses, alexithymia, measured by the 20-Item Toronto Alexithymia Scale, was associated with less frequent mobile phone use. Not having enough relationships or a close friend, and relationships being less satisfactory mediated the effect of alexithymia on less frequent mobile phone use. The results support the findings of earlier studies that have linked interpersonal problems with alexithymia.

The outcomes of interpersonal counselling on depressive symptoms and distress after myocardial infarction.

AIMS: Depression is not treated adequately after myocardial infarction (MI). This study evaluates the interpersonal counselling (IPC) implemented by a registered nurse on outcomes for depressive symptoms and distress in MI patients. METHODS: We studied MI patients (n = 103) randomized into intervention group (n = 51) and control group (n = 52) in hospital and at 6 and 18 months after discharge using validated questionnaires, Beck's Depression Inventory (BDI) and the Symptom Checklist-25 (SCL-25). RESULTS: During the 18-month follow-up, depressive symptoms decreased statistically significantly (P = 0.009) in the intervention group compared with the control group. In the IPC intervention group, depressive symptoms decreased from 37.3% to 20.4% at 6 months (P = 0.014), and to 16.7% at 18 months (P = 0.001), while distress decreased from 37.3% to 26.5% (P = 0.132) during the 6-month follow-up, and to 20.8% (P = 0.015). In the control group with normal care, the number of patients with depressive symptoms and distress varied slightly at the three measurements, from 30.2 to 39.6%. CONCLUSIONS: The number of patients with depressive symptoms and distress decreased in the intervention group and remained high in the control group. The progress of severity level of depressive symptoms was toward milder symptoms in the intervention group during the 18-month follow-up. This brief intervention that can rapidly be adopted may result in enduring benefits of clinical value.

[Psychotherapy of a depressed patient--presentation of treatment modalities]. / Masennuspotilaan psykoterapiat.

The article includes a brief introduction to five forms of psychotherapy that are in active use in Finland: psychodynamic, cognitive and group psychotherapy, family therapy of a depressed patient, and resource and solution-oriented working attitude. An advocate of each treatment modality provides a description of the suitability of the particular modality for a depressed patient. Different treatment modalities are not compared as such; the aim is rather to provide clinical thinking tools for the doctor, who considers the patient's suitability for and referral to psychotherapy.

[Update on current care guidelines. Depression, current care guideline]. / Depressio.

The treatment of depression is based on careful diagnostic evaluation. In the acute phase of treatment, brief psychotherapies (cognitive, interpersonal, psychodynamic or problem-solving) are effective in cases of mild to moderate depression. Antidepressants are also effective, their importance increasing alongside the level of severity. Electroconvulsive therapy (ECT) is effective for severe or psychotic depression. After the acute phase, antidepressants must be continued for at least six months to prevent a relapse; maintenance antidepressant treatment must be considered after three lifetime episodes. Primary health care is responsible for the majority of mild to moderate cases of depression, but psychiatric consultation services and nurse case managers are required to fulfill this task.

Adverse childhood experiences leads to perceived negative attitude of others and the effect of adverse childhood experiences on depression in adulthood is mediated via negative attitude of others.

BACKGROUND: The attachment theory suggests that adverse childhood experiences (ACEs) can have an effect on how individuals perceive other people's attitude towards them. ACEs have also been associated with adult depression. We hypothesised that ACEs associate with perceived negative attitude of others (AoO) and depressive symptoms (DEPS), and that these associations differ between the genders. METHODS: Altogether, 692 participants drawn from the general population completed the Trauma and Distress Scale, as a measurement of ACE and its domains: emotional abuse (EmoAb), physical abuse (PhyAb), sexual abuse (SexAb), emotional neglect (EmoNeg) and physical neglect (PhyNeg); a visual analog scale with the question: "What kind of attitude do other people take towards you?", and the self-report scale DEPS on depressive symptoms. RESULTS: ACEs, AoO and DEPS correlated strongly with each other. In path analyses, ACE total and all its domains associated directly and indirectly, via DEPS, to negative AoO in the whole sample, and in females separately. ACE total, EmoAb, PhyAb, EmoNeg and PhyNeg associated directly and indirectly, via AoO, to DEPS in the whole sample and in both genders separately. EmoNeg, in all, and EmoAB, in males, had specific associations both with negative AoO and DEPS. Mediation effect via AoO was greater than via DEPS. CONCLUSIONS: ACEs have a direct and indirect, via depression, negative effect on how adult individuals perceive other people's attitude towards themselves. Additionally, negative AoO mediates the effects of ACEs on depression. Childhood EmoNeg associates specifically with negative AoO and DEPS in adulthood.

Psychometric properties of the Trauma and Distress Scale, TADS, in an adult community sample in Finland.

BACKGROUND: There is increasing evidence that a history of childhood abuse and neglect is not uncommon among individuals who experience mental disorder and that childhood trauma experiences are associated with adult psychopathology. Although several interview and self-report instruments for retrospective trauma assessment have been developed, many focus on sexual abuse (SexAb) rather than on multiple types of trauma or adversity. METHODS: Within the European Prediction of Psychosis Study, the Trauma and Distress Scale (TADS) was developed as a new self-report assessment of multiple types of childhood trauma and distressing experiences. The TADS includes 43 items and, following previous measures including the Childhood Trauma Questionnaire, focuses on five core domains: emotional neglect (EmoNeg), emotional abuse (EmoAb), physical neglect (PhyNeg), physical abuse (PhyAb), and SexAb.This study explores the psychometric properties of the TADS (internal consistency and concurrent validity) in 692 participants drawn from the general population who completed a mailed questionnaire, including the TADS, a depression self-report and questions on help-seeking for mental health problems. Inter-method reliability was examined in a random sample of 100 responders who were reassessed in telephone interviews. RESULTS: After minor revisions of PhyNeg and PhyAb, internal consistencies were good for TADS totals and the domain raw score sums. Intra-class coefficients for TADS total score and the five revised core domains were all good to excellent when compared to the interviewed TADS as a gold standard. In the concurrent validity analyses, the total TADS and its all core domains were significantly associated with depression and help-seeking for mental problems as proxy measures for traumatisation. In addition, robust cutoffs for the total TADS and its domains were calculated. CONCLUSIONS: Our results suggest the TADS as a valid, reliable, and clinically useful instrument for assessing retrospectively reported childhood traumatisation.

Striatal dopamine D1 and D2 receptors in burning mouth syndrome.

Animal studies have indicated that the nigrostriatal dopaminergic system is involved in central pain modulation. In a recent positron emission tomography (PET) study, we demonstrated presynaptic dysfunction of the nigrostriatal dopaminergic pathway in burning mouth syndrome, which is a chronic pain state. The objective of the present study was to examine striatal dopamine D1 and D2 receptors in these patients. We used 11C-NNC 756 and 11C-raclopride to study D1 and D2 receptor binding in a PET study in ten burning mouth patients and 11 healthy controls. Patients underwent a structured psychiatric evaluation and an electrophysiological test for the excitability of the blink reflex. The striatal uptake of 11C-NNC 756 did not differ between patients and controls. In a voxel-level analysis, the uptake of 11C-raclopride was statistically significantly higher in the left putamen in burning mouth patients (corrected P-value 0.038 at cluster-level). In the region of interest analysis, the D1/D2 ratio was 7.7% lower in the right putamen (0.64+/-0.04 vs. 0.69+/-0.04, P=0.01) and 6.4 % lower in the left putamen (0.65+/-0.05 vs. 0.70+/-0.05, P=0.05) when compared to controls. Increased 11C-raclopride uptake and the subsequent decrease in the D1/D2 ratio may indicate a decline in endogenous dopamine levels in the putamen in burning mouth patients.

Childhood trauma and premorbid adjustment among individuals at clinical high risk for psychosis and normal control subjects.

AIM: Traumatic childhood experiences are associated with psychotic illness and are frequently reported in patients at clinical high risk (CHR) for psychosis. Moreover, deteriorating premorbid functioning from childhood, and through adolescence, is related to greater severity of overall symptomatology and poorer outcomes in patients with psychosis. We studied the prevalence of traumatic childhood experiences and premorbid adjustment and their association with each other in patients at CHR for psychosis and normal control subjects (NCSs). METHODS: A total of 20 CHR patients for psychosis and 30 NCSs aged 14 to 35 participated in the present study. The CHR patients were identified as prodromal to psychosis using the Structured Interview for Prodromal Syndromes/Scale of Prodromal Symptoms. Premorbid adjustment was assessed by using the premorbid adjustment scale (PAS), and self-reported childhood trauma was assessed with the Trauma and Distress Scale (TADS). RESULTS: In CHR patients, TADS and PAS scores were higher than in NCSs. In CHR patients, TADS correlated significantly with the PAS general section and observably, but not significantly, with adolescence and adulthood sections. CONCLUSION: CHR patients reported more childhood trauma experiences and poorer premorbid adjustment than NCSs. In CHR patients, traumatic childhood experiences are associated with poor general premorbid adjustment.