Schizotypy: phenotypic marker as risk factor.

OBJECTIVE: To evaluate measures of schizotypy as familial risk factors for schizophrenia with the aim of making recommendations for assessing schizotypy as part of screening procedures for identifying people at risk of schizophrenia. METHOD: Published studies using self-report and interview-based measures of schizotypy to assess relatives of patients with schizophrenia are reviewed. A parent study is reported evaluating the diagnostic accuracy of parental schizotypy as assessed by three questionnaire-based measures: the Chapman Perceptual Aberration and Physical Anhedonia Scales, and the Eysenck Psychoticism Scale. Group scores for these self-report ratings of 23 parent-pairs of patients with schizophrenia, 20 parent-pairs of patients with chronic nonpsychotic psychiatric disorder, and 19 parent-pairs of healthy comparison subjects are compared. RESULTS: Consistent with published evidence that self-report measures of psychosis-proneness and schizotypy do not consistently reflect familial risk factors that are specific for schizophrenia, scores on questionnaire measures of schizotypy did not distinguish the parents of patients with schizophrenia from the parents in the other two groups. CONCLUSIONS: Interview-based assessments of schizotypy better assess familial risk factors than self-report measures of schizotypy. Questionnaire measures of schizotypy should be supplemented by interview-based assessments when screening for individuals at risk of schizophrenia.

Should we ignore dimensional risk factors in prevention of schizophrenia? Signposts to prevention.

OBJECTIVE: The objective was to outline the development of the concept of allusive thinking as a genetic marker of predisposition to schizophrenia and relate this to other cognitive markers of this predisposition. METHOD: Publications were reviewed which were considered relevant to the objective. RESULTS: Allusive thinking as detected clinically could be measured objectively from subjects' performance on an Object Sorting Test. Using this test it was shown that parents, both of patients with schizophrenia and of university students with allusive thinking, themselves showed allusive thinking, indicating it was familially transmitted. Subjects with allusive thinking showed reduced cortical evoked brain P300 potentials, suggesting the transmission was genetic. The hypothesis that allusive thinking was associated with weaker cortical inhibitory processes was supported by the finding that subjects with such thinking chose more remote word associations. It was suggested that reasons allusive thinking has not been used as a marker in intervention studies is that as a dimension of abstract thinking, marked allusive thinking is not associated with a high risk of developing schizophrenia, and that administration of the Object Sorting Test is time-consuming. Other dimensional cognitive factors, such as psychoticism and perceptual anhedonia and aberration, are independent of allusive thinking and are also associated with a low risk of developing schizophrenia. Genetic transmission of schizophrenia would appear to involve a number of predisposing factors distributed dimensionally in the population with the contribution of each factor being small. CONCLUSIONS: As they are associated with only a low risk of predisposition to schizophrenia, cognitive markers may not be of immediate value in the prevention of schizophrenia when compared with the less specific markers used for this purpose. However, it would seem that their study will be necessary if the nature of the genetic transmission of the illness is to be understood. This understanding could be expected to ultimately lead to more effective prevention.

Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission.

OBJECTIVE: The objective of this study was to investigate the readmission rate, and the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia. METHOD: The readmission rates of all patients given CTOs within a 4-year period and a matched comparison group were investigated. The following factors were compared before, during and following a CTO: medication non-compliance, number of clinical services and duration of disturbed behaviour preceding hospitalisations. RESULTS: Of 123 patients on CTOs (mean length, 288 days; SD, 210 days), 38 were readmitted during the CTO, the majority in the first 3 months and a further 21 patients were readmitted following termination of the CTO. Evidence of lower severity of illness in the comparison patients prevented meaningful evaluation of the readmission rates of the two groups. While on CTOs, patients receiving depot medications showed high compliance and a significantly reduced readmission rate compared with that of patients receiving oral medications. In the 2 months prior to hospitalisations during CTOs, compared with those before or after CTOs, patients received more frequent consultations and showed a shorter duration of medication non-compliance and disturbed behaviour. The level of services in the 3 months following discharge were comparable for patients on CTOs and the comparison group. CONCLUSIONS: CTOs may reduce rehospitalisations by use of depot medication. Earlier and possibly more frequent readmissions in the CTO group shortened the disturbance associated with illness recurrence. It would appear that to establish a control group with equivalent severity of disorder necessary to evaluate the impact of CTOs requires a random allocation design.

Emotional suppression: can it predict cancer outcome in women with suspicious screening mammograms?

BACKGROUND: Previous studies have implicated emotional suppression, in particular suppression of anger, in the onset and progression of breast cancer. Many of these studies used non-standardized measures and failed to control for the effects of age and/or possible knowledge of diagnosis. The present study aimed to avoid these methodological errors in investigating the relationship of emotional suppression to a diagnosis of breast cancer in a large mammography screened population. METHOD: Data were collected from 1151 women with suspicious mammograms recalled to a breast screening programme. Prior to multidisciplinary assessment women were asked to complete the Courtauld Emotional Control Scale. Imaging assessment outcome data and biopsy results were collected. RESULTS: Fifteen per cent of this population subsequently were diagnosed with breast cancer. There were no significant associations between a cancer outcome and emotional suppression before or after the highly significant effect of age was taken into account. CONCLUSIONS: These results suggest that suppression of emotion may not be relevant to the development of breast cancer. Its role in the progression of existing disease requires clarification.

Unresolved issues in scientific sexology.

A number of unresolved issues in sexology research and practice are reviewed. Penile volume assessment of sexual arousal has consistently proved more sensitive than penile circumference assessment and requires much shorter exposure to the erotic stimuli eliciting the arousal, reducing the subjects' ability to modify their responses. Failure to acknowledge this has allowed acceptance of evidence based on penile circumference assessment that behavioral treatments such as directed masturbation can increase the ability of sex offenders to be heterosexually aroused and aversive therapy can reduce their deviant urges whereas penile volume assessment indicates these procedures are ineffective. A randomized controlled trial of relapse prevention versus no treatment for sex offenders found more treated than untreated subjects reoffended after a mean follow-up period of 4 years. Researchers and therapists accepted that a post hoc statistical manipulation of the results provided evidence of a treatment effect. Subsequently it has been recommended that randomized controlled evaluations of treatments of sex offenders be abandoned. Meta-analysis of outcome studies has been used uncritically. The majority of men and women who report homosexual feelings and/or behavior report predominant heterosexual feelings and behavior and do not identify as homosexual. These consistent findings remain ignored. Studies of the etiology and development of homosexuality and heterosexuality treat them as distributed categorically rather than dimensionally and investigate only self-identified homosexuals and heterosexuals. With this methodology the predominantly heterosexual majority are excluded or misclassified. The belief that the European concept of the homosexual is a late 19th-century invention is based on an inadequate reading of literature. Limitations of the DSM classification of sexual and gender identity disorders are pointed out. The validity of self-report of sexual behavior has been questioned on the basis that men report a markedly higher average number of sexual partners than women. Possible sex differences in reporting the number of partners who are of the same sex, casual, or perpetrators or victims of sexual coercion and child abuse have not been taken into account. Failure of sexology to progress due to lack of resolution of conflicting issues may contribute to the low impact factor of its journals.

Methodological issues concerning evaluation of treatment for sexual offenders: randomization, treatment dropouts, untreated controls, and within-treatment studies.

The value of randomized controlled trials in evaluation of sexual offender treatment has been questioned. Concern was expressed that randomization fails to produce equivalent samples, without apparent appreciation this is inevitable when variables are distributed by chance; lack of equivalence is controlled by use of tests of significance. A further uncriticized and inappropriate procedure in treatment evaluation is separation of the results of subjects who did not complete treatment from those who did, when the outcome of the former group was known. Despite an APA Task Force recommendation, no attention has been given to the consistent finding that no treatment is less effective than placebo psychological therapies. The significance of Type II errors is discussed and the recommendation criticized that within-treatment research be encouraged as an alternative to outcome research. Demonstrating a within-treatment response when that response is associated with a better outcome does not necessarily mean that the treatment was effective. Subjects with a good prognosis could be more able to demonstrate a within-treatment response to the treatment. Nonrandomized matched samples do not adequately control all sample differences. The post hoc statistical reversal of a reported trend for sexual offenders treated with relapse prevention to show a worse outcome than untreated offenders, in order to correct lack of equivalence of the two groups, is considered inappropriate. That relapse prevention was found less effective than no treatment raises the possibility that it has a negative effect. To continue the use of relapse prevention other than in randomly controlled evaluative studies would appear to be unethical.

Megavitamin and dietary treatment in schizophrenia: a randomised, controlled trial.

OBJECTIVE: The aim of this study was to assess the efficacy of adjunctive megavitamin and dietary treatment in schizophrenia. METHOD: A random allocation double-blind, controlled comparison of dietary supplement and megavitamin treatment, and an alternative procedure was given for 5 months to 19 outpatients with a diagnosis of schizophrenia. In addition to usual follow-up, the experimental group received amounts of megavitamins based on their individual serum vitamin levels plus dietary restriction based on Radioallergosorbent (RAST) tests. The control group received 25 mg vitamin C and were prescribed substances considered allergenic from the RAST test. RESULTS: Five months of treatment showed marked differences in serum levels of vitamins but no consistent self-reported symptomatic or behavioural differences between groups. CONCLUSIONS: This study does not provide evidence supporting a positive relationship between regulation of levels of serum vitamins and clinical outcome in schizophrenia over 5 months.

Paedophilia: a review of the evidence.

OBJECTIVE: The aim of this study was to critically review the literature concerning the nature ane prevalence of paedophilia. METHOD: The literature of the past 30 years was examined in relation to the author's clinical experience and with emphasis on methodologically appropriate empirical studies. RESULTS: Concern and reporting of child-adult sexual activity has increased markedly in the last decade, although its prevalence has not increased at least since the 1960s. The prevalence in women can be as high as 60%, depending on the definition and method of enquiry used, and female compared to male victims report more negative effects, although a percentage of both men and women report the experience as positive. Validation of effects requires multivariate statistical analysis. Current pro-active procedures to identify paedophiles detect those who victimise boys but do not detect the much greater number of paedophiles who victimise girls. Perpetrators are known to the majority of their female and male victims, and those reported are almost all male; most boys do not consider their prepubertal experiences with older women abusive. Relapse prevention, the current most popular treatment, has been shown to be ineffective for incarcerated child molesters. CONCLUSIONS: Child-adult sexual activity should be opposed as an infringement of children's rights rather than requiring a false belief that it is invariably harmful; whether it should be mandatory for therapists to report it requires examination. Scientifically appropriate evaluation should be an essential component of current treatment programs.

The effect of decreased catecholamine transmission on ERP indices of selective attention.

This study examines the effect of decreased catecholamine transmission on event-related potential (ERP) indices of selective attention. Intravenous clonidine (1.5 micrograms/kg Catapres), droperidol (15 micrograms/kg Droleptan), or placebo were administered to healthy adult males prior to performance of a multidimensional auditory selective attention task (SAT) in which dichotically presented sequences of tone pips varied on dimensions of location (left or right ear), pitch (high or low), and duration (short or long). Subjects were required to make a button press response to infrequent "target" stimuli that matched a prespecified stimulus on the three dimensions. ERPs were recorded during the task. Clonidine led to a significant increase of processing negativity (PN) over 200-400 ms at the irrelevant location. Droperidol led to a significant increase in reaction time (RT), a significant decrease in hit rate, and an attenuation of PN over the 200- to 400-ms and 400- to 700-ms epochs. Neither substance led to a significant change in P3 amplitude. The role of catecholamines in the selective attention subprocesses of "tuning" and "switching" is discussed.

Impulsivity in pathological gambling: the antisocial impulsivist.

The construct of impulsivity has to date remained relatively unexplored in the pathological gambling literature. This is in spite of recent claims suggesting that impulsivity may be an important feature characterizing a subgroup of pathological gamblers who are claimed to suffer from a Multi-Impulse Personality Disorder. The present study examined the potential role of impulsivity using the Eysenck Impulsivity Scale among 115 pathological gamblers. Results indicate that heightened impulsivity is associated with the degree of severity of psychological and behavioural change in pathological gamblers. However, the findings also indicate that impulsivity closely mirrors components contained in Eysenck Personality Questionnaire Psychoticism Scale, the California Personality Inventory Socialization Scale and DSM-III Antisocial Personality Disorder. This is manifest both in terms of high intercorrelations between the measures of psychopathy and impulsivity and in their predictive relationship to the level of psychological distress suggesting a uniform impulsivity/psychopathy construct. Thus, the research supports a model of pathological gambling in which the severity of associated behavioural and psychological disturbance is mediated by a impulsivity/ psychopathy construct.

Defective Self and/or Other Mentalising in Schizophrenia: A Cognitive Neuropsychological Approach.

The mentalising abilities of schizophrenic patients and normal controls were tested using picture sequencing and story-telling tasks that required subjects to infer causal mental states in story characters, and a recall task that required subjects to dissociate subjective mental states from objective realities. Selective mentalising deficits were found in some patients. For other patients, general sequencing errors, "sensory" mentalising, and poor recall of symbolic representations suggested more profound problems. Task results were best accounted for by dissociable cognitive abnormalities, rather than graded dysfunction of a central mentalising mechanism. Symptom profiles of patient subgroups and correlations between task measures and clinical ratings linked these cognitive abnormalities to specific symptoms. General sequencing difficulty was associated with both poverty symptoms and reality distortion, suggesting that two mechanisms may underpin such errors: one, inability to manipulate symbolic representations, being linked to poverty; the other, failure to critically evaluate plausible cause-and-effect, being linked to reality distortion. There was some evidence that defective self-monitoring underpins thought disorder. Impaired metarepresentation was linked to the autisticlike symptoms of flat affect, social dysfunction, and alogia, rather than reality distortion. Implications of these findings are discussed with respect to theoretical and methodological issues confronting current schizophrenia research.

Increased production of interleukin-2 (IL-2) but not soluble interleukin-2 receptors (sIL-2R) in unmedicated patients with schizophrenia and schizophreniform disorder.

This study investigated immune activation, as measured by production of interleukin-2 (IL-2) and soluble interleukin-2 receptors (sIL-2R) from stimulated lymphocytes, in schizophrenia and schizophreniform disorder. The study included 13 neuroleptic-free patients, 13 medicated patients and 13 age- and sex-matched control subjects. Production of IL-2 and sIL-2R by peripheral blood mononuclear cells (PBMCs) was measured after in vitro stimulation with phytohaemagglutinin (PHA). Patients' symptoms were rated on the Scales for Assessment of Positive (SAPS) and Negative Symptoms (SANS) and the Brief Psychiatric Rating Scale (BPRS). IL-2 production by stimulated lymphocytes was significantly elevated in neuroleptic-free patients compared with both medicated patients and control subjects. IL-2 production was inversely correlated with the SAPS subscales of bizarre behaviour and formal thought disorder. The pattern of increased IL-2 production is in contrast to previous findings in patients with schizophrenia. Significant associations with clinical rating scores suggest that IL-2 production may vary in different biological subgroups of schizophrenia and schizophreniform disorder.

Heterosexual and homosexual coercion, sexual orientation and sexual roles in medical students.

Rape has been conceptualized on a dimension of normal male behavior. The Koss and Oros (1982) study used a questionnaire that allowed men to respond only as sexual aggressors of women, and women only as victims of men. Medical students' responses to a modified questionnaire, in which both sexes reported being aggressors and/or victims, revealed that relatively comparable proportions of men and women were victims of coercive experiences: 35% of women and 30% of men experiencing constant physical attempts to have sexual activity. Forms of coercion not involving threat or use of force were more common, more exclusively heterosexual, and carried out by more equivalent percentages of men and women. 15% of women and 12% of men felt initially coerced into sexual activity but then enjoyed it. Threat or use of force to attempt to or to obtain intercourse were employed by 4% of men and 2% of women and experienced by 5% of both sexes. Half the male victims and female aggressors and a quarter of the male aggressors and female victims who reported such coercion stated it was homosexual. The ratio of homosexual/heterosexual feelings reported by male, but not female, students correlated with the degree of the homosexual coercion they both carried out and experienced. The degree of sexual coercion carried out by men and women correlated with their masculine sex role scores, suggesting, if the dimensional concept of rape is valid, that rape is on a continuum with masculine rather than male behaviors.

Sissiness, tomboyism, sex-role, sex identity and orientation.

Masculinity and femininity have been studied by self-ratings in independent areas of research: one investigating personality traits considered masculine (M) or feminine (F); the other, behaviours statistically more common in one than in the other sex (sex-linked behaviours). The two approaches were compared for the first time in the present study of 66 male and 51 female medical students. Consistent with previous findings using the second approach, male but not female subjects' opposite sex-linked "sissy" and "tomboyish" behaviours correlated significantly with their reported ratio of homosexual to heterosexual feelings (Ho/Het). Ho/Het did not correlate with either sex's M and F scores, but high M scores in women correlated strongly with several "tomboyish" behaviours. As "tomboyish" behaviours are shown more strongly by women exposed prenatally to increased levels of opposite sex hormones compared to controls, the findings have implications for the biological theory attributing Ho/Het to such prenatal hormonal exposure.

Brain potential evidence for an auditory sensory memory deficit in schizophrenia.

OBJECTIVE: The multiple disorders of selective attention found in schizophrenia could be secondary to disturbances in sensory processing. The authors investigated this possibility by using an event-related potential index of auditory sensory memory, called "mismatch negativity." METHOD: Medicated (N = 11) and neuroleptic-free (N = 11) patients with schizophrenia and patients with bipolar affective disorder (N = 11) were compared with age- and sex-matched healthy comparison subjects. Auditory stimuli were presented while the subjects were distracted with an attention-demanding visual task. Event-related potentials were elicited by infrequently occurring auditory stimuli (deviants) and by regularly presented auditory stimuli (standards), which differed slightly in duration. The difference in amplitude between the event-related potentials elicited by the deviant and standard stimuli was the mismatch negativity. RESULTS: The amplitude of the mismatch negativity was significantly lower in both groups of schizophrenic patients than in the healthy comparison subjects. Mismatch negativity amplitude was significantly correlated with ratings of negative schizophrenic symptoms but not with positive symptoms. Compared with the matched comparison subjects, the bipolar affective disorder patients did not show lower amplitude of mismatch negativity. There was a significant negative correlation between age and mismatch negativity amplitude. CONCLUSIONS: The abnormal auditory sensory memory processing indicated by low mismatch negativity amplitude in the schizophrenic patients cannot be accounted for by neuroleptic medication status. Because this abnormality was significantly related to measures of negative symptoms only, it may be a chronicity marker or reflect a predisposition to the development to schizophrenia. These findings implicate the auditory cortex in the pathophysiology of schizophrenia.

Opposite sex-linked behaviors and homosexual feelings in the predominantly heterosexual male majority.

Whether homosexual feelings are distributed categorically or dimensionally remains controversial. In an earlier series of studies, medical students anonymously reported a dimensional distribution of homosexual feelings, the ratio of homosexual to heterosexual feelings in men correlating with opposite sex-linked behaviors in childhood and adolescence, and, in both sexes, with current degree of opposite sex identity. Prevalence of homosexual feelings was markedly higher than that found in nonanonymous studies. In the present investigation, a study of male twins allowed investigation of the findings in 411 educationally more representative subjects. Awareness of some homosexual feelings was reported in adolescence by 20% and currently by 12%. As with medical students, the majority of those who reported some homosexual feelings were predominantly heterosexual, which could be considered to indicate such feelings were distributed dimensionally. Correlations between degree of homosexual feelings and avoidance of contact sport in childhood and adolescence, current wish to be of the opposite sex, and opposite sex identity remained present when subjects with equally bisexual and predominantly homosexual feelings were excluded from analysis. The finding that the majority of men with homosexual feelings are predominantly heterosexual renders implausible the theory that homosexual feelings result from fear of heterosexuality.

Criminal offenses in gamblers anonymous and hospital treated pathological gamblers.

The purpose of this study was to compare the nature and prevalence of gambling and non-gambling related offenses in samples of pathological gamblers seeking behavioural treatment from a hospital-based program and those attending Gamblers Anonymous. A semi-structured interview schedule obtaining demographic data and details of the nature, frequency, and consequent legal action of criminal offenses committed was administered to 152 consecutive hospital treated pathological gamblers, and 154 Gamblers Anonymous attendees who volunteered to participate in the study. Of the total sample, 59% admitted a gambling-related offense, and 23% to a conviction. There was no difference in the proportion of hospital treated and Gamblers Anonymous subjects who offended. The most common gambling-related offenses were larceny, embezzlement and misappropriation. Gamblers committed a median of ten offenses over an average ten year period of pathological gambling with a median value of $ A 300(1) per offense. The median value for each non-gambling-related offense was $ A 130. Except for the significantly older mean age of Gamblers Anonymous subjects, hospital treated gamblers did not differ from Gamblers Anonymous attenders on relevant demographic features or parameters of gambling behaviour. Findings were interpreted to suggest a possible causal link between pathological gambling and the commission of non-violent property offenses.