Insights from Expanded Adverse Childhood Experiences Screening in a Hospital-Based Outpatient Psychiatry Service.

Adverse childhood experiences (ACEs) are associated with poor mental health in adulthood. Comprehensive prevalence data encompassing all 10 ACE questionnaire items has not previously been described in a hospital-based outpatient psychiatric clinic. This study assessed the prevalence of 10 ACEs in such a clinic and correlated ACEs with indicators of case severity. For 252 patients newly evaluated in an urban clinic, a retrospective chart review was completed and data was collected on ACE questionnaire responses, psychiatric, substance-related, and medical diagnoses, psychiatric hospitalizations, suicide attempts, and suicide and violence risk. Patients in the clinic had an average of 3.4 ACEs, higher than national community sample averages of 1.6. The percentages of patients with at least one, two, and four ACEs were 82% (n = 207), 68% (n = 172), and 42% (n = 106) respectively (compared with 61%, 38%, and 15% nationally). ACEs had statistically significant correlations with an increased number of psychiatric diagnoses, substance use disorders, medical illnesses, suicide attempts, and suicide risk level. This study demonstrated that patients seeking psychiatric care from a hospital-based outpatient clinic are likely to be traumatized to a degree far exceeding what is typical in the general population. While a high prevalence of ACEs in a psychiatric population is an expected finding given the literature to date, this is the first study presenting data on the prevalence of ACEs in such a hospital-based community clinic. Additionally this study reinforces prior research correlating childhood adversity and case severity.

Facial and Vocal Markers of Schizophrenia Measured Using Remote Smartphone Assessments: Observational Study.

BACKGROUND: Machine learning-based facial and vocal measurements have demonstrated relationships with schizophrenia diagnosis and severity. Demonstrating utility and validity of remote and automated assessments conducted outside of controlled experimental or clinical settings can facilitate scaling such measurement tools to aid in risk assessment and tracking of treatment response in populations that are difficult to engage. OBJECTIVE: This study aimed to determine the accuracy of machine learning-based facial and vocal measurements acquired through automated assessments conducted remotely through smartphones. METHODS: Measurements of facial and vocal characteristics including facial expressivity, vocal acoustics, and speech prevalence were assessed in 20 patients with schizophrenia over the course of 2 weeks in response to two classes of prompts previously utilized in experimental laboratory assessments: evoked prompts, where subjects are guided to produce specific facial expressions and speech; and spontaneous prompts, where subjects are presented stimuli in the form of emotionally evocative imagery and asked to freely respond. Facial and vocal measurements were assessed in relation to schizophrenia symptom severity using the Positive and Negative Syndrome Scale. RESULTS: Vocal markers including speech prevalence, vocal jitter, fundamental frequency, and vocal intensity demonstrated specificity as markers of negative symptom severity, while measurement of facial expressivity demonstrated itself as a robust marker of overall schizophrenia symptom severity. CONCLUSIONS: Established facial and vocal measurements, collected remotely in schizophrenia patients via smartphones in response to automated task prompts, demonstrated accuracy as markers of schizophrenia symptom severity. Clinical implications are discussed.

Childhood adversity and psychotic disorders: Epidemiological evidence, theoretical models and clinical considerations.

While genetic factors play a critical role in the risk for schizophrenia and other psychotic disorders, increasing evidence points to the role of childhood adversity as one of several environmental factors that can significantly impact the development, manifestations and outcome of these disorders. This paper reviews the epidemiological evidence linking childhood adversity and psychotic disorders and explores various theoretical models that seek to explain the connection. We discuss neurobiological parallels between the impact of childhood trauma and psychosis on the brain and then explore the impact of childhood adversity on different domains of clinical presentation. Finally, implications for prevention and treatment are considered, both on individual and structural levels.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A validation study of a novel tool for suicide risk assessment.

BACKGROUND: Reliable diagnostic tools for the short-term suicide risk assessment are needed. The recently developed multi-informant Modular Assessment of Risk for Imminent Suicide (MARIS) includes four modules: two are patient-rated and two clinician-rated. The patient-rated modules assess a proposed pre-suicidal cognitive/emotional state (Module 1) as well as patients' attitudes towards suicide (Module 2). The clinician-rated modules assess traditional suicide risk factors (Module 3) and clinicians' emotional responses to the patient (Module 4). METHODS: With the aim of extending our previous preliminary proof of concept findings, the MARIS was administered to 618 psychiatric patients (167 inpatients, 451 outpatients) and their clinicians (N = 115). Patients were assessed with a battery including the Columbia-Suicide Severity Rating Scale. Four outcomes were considered: lifetime and past month suicidal thoughts and behaviors (STB) (0-10 point scale) and suicidal behaviors (SB) (0-5 point scale). Reliability and concurrent, convergent/divergent and incremental validity were assessed. RESULTS: Good internal consistency was found for modules 1 and 4 (Cronbach's α: 0.87 and 0.86, respectively) but not for the others. Module 1's total score positively correlated with lifetime STB/SB and past month STB (all p ≤ 0.003). Module 4's total score positively correlated with all four outcomes (all p < 0.001). Modules 1 and 4 showed additional capacity to detect patients' lifetime and past month STB/SB beyond other associated factors. LIMITATIONS: Lack of prospective assessment. Inpatients were evaluated at discharge, whereas outpatients at intake. CONCLUSIONS: These findings supported the utility of multiple data sources to identify patients at imminent suicide risk, and in particular clinicians' emotional responses.

Emotional Pain Mediates the Link Between Preoccupied Attachment and Non-suicidal Self-Injury in High Suicide Risk Psychiatric Inpatients.

Background: Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts (SA). Both attachment disturbances and cognitive and emotional problems (e.g., emotional pain) have been associated with SA history. This study sought to determine differential contributions of attachment styles and cognitive and emotional states associated with SA to lifetime NSSI occurrence among adults hospitalized for suicide risk. Sampling and Methods: Adult psychiatric inpatients (n = 200) were assessed for attachment style, cognitive and emotional states, and lifetime NSSI within 72 h of hospitalization. Binary logistic regression and mediation analyses were performed. Results: Preoccupied attachment and emotional pain at admission were independently associated with lifetime NSSI. Emotional pain partially mediated the relationship between preoccupied attachment and lifetime NSSI. Limitations: The cross-sectional nature of the study and the use of a dichotomous (yes/no) measure of NSSI, not specifically designed for its assessment. Conclusions: Preoccupied attachment and emotional pain are associated with NSSI and may be useful targets for assessing risk of NSSI.

Complex PTSD in ICD-11: A Case Report on a New Diagnosis.

The World Health Organization (WHO) has included complex post-traumatic stress disorder (C-PTSD) in the final draft of the 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), which was published in June, 2018 and is scheduled to be submitted to WHO's World Health Assembly for official endorsement in 2019. Mental health providers will want to be informed about this diagnosis in order to provide effective treatment. Complex PTSD, or developmental PTSD as it is also called, refers to the constellation of symptoms that may result from prolonged, chronic exposure to traumatic experiences, especially in childhood, as opposed to PTSD which is more typically associated with a discrete traumatic incident or set of traumatic events. Although it has been a controversial diagnosis and is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), lines of evidence support its distinct profile and utility. In this case study, we elucidate and discuss some aspects of the diagnosis and its treatment.

Later paternal age and sex differences in schizophrenia symptoms.

OBJECTIVE: Advanced paternal age is consistently associated with an increased risk for schizophrenia, accounting for up to a quarter of cases in some populations. If paternal age-related schizophrenia (PARS) involves a distinct etiopathology, then PARS cases may show specific characteristics, vis-à-vis other schizophrenia cases. This study examined if PARS exhibits the symptom profile and sex differences that are consistently observed for schizophrenia in general, wherein males have an earlier onset age and more severe negative symptoms than females. METHOD: Symptoms were assessed at baseline (admission) and during medication-free and treatment phases for 153 inpatients on a schizophrenia research unit, 38 of whom fulfilled operationally defined criteria for PARS (sporadic cases with paternal age > or = 35). RESULTS: Males and females with PARS had the same age at onset and a similar preponderance of negative symptoms, whereas the other (non-PARS) cases showed the typical earlier onset age and more severe negative symptoms in males. When medications were withdrawn, PARS cases showed significantly worse symptoms than non-PARS cases (higher total PANSS scores and positive, activation, and autistic preoccupation scores). However these symptoms globally improved with antipsychotic treatment, such that the differences between the PARS and other schizophrenia cases receded. CONCLUSION: The lack of sex differences in the age at onset and the greater severity of medication-free symptoms bolster the hypothesis that PARS has a distinct etiopathology. It also suggests that female sex does not exert a protective effect on the course of PARS, as it may in other forms of schizophrenia.

Poison or cure: meanings of medication in schizophrenia.

Antipsychotic medications provide tremendous relief to many individuals with schizophrenia, but can have significant costs, including adverse metabolic, neurological, and psychological effects. Prescribers and consumers of these medications often have different perceptions of the safety and utility of medications, ranging from "poison" to "cure." While much of the literature on the meaning of medication in schizophrenia discusses patients' negative perceptions of medication, poor insight, and other risk factors for nonadherence, a variety of additional factors should be considered, including both doctors' and patients' perspectives. Historical, cultural, and scientific, as well as individual factors, influence both the prescribing and taking of antipsychotic medications. The relationship between doctors and patients, as informed by these factors, plays a central role in the creation of the meanings of medications. An understanding of this relationship can help to establish more collaborative treatment relationships, beyond the dichotomy of poison or cure.

High-dose ziprasidone-induced acute dystonia.

There are few clinical data describing the relative risks of extrapyramidal symptoms (EPS) at higher doses of ziprasidone (i.e., greater than 160 mg/day) when compared to lower doses. We report on a patient who displayed no EPS with ziprasidone 160 mg/day for several months, but did display marked, acute dystonic reactions on ziprasidone 240 mg/day. The observations from the present case indicate that high-dose, ziprasidone-induced acute dystonia may occur even if no such side effects have been experienced at doses up to and including 160 mg/day.

Striking a balance: training medical students to provide empathetic care.

INTRODUCTION: Medical students face many challenges as they progress through training, some of which refer to learning how to manage the stresses and anxiety of confronting illness and suffering. In trying to relieve anxiety, they may develop maladaptive responses that lead to a decrease in their level of empathy for patients. Education should aim to teach students how to deal with their responses so that they can tolerate patients' distress and treat them effectively. AIMS: This paper will address central dilemmas in students' attitudes towards patients during clerkships and suggest positive developmental goals to strive for in this formative time. It may be used as a reference tool for medical student educators and medical students to elucidate the educational tensions in teaching and learning about how to provide empathetic care. CONCLUSION: Students and teachers can benefit from an awareness of the tension between the poles of pathology and health, not knowing and too much knowing, vulnerability and denial and reaction and inaction. Medical students can learn adaptive methods of managing their anxiety about dealing with illness and death and strike a balance in their approach to patients.

Olfactory identification and WAIS-R performance in deficit and nondeficit schizophrenia.

INTRODUCTION: An expanding database supports the notion that the deficit syndrome (DS) is a discrete condition within schizophrenia and recent data argues that Smell Identification Deficits (SID) may have a primary relationship with its pathophysiology. If so, then the relationship of University of Pennsylvania Smell Identification Test (UPSIT) scores with other neurocognitive measures in DS patients may point to the neural substrate of the deficit syndrome. METHOD: We examined the relationship of UPSIT scores and Wechsler Adult Intelligence Scale-Revised (WAIS-R) performance in 46 DSM-IV schizophrenia patients. The Schedule for the Deficit Syndrome (SDS) interview was used to subgroup the sample into 13 DS and 33 nondeficit syndrome (NDS) patients. RESULTS: DS and NDS groups had similar mean ages, age of onset, and GAF scores, but DS patients had fewer years of education. DS and NDS patients also did not differ in full scale, verbal or performance IQ or in any WAIS-R subtest. However, UPSIT scores were significantly worse in the DS patients, most of whom met criteria for a clinically meaningful olfactory impairment. In DS patients, UPSIT scores were significantly correlated with Performance IQ, Block Design, and Object Assembly, all of which are associated with complex visual-motor organizational function thought to be mediated by parietal circuitry. UPSIT scores in NDS patients were significantly related with Vocabulary, Similarities, and Digit Symbol subtests, which are indicative of verbal functioning. CONCLUSION: These preliminary data support previous findings suggesting that in addition to frontal neuropsychological abnormalities, DS patients may have greater performance impairments on tasks associated with parietal functioning. Our findings furthermore suggest that the parietal circuitry may be a conspicuous substrate for impaired odor identification ability in these patients. The lesser abnormalities in UPSIT ability in NDS patients may be attributed to verbal ability. These data are preliminary and further investigations with larger samples are needed to support our findings.