An overview on Hebephrenia, a diagnostic cornerstone in the neurodevelopmental model of Schizophrenia.

Pre-Kraepelinian observations converged in Kahlbaum's and Hecker's description of Hebephrenia. For Kraepelin, Hebephrenia was an 'idiopathic incurable dementia whose onset is in adolescence'. It became the core of 'Dementia Praecox', and then Bleulerian 'Schizophrenia'. In recent decades, the resurgence of the 'late neurodevelopment' hypothesis of schizophrenia has brought into focus Hecker's clinical reports of adolescents who, as a result of a putative loss of psychic energy, showed a rapidly progressive cognitive impairment leading to functional and behavioural disorganization. This paper summarizes the nineteenth-century conceptualization of Hebephrenia as a developmental illness.

[Hebephrenia - a viable psychopathological construct?] / Hebephrenie ­ ein brauchbares psychopathologisches Konstrukt?

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

Psicosis de transferencia en la psicoterapia de la esquizofrenia crónica / Transference psychosis in the psychotherapy of chronic schizophrenia / Psychose de transfert dans la psychothérapie de la schizophrénie chronique

El autor, partiendo de su experiencia en la psicoterapia con pacientes esquizofrénicos ingresados en una institución, expone su modo de entender los movimientos transferenciales psicóticos, así como el modo en que el analista es convocado en su contratransferencia. Define cuatro modalidades: una primera en la que, partiendo de lo presimbiótico en Mahler, habla de relaciones autísticas en que la investidura no es humana o resulta inanimada o muy parcializada; una segunda en la que el vínculo es simbiótico y altamente ambivalente; una tercera, en la que los movimientos hacia la autonomía o independencia del sujeto se viven como ataques al objeto; y una cuarta en la que la confusión predomina en la relación y el objeto tiene que hacerse cargo del pensamiento del sujeto. Todo ello es ilustrado ampliamente por material clínico y puesto en discusión sobre todo con autores como Bion, Rosenfeld y Little

Drawing upon his experience in psychotherapy with schizophrenic inpatients, the author sets out his understanding of psychotic transference movements, and the way in which the analyst is summoned in his countertransference. He defines four modalities: a first, in which, drawing upon the pre-symbiotic in Mahler, he discusses autistic relationships in which investment is not human, or is inanimate or very partialized; a second, in which the link is symbiotic and highly ambivalent; a third, in experienced as attacks on the object; and a fourth, in which confusion predominates in the relationship and the object must take on the subject's thinking. All of this is extensively illustrated by clinical material and discussed primarily with authors such as Bion, Rosenf eld and Little

L' auteur, partant de son expérience dans la psychothérapie avec des patients schizophrenes hospitalisés en institution, expose sa façon de comprendre les mouvements transf érentiels psychotiques, ainsi que la façon dont l' analyste est convoqué dans son contretransfert. Il définit quatre modalités: la premiere, ou en partant du pré-symbiotique de Mahler, il parle de relations autistiques ou l'investissement n'est pas humain ou bien résulte inanimé ou tres partiel; une deuxieme, ou le lien est symbiotique et hautement ambivalent; une troisieme, ou les mouvements vers l' autonomie ou l'indépendance du su jet sont vécus comme des attaques al' objet, et une quatrieme, ou la confusion prévaut dans la relation et l'objet doit prendre en charge la pensée du sujet. Tout ceci est illustré largement par du matériel clinique et discuté surtout avec des auteurs tels que Bion, Rosenfeld et Little

Disorganised schizotypy is selectively associated with poorer semantic processing in non-clinical individuals.

The nature and severity of semantic memory (SM) impairments in schizophrenia has been related to symptoms, mainly formal thought disorder (FTD), and other clinical factors like length of illness. Symptom-related studies in schizophrenia are often confounded by clinical factors, for example medication and hospitalisations. We completed a schizotypy analogue study to examine the relationship between SM processing and FTD using an analogue schizotypy score referred to as cognitive disorganisation. Sixty individuals without a history of mental illness (M=22.92, SD=2.70) completed a schizotypy questionnaire and three semantic tasks - naming pictures, category fluency and semantic priming. Only decreasing fluency was associated with increasing cognitive disorganisation scores (p=0.029). In line with the prevailing dyssemantic theories, the results highlight that cognitive disorganisation is associated with some difficulties in SM processes, though not all. The observed differential relationships of SM processes to disorganised schizotypy are discussed in relation to previous work, and in terms of potential developmental trajectories for SM impairment in schizophrenia.

Prevalence of aggression in hospitalized patients with schizophrenia in China: A meta-analysis.

INTRODUCTION: Aggression is a major concern in psychiatric inpatient care. Variations in study designs, settings, populations and data collection methods render comparisons of the prevalence of aggressive behavior in high-risk settings difficult. We proposed to estimate the pooled prevalence of aggression among inpatients with schizophrenia in China. METHODS: Reports on aggressive behaviour involving physical contact or risks of interpersonal violence, in schizophrenia in Chinese general psychiatric wards were retrieved by using computer-assisted searches and manual searches of the reference lists of the relevant literature. Statistical analyses were conducted using the Comprehensive Meta-Analysis V2 software. Potential sources of heterogeneity were analyzed with Cochrane's Q analysis. RESULTS: The search yielded 19 eligible studies involving a total of 3,941 schizophrenia patients. The prevalence of aggressive behavior in psychiatric wards ranged between 15.3% and 53.2%. The pooled prevalence of aggression was 35.4% (95% CI: 29.7%, 41.4%). The most commonly reported significant risk factors for aggression were positive psychotic symptoms: hostility or suspiciousness, 78.9% (15 studies); delusions, 63.2% (12 studies); disorganized behavior, 26.3% (5 studies); and auditory hallucinations, 10.5% (2 studies); together with: past history of aggression, 42.1% (8 studies); and involuntary admission, 10.5% (2 studies). CONCLUSIONS: Aggressive behaviour is common in Chinese inpatients with schizophrenia. The prevalence figures indicate the need to identify reliable clinical and illness predictors for aggression in inpatient psychiatric wards and to test investigations aimed at reducing aggressive episodes and their adverse outcomes.

Correlation between neuropsychological and social cognition measures and symptom dimensions in schizophrenic patients.

Neurocognitive and social cognition deficits have been largely reported in Schizophrenia (SKZ) but their association with psychopathology remains uncertain. Our purpose was to explore the relationship between symptom dimensions and neuropsychological performances. We enrolled 35 stabilized schizophrenic outpatients of the Department of Psychiatry of Policlinico Hospital, University of Milan, who completed psychiatric Rating Scales, the Brief Assessment of Cognition in Schizophrenia (BACS) and the Executive and Social Cognition Battery (ESCB). Disorganized dimension seems to have the most significant impact on cognition, being associated with performance in several BACS subtests (verbal memory, working memory, motor speed, symbol coding, Tower of London) and ESCB tasks (MET and Hotel task number of tasks attempted, number of broken MET rules, sum of deviations in Hotel Task). Positive dimension correlated with performance in verbal fluency, negative dimension with IOWA Test results, cognitive dimension with MET number of inefficiencies and Eyes test score. Impulsive-aggressive and depressive dimensions weakly correlated only with Faux Pas test. Our study supports the existence of a specific disorganized dimension in SKZ, separated from cognitive dimension evaluated through clinical instruments (e.g. PANSS), but capable of influencing cognitive abilities. Furthermore, it strengthens the validity of ecological tasks in evaluating cognition in SKZ.

Psychiatric Autoimmunity: N-Methyl-D-Aspartate Receptor IgG and Beyond.

BACKGROUND: Descriptions of psychiatric autoimmunity beyond N-methyl-D-aspartate (NMDA) receptor encephalitis are sparse. OBJECTIVE: To report the autoimmune psychiatric spectrum currently recognized in Mayo Clinic practice. METHODS: Medical record review, testing of stored serum and cerebrospinal fluid for IgGs reactive with synaptic receptors and ion channels, neuronal nuclear and cytoplasmic antigens (including glutamic acid decarboxylase 65-kDa isoform) and case-control comparison were conducted. Patients were categorized into group 1, all adult psychiatric inpatients tested for neural autoantibodies (2002-2011; n = 213), and group 2, all Mayo NMDA receptor IgG-positive patients (2009-2013; n = 13); healthy control subjects were also included (n = 173). RESULTS: In group 1, at least 1 serum autoantibody (but not NMDA receptor IgG) was detected in 36 of 213 psychiatric inpatients. In total, 12 patients were determined retrospectively to have high-likelihood autoimmune encephalitic diagnoses. The most commonly detected autoantibody specificities were voltage-gated potassium channel ([Kv1] VGKC) complex (6) and calcium channel (P/Q type or N type; 5). Symptoms seen were as follows: depressive (8), anxious (7), psychotic (7), disorganized (5), suicidal (3), manic (1) and catatonic (1). In group 2, among 13 NMDA receptor IgG-positive patients, 12 had encephalitis; their psychiatric symptoms were as follows: depressive (9), catatonic (9), disorganized (8), anxious (8), psychotic (7), manic (6), and suicidal (3). Catatonic symptoms were more common in the 12 NMDA receptor IgG-positive patients than in the 12 group 1 patients with high likelihood of encephalitis (p = 0.002). Antibody positivities were usually low positive in value among healthy controls (12 of 16 vs 3 of 12 group 1 encephalitis cases, p = 0.025). NMDA receptor IgG was not detected in any healthy control subject. CONCLUSIONS: A spectrum of psychiatric autoimmunity beyond NMDA-R IgG may be under-recognized. Diagnosis is facilitated by combining results of comprehensive psychiatric, laboratory, radiologic, and electrophysiologic evaluations.

Association between psychopathology and suicidal behavior in schizophrenia. A cross-sectional study of 509 participants.

BACKGROUND: Suicide in schizophrenia is a serious problem--ideation rates go up to 40%, and approximately one half of patients attempt suicide at least once. The distinction between attempters and ideators is vital in everyday clinical practice. AIM: To explore the association between psychopathology and suicidal behavior in a comparative study of three groups of patients with schizophrenia: suicide ideators, suicide attempters, and subjects without suicide ideation and behavior. METHOD: The study included 509 patients: suicide attempters (n = 159), ideators (n = 180), and a comparative group (n = 170). The clinical assessment consisted of a structured psychiatric interview and an evaluation of sociodemographics, suicidality (SIBQ), psychopathology (PANSS), and depression (CDSS). RESULTS: Suicide attempters were more depressed than ideators, and both groups had higher CDSS scores than the comparative group. The overall contribution of positive, negative, and general PANSS symptoms was not statistically significant enough to differentiate ideators from attempters. A principal component analysis of the PANSS items revealed five components: disinhibition, withdrawal, anxiety and guilt, reality distortion, and disorganization. Two logistic regression analyses showed that suicide ideation or attempt was significantly related to depression, anxiety, guilt, gender, age, and number of previous hospitalizations. Compared to suicide ideators, attempters were more depressed, had a higher number of previous hospitalizations, and lower education. CONCLUSION: The results indicate that clinicians should look for depression, anxiety, and guilt feelings, while positive and negative symptoms seem to be less relevant for suicide assessment in schizophrenia.

Verbal working memory in individuals with schizophrenia and their first degree relatives: relationship with negative and disorganized symptoms.

OBJECTIVE: To determine whether there are differences in verbal working memory amongst subjects with schizophrenia, their first degree relatives and controls, and to evaluate the influence of symptoms on these differences, as an initial step to assess whether this cognitive function is an endophenotype. METHODS: We examined 197 cases with schizophrenia, 197 first degree relatives and 200 controls through psychiatric interviews and the Letters and Numbers Sequencing test (LNS). Performance was compared among the three groups adjusting for age, sex and education level. Adjustment for "negative symptoms" and "disorganization" was performed afterwards. RESULTS: Subjects with schizophrenia showed lower performance in the LNS than their first degree relatives and the healthy controls; the effect sizes were 0.75 and 1.18 respectively. There was a small difference between relatives and controls (effect size =0.38). These differences were significant after adjustment for negative and disorganized symptoms, but the effect sizes became smaller: 0.26 for relatives vs. subjects with schizophrenia, 0.56 for controls vs. subjects with schizophrenia and 0.33 for relatives vs. controls. Among individuals with schizophrenia, performance in the LNS was not associated with disorder duration, disease onset age, antipsychotics, history of depressive episodes or substance use disorders. CONCLUSION: Results suggest verbal working memory may be considered as an endophenotype in schizophrenia.

[Life-threatening complication of schizophrenia]. / Lebensbedrohliche Komplikation bei Schizophrenie.

The Wernicke Encephalopathy (WE) as a result of a (sub)acute thiamine deficiency remains, unfortunately, still under-diagnosed, especially among non-alcoholics. It should be considered in each occurrence of delirium as well as in any ocular motor disorder and ataxia, in particular if there is a history of weight loss with or without gastrointestinal symptoms. In cases with suspected WE an immediate intravenous substitution of 3×200 mg/d is recommended.