Changing perceptions of illness in the early course of psychosis: psychological pathways to self-determination and self-management of treatment.

Treatment early in the course of psychosis can improve prognostic outcomes, facilitate adaptive functioning, and reduce familial and societal burden. However, little is known about the pathway of first episode psychosis (FEP) from the perspective of highly adherent adolescents and young adults. This study sought to understand the pathways in youth self-determination and self-management of treatment by investigating youth and parents' changing perceptions of illness in the early course of psychosis. Twenty-eight (n = 28) interviews were conducted using a semistructured interview guide on 12 adolescents following their FEP hospitalization and 16 parents. Standardized self-report forms and hospital inpatient records were used to collect and confirm demographic and clinical data. On average, three years had passed from initial hospitalization (age 16.2 years, SD = 1.2) to time of interview (age 19.3 years, SD = 2.3), thus allowing for a range of experiences across the early period of illness. Highly adherent adolescents experienced identifiable temporal phases of early psychosis, comprised of emergent and specific themes. Parents described a parallel pathway toward supporting their child's self-determination and self-management of treatments, with some distinct experiential differences. Five dominant themes that emerged across time were symptom recognition, awareness of change, negative appraisals, positive appraisals, and treatment self-management. Examining how these themes evolve over the early course of psychosis can help guide interventions that are compatible with the parent and adolescent's perceptions of illness at that point in time, and can therefore work in concert with the family's existing efforts to understand and manage their emerging condition and progress toward recovery.

Use of atypical antipsychotic medications in adolescent psychiatric inpatients: a comparison with inpatients who did not receive antipsychotic medications during their stay.

The use of atypical antipsychotic medications has been reported to be increased in adolescent psychiatric outpatients and to include many patients with non-psychotic disorders. This study examined the correlates of antipsychotic usage in adolescent inpatients and compared their characteristics with a sample of adolescent inpatients who did not receive antipsychotics during their hospitalisation. A total of 159 consenting consecutive patients treated with atypical antipsychotic medications were compared with 150 patients who were admitted during the same time period and not treated with antipsychotics. The samples were compared for demographic factors, clinical diagnoses, clinical symptoms at admission and other medications received during their inpatient stay. Sex and ethnicity did not differ significantly as a function of antipsychotic mediation status. Significantly few patients with an admission diagnosis of major depression received antipsychotic medications and more patients with admission diagnosis of bipolar and/or conduct disorder were treated with antipsychotic medications. Clinical symptom differences and additional medications received were consistent with the differences in admission diagnoses. Despite the fact that significantly fewer patients with major depression received antipsychotic medications, 47% of the patients who did receive antipsychotic medications in this study had an admission diagnosis of major depression. There are several differences between these inpatient data and previous studies of outpatient claims databases, the majority of adolescent inpatient cases treated with antipsychotic medications had admission diagnoses consistent with both adult indications and previous research with adolescent patients. These data suggest an urgent need to study the safety and efficacy of atypical antipsychotic medications on aspects of depression in adolescents.

The relationship of the Rorschach Schizophrenia Index to psychotic features in a child psychiatric sample.

In this study we investigated the reliability and validity of the Rorschach Schizophrenia Index (SCZI) from Exner's (1978, 1993) Comprehensive System for a sample of 413 child psychiatric inpatients by examining relationships with the Personality Inventory for Children-Revised (PIC-R) and chart diagnoses. Interscorer reliability and internal consistency were acceptable. Multivariate analyses of variance results revealed significantly different PIC-R profiles for those with and without elevated SCZI scores, with significant differences emerging on the PIC-R Psychosis (PSY) scale and 2 cognitive triad scales (Intellectual Screening and Development), which have been reported to be more frequently elevated in PIC-R profiles of children with psychotic disorders. Significant differences were found across SCZI groups for the PSY scale, Reality Distortion scale, reality testing critical items and chart diagnoses of psychotic disorder. Implications for clinical interpretation of the SCZI with children and issues for further research with this population are discussed.

Diagnosis of manic episodes in adolescent inpatients: structured diagnostic procedures compared to clinical chart diagnoses.

This study examined the accuracy of clinical chart diagnoses of manic episodes in adolescent psychiatric patients, as well as treatment selection and patient outcome. A consecutive sample of 120 consenting adolescent patients was assessed at admission, discharge, and 30 and 120 days post-discharge. Clinical chart diagnoses were compared to research-quality diagnoses involving structured interview, chart review, and consensus. Agreement statistics were computed, and the symptom and treatment differences were compared between patients for whom there was and was not diagnostic agreement. Clinical diagnoses of manic episodes were more common than research diagnoses, and the rate of agreement between diagnoses was low (kappa = 0.15). Patients diagnosed as experiencing a manic episode by the clinical chart, but not via the research procedure, had reduced severity scores on elation and activity, and higher scores on depression. These patients also had more severe scores on depressive symptoms at follow-up. Manic episodes were diagnosed more frequently by clinicians relative to research-quality procedures. Patients who were diagnosed as experiencing manic episodes by the clinician, but not the research procedure, appeared to have depression and hostility, but not elation. The depression in these patients may not be adequately treated, and there are potential clinical implications of over-diagnosis of manic episodes in adolescents.

Development of an Infrequency-Psychopathology scale for the MMPI-A: the Fp-A Scale.

This article describes the development and initial validation of the Infrequency-Psychopathology scale, Fp-A, for the MMPI-A (Butcher et al., 1992). The scale parallels the Infrequency-Psychopathology scale, F(p), that has been developed for the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). Results demonstrated that the 40-item Fp-A scale is superior to the F scale at discriminating between faking-bad and accurate reports of psychopathology, although the improvement over F was modest, particularly when compared to the improvement found for the F(p) scale. The difference seemed to reflect the superiority of the MMPI-A F scale to the MMPI-2 F scale. Even so, the findings suggest that the identification of overreporting on the MMPI-A could potentially be enhanced by using Fp-A as an adjunct to the F scale.

A new perspective on gender orientation measurement with the MMPI-2: development of the Masculine-Feminine Pathology Scale.

A new scale of gender orientation for the MMPI-2 (Minnesota Multiphasic Personality Inventory-II; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) called the Masculine-Feminine Pathology Scale, or Mfp, was developed as an alternative to the available Mf, GM, and GF scales. It differs from previous scales in its emphasis on symptomatic correlates of gender. Items were included in the new scale if they (a) discriminated between male and female psychiatric patients and (b) were likely to be indicators of psychopathology. Statistical analyses suggested an acceptably reliable but factorially complex scale. When used to predict clinician ratings of global psychopathology, the scale demonstrated incremental validity over both the existing gender-related scales and the traditional clinical scales. Scores at the "feminine" end of the Mfp scale seem to reflect distress characterized by high levels of anxiety. Scores at the "masculine" end of the Mfp scale suggest a more composed interpersonal presentation, which may reflect an amoral attitude. It is suggested that the new scale may prove superior to the existing gender role scales as a supplement to other clinical scales. Avenues for future research with the Mfp scale are discussed.

Predictors of medication compliance after hospital discharge in adolescent psychiatric patients.

Failure in medication compliance in adult psychiatric patients is often found to be due to side effects or associated with unawareness of illness. Little research has been conducted on medication compliance in adolescent psychiatric patients. In this study, 97 adolescent psychiatric patients, including 46 with substance abuse, were followed up an average of 14 months after their discharge from inpatient psychiatric care. Compliance with prescribed medications was examined and the association between several potential predictors and compliance was examined. The overall rate of medication compliance was only 38% at 14-month follow-up, whereas the rate of patients stopping their medications because of side effects was only 23%. Significant predictors of compliance failures were general noncompliance with the discharge plan, followed by postdischarge substance abuse. Side effects did not contribute any additional variance when these factors were considered. These data suggest that medication compliance may be adversely impacted by general tendencies toward noncompliance with treatment, which may be mediated by several possible factors. Interventions to increase awareness of the need for psychotropic medications as well as careful monitoring for substance abuse relapse in this population are suggested.

Code type-specific tables for interpretation of MMPI-2 Harris and Lingoes subscales: consideration of gender and code type definition.

Normative tables for various MMPI-2 code types, which may be used to enhance the interpretation of the Harris and Lingoes subscales, were developed. It was found that scores on the subscales covaried significantly as a function of code type. Gender and code type definition strategy were considered as moderators of the relationship between code type and subscale scores, but neither accounted for a large enough proportion of variance to justify consideration in the tables.

Learning and memory in adolescent psychiatric inpatients with major depression: a normative study of the California Verbal Learning Test.

Depressed adults have deficits in memory functions, especially on demanding tasks, but few studies of depressed adolescents have been published. In order to examine the extent of memory impairment and its diagnostic specificity, adolescent inpatients with DSM-III-R diagnoses of Major Depression (n = 56), Conduct Disorder (n = 42), or mixed Depression and Conduct Disorder (n = 22) were tested on the California Verbal Learning Test (CVLT) and compared to each other, to CVLT norms, and to previously published CVLT norms for adults with Major Depression. Adolescents with Major Depression performed below normative standards on all aspects of the CVLT, but did not have a specific profile of memory impairments that was different from the two comparison samples. Relative to norms for adult patients with Major Depression, adolescent females under performed across all CVLT measures, but males did not differ from adults Depression in adolescence is not associated with specific memory impairments, but adolescent females with depression may have more severe deficits than depressed adults.

Empirical evaluation of the factorial structure of attention in adolescent psychiatric patients.

Adolescent psychiatric inpatients (N = 278) were examined with a structured battery of measures of attentional functioning. The factorial structure of the attentional performance was then examined through confirmatory factor analysis (CFA). Two conceptually related models of attentional functioning were compared to null and unifactorial comparison models. One of the conceptual models, previously described in a series of studies by Mirsky, separates attentional functions into four factors and the other conceptual model, developed by the present authors, collapses two of Mirsky's factors into one. Both of the substantive models fit the data with the four-factor model failing to improve substantially on the simpler three-factor model. These data provide support for the validity of the Mirsky model of attention and suggest that these factors merit further research to validate the brain localization hypotheses that underlie them.

Empirical assessment of the factorial structure of clinical symptoms in schizophrenic patients: formal thought disorder.

Male schizophrenic patients (n = 142) were examined with a clinical assessment of their language dysfunctions with the Scale for the Assessment of Thought, Language, and Communication (TLC). Confirmatory factor analyses were conducted to test the relative fit of several differential theoretical models of the factorial structure of thought disorders. The models examined were positive-negative thought disorder, a three-factor model based on the results of an earlier exploratory factor analysis, and a simpler verbal productivity-disconnection model that can be extracted from other exploratory analyses and empirical studies. The positive-negative thought disorder model failed to fit the data, while the three-factor model fit the data, but no better than the simpler verbal productivity-disconnection model.

Psychometric vs. attentional correlates of early onset alcohol and substance abuse.

Adolescent inpatients with a diagnosis of alcohol abuse (n = 28), nonalcohol substance abuse disorders (n = 15), or psychiatric disorders without substance abuse (n = 46) were examined on measures of attentional, intellectual, and personality functioning. High scores on a personality measure, the Substance Abuse Proclivity Scale (SAP), was the best predictor of substance abuse in general. Alcohol abusers were differentiated from other substance abusers by their increased impairment on the Continuous Performance Test. Adolescents with alcohol abuse did not manifest the types of cognitive impairments associated with chronic alcoholism. These data suggest that certain attentional impairments may be associated with early onset alcohol abuse and that earlier conceptions of the role of attentional impairments in risk prediction for alcohol abuse are supported.

Evaluation of psychotherapeutic interpretations : an example of the application of the phenomenological method to discovery-based psychotherapy research.

If much psychotherapy literature goes unread and unused by therapists, one reason may be the apparent irrelevance of theory-derived hypotheses to actual practice. Methods that uncover tacit knowledge that practicing therapists already possess can provide the empirical basis for more relevant theories and the testing of more meaningful hypotheses. This study demonstrates application of the phenomenological method to the question of evaluating psychotherapy. To discover how experienced psychotherapists evaluate interpretations made in actual psychotherapy sessions, therapists were asked to evaluate such interpretations from videotapes; analysis of responses yielded a set of 10 dimensions of evaluation. Such methods offer both practical utility and a source of theoretical growth anchored in the real world of the practicing therapist.