Alexei Gil

The association of child abuse and neglect with adult disability in schizophrenia and the prominent role of physical neglect

OBJECTIVE To assess long-lasting effects of childhood trauma on the functional outcome of adult patients diagnosed with schizophrenia. METHOD Ninety-nine stable patients with schizophrenia followed in an outpatient program at a public university hospital in Porto Alegre, southern Brazil, were investigated for childhood traumatic experiences by the Childhood Trauma Questionnaire (CTQ) and for functional impairment by the World Health Organization Disability Assessment Schedule (WHO/DAS). The schizophrenia diagnosis was assessed by ICD-10 and DSM-IV criteria according to the Operational Criteria Checklist for Psychotic Illness (OPCRIT). RESULTS Childhood trauma in general was associated with increased disability in adulthood, reflected by impaired Overall Behavior (p=.023) and Global Evaluation (p=.032). Analysis of specific traumatic domains revealed that increased childhood physical neglect was associated with functional impairment in Overall Behavior (p<.000), Social Role Performance (p=.037) and Global Evaluation (p=.014). Higher emotional abuse was associated with impaired Overall Behavior (p=.026), and higher emotional neglect with poor Global Evaluation (p=.047). Additionally, earlier onset of illness was associated with lower level of functioning evidenced by impairment in Overall Behavior (p=.042). Linear regression using WHO/DAS sections (Overall Behavior, Social Role Performance and Global Evaluation) as dependent variables and CTQ subscales indicated that only physical neglect had an effect on adult functionality. CONCLUSIONS Childhood trauma was associated with functional and social impairment in adult patients with schizophrenia. Specific types of abuse and neglect, such as physical neglect and emotional abuse and neglect, influenced disability, and the most robust association was physical neglect. Studies involving more patients, with normal controls and additional measurements of biological liability, should be conducted to confirm this association and to increase the understanding of gene-environment relationship in schizophrenia and pathways to disability. PRACTICE IMPLICATIONS Further investigation is warranted to clarify the association between childhood trauma and disability in schizophrenia, as well as to develop standardized instruments for the assessment of trauma and earlier detection of risk along with education of patients and families about adequate care, in an effort to reduce the incidence of disability in schizophrenia.

A pilot double-blind sham-controlled trial of repetitive transcranial magnetic stimulation for patients with refractory schizophrenia treated with clozapine

Schizophrenia is a complex and heterogeneous psychiatric disorder. Auditory verbal hallucinations occur in 50-70% of patients with schizophrenia and are associated with significant distress, decreased quality of life and impaired social functioning. This study aimed to investigate the effects of active compared with sham 1-Hz repetitive transcranial magnetic stimulation (rTMS) applied to the left temporal-parietal cortex in patients with schizophrenia treated with clozapine. Symptom dimensions that were evaluated included general psychopathology, severity of auditory hallucinations, quality of life and functionality. Seventeen right-handed patients with refractory schizophrenia experiencing auditory verbal hallucinations and treated with clozapine were randomly allocated to receive either active rTMS or sham stimulation. A total of 384 min of rTMS was administered over 20 days using a double-masked, sham-controlled, parallel design. There was a significant reduction in Brief Psychiatric Rating Scale (BPRS) scores in the active group compared with the sham group. There was no significant difference between active and sham rTMS on Quality of Life Scale (QLS), Auditory Hallucinations Rating Scale (AHRS), Clinical Global Impressions (CGI) and functional assessment staging (FAST) scores. Compared with sham stimulation, active rTMS of the left temporoparietal cortex in clozapine-treated patients showed a positive effect on general psychopathology. However, there was no effect on refractory auditory hallucinations. Further studies with larger sample sizes are needed to confirm these findings.

Repeated transcranial magnetic stimulation effect over treatment-resistant auditory hallucinations in a female patient with schizophrenia

A 59 year-old female patient, who had her illness onset at age 26, presented to treatment with persistent and severe auditory hallucinations and persecutory delusions. Over 33 years she was continuously treated with several typical and atypical antipsychotics at full therapeutic dosages and for sufficient time, having had slight improvement of overall status, maintaining severe hallucinations and delusions and related social and professional disability and impairment. After 11 unilateral electroconvulsive therapy sessions her Brief Psychiatric Rating Scale (BPRS) scores dropped from 33 to 22, and her Mini-Mental State Examination (MMSE) dropped from 28 to 19. However, the treatment was interrupted due to cognitive side effects. She was maintained on clozapine 800 mg/day, amisulpride 600 mg/day and lamotrigine 400 mg/day for one year, with limited effect over social activities and persecutory delusions, maintaining severe auditory hallucinations (AHS = 30). In early 2005 she received twenty 20-minute sessions of 1-Hz LTPC rTMS, at 90% motor threshold with a clinically relevant 50% AHS reduction. The largest effects were in auditory hallucinations frequency and intensity. Patient, relatives and Care Provider reported global improvement in social and family interaction and self-care. One year after the first treatment, the patient reported recurrence of the auditory hallucinations and received the same treatment protocol with significant symptom improvement, having AHS scores dropped from 24 to 17 and BPRS scores from 43 to 15, without cognitive deficits (MMSE = 28). Patient and relatives reported marked improvement in spontaneity, social skills, and family relations. These findings not only replicate previous studies, but also suggest that patient’s outcomes goes beyond symptom relief, including reduction of negative symptoms and improvement in quality of life. We also suggest that large-duration protocols may be better, and that effects may last about 6-8 months, being the treatment repetition capable to induce similar effects, without the development of tolerance. These findings require replication in larger samples using sham-control led double-bl ind procedures, and with the assessment of additional outcomes, such as quality of life and affect regulation. Dear Editor, Treatment-resistant auditory hallucinations (TRAH) occur in 20% of treated schizophrenia patients and contribute to disability and morbidity. Repeated transcranial magnetic stimulation (rTMS) is a recent strategy for TRAH which has been tested in around 20 randomized controlled trials, and found controversial results. Hoffmann et al. reported data from 50 schizophrenia/schizoaffective disorder patients showing superiority of rTMS over sham stimulation in auditory hallucinations with a 9-day, 1-Hz stimulation in the left temporo-parietal cortex (LTPC), using the Auditory Hallucination Hoffmann Scale (AHS) and the Clinical Global Impression Scale (CGI) as assessment instruments. Similar studies evidenced conflicting results putatively due to differences in stimulation parameters, such as length, number, potency, interval, and brain side. Session number was important in treatment – resistant depression, with clear superiority of 20-session over 10-session protocols. Additionally, in the studies reviewed, all interventions were provided for short time span, with no randomized controlled trials providing long-duration rTMS and prolonged follow-up. We describe here one case of a patient with TRAH who was submitted to a long-duration rTMS (20 days), followed by initial remission and further relapse after 10 months, although with a significant improvement after repeated intervention. Carta aos editores

Aspectos do funcionamento de uma unidade de internação psiquiátrica de um hospital geral

The aim of this study is describe the general hospital psychiatric unit functioning regarding their empirical and practical aspects. Getting together to care many inpatients with several mental disorders can be a hard task. The pharmacology is empirical and palliative despite great efforts and development neuroscientific in last years. Try to discuss the conducts and management of the care with this inpatients can brig the light to the know how to proceed with them, mainly for who is beginning the psychiatric practice like students and residents.

Humor e psicose em esquizofrenia: explorando fronteiras diagnósticas com o Inventário de Critérios Operacionais para Doenças Psicóticas (OPCRIT) e o caso John Nash

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.

Ánimo y psicosis en esquizofrenia: explorando fronteras diagnósticas con el Inventario de Criterios Operacionales para Enfermedades Psicóticas (OPCRIT) y el caso John Nash

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.

Mood and psychosis in schizophrenia: exploring diagnostic frontiers with the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and John Nash case

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.