Barbara E. McDermott

Etiologic Heterogeneity of the Psychoses: Is There a Dopamine Psychosis?

The distribution of drug-free plasma homovanillic acid (pHVA) concentrations was studied in a sample of psychotic patients, some of whom were selected for good prognostic features. Baseline pHVA was bimodally distributed, suggesting two different patient populations. The high-pHVA patients showed periods of better functioning and/or fewer symptoms 5 years before admission (p <. 05) and had a more rapid (p <. 05) and complete (p <. 001) subacute neuroleptic response than lower-pHVA psychotics. High-pHVA psychotics did not differ in other aspects of demographics or clinical presentation from lower-pHVA psychotics. Compared to the general population, there were more psychotics in the families of high-pHVA patients (p <. 005). Rapid antipsychotic response by high-pHVA psychotics is consistent with blockade of the effects of excess synaptic dopamine at D2 receptors for these patients. Results are discussed in the context of the syndromic heterogeneity of the psychoses.

Patterns of neuropsychological deficit in cases of schizophrenia spectrum disorder with and without a family history of psychosis.

This study was designed to identify the types of neuropsychological deficits that are unique to familial and nonfamilial forms of schizophrenia. Seventy-two patients who met Research Diagnostic Criteria for schizophrenia or schizoaffective disorder, mainly schizophrenic, were divided into two groups on the basis of the presence or absence of a family history of psychosis. The two groups were then compared for differences on six neuropsychological parameters as well as for differences in psychotic symptoms. Multivariate analyses indicated that schizophrenic patients with a family history of psychosis showed significantly higher levels of overall neuropsychological deficit and significantly greater deficits on tests of motor-control and abstraction and problem-solving. Factor analyses indicate that schizophrenic patients with a family history of psychosis show a pattern of specific neuropsychological deficits, while schizophrenic patients without a family history show a pattern of more consistent cognitive deficits. The results of this study indicate that recent-onset schizophrenic patients with and without a family history of psychosis show distinctly different patterns of neuropsychological dysfunction. These data suggest that abnormalities in the dorsolateral prefrontal cortex and nonprimary motor areas may be associated with an increased familial risk for psychotic disorder.

Lipoplasty in the bulimic patient

Recent cases in our Eating Disorders Clinic suggest that patients diagnosed with bulimia nervosa seeking surgical fat removal may be exhibiting a variant of the purging behavior seen in bulimic patients. These same patients exhibit historical or concurrent abuse of laxatives and/or diuretics or self-induced vomiting in a pathologic attempt to obtain or maintain an idealized body image. This paper presents two case studies that illustrate the bulimic patients compulsive quest for lipectomy with unrealistic expectations that surgical alteration of the body will be an emotional and physical panacea. Plastic surgeons must be cautioned regarding this potential manifestation of bulimia nervosa and the dangers inherent in colluding with the patient in a pathologic request for surgery. It is important for plastic surgeons to recognize appropriate use of lipectomy as an alternative to traditional purging behavior in the bulimic patient.

Familial Differences between Rapid Neuroleptic Response Psychosis and Delayed Neuroleptic Response Psychosis

Recent data suggest that latency of neuroleptic response may be used to separate distinct subtypes of psychotic disorders. In this preliminary study we contrast family patterns of illness of rapid neuroleptic response psychotics and delayed neuroleptic response psychotics. The data show that first-degree relatives of delayed neuroleptic response psychotics evidence higher levels of psychiatric disorder than rapid responders: relatives of delayed neuroleptic response psychotics evidenced a morbid risk for schizophrenic-spectrum disorder that was more than twice as high as the morbid risk for such disorders among relatives of rapid neuroleptic response psychotics. Relatives of delayed neuroleptic responders that received a diagnosis of schizophrenia, schizoaffective, or schizophreniform disorder evidenced significantly more residual impairment than schizophrenic-spectrum relatives of rapid neuroleptic responders. These preliminary data indicate the possibility that latency of therapeutic response to neuroleptic medication may be used to discriminate two familially distinct psychotic disorders and they suggest that delayed neuroleptic response may characterize a familially transmitted poor-outcome disease.

Heterogeneity of schizophrenia: Relationship to latency of neuroleptic response

Patients with an index diagnosis of schizophrenia were compared to patients with an index diagnosis of schizophreniform disorder to determine if they differed in latency to therapeutic response to haloperidol. The results of a survival analysis showed that patients with a diagnosis of schizophreniform disorder responded to haloperidol significantly more rapidly than did patients with a diagnosis of schizophrenia. Inspection of time-to-response slopes revealed that approximately 75% of the schizophreniform patients responded to neuroleptics on or before day 8 of treatment, whereas only 20% of the schizophrenic patients responded this rapidly. Forty percent of schizophrenic patients responded between day 8 and day 18, and 30% between day 18 and day 36. These results indicate that schizophreniform disorder has been successfully separated from schizophrenia in DSM-III, at least in relationship to drug response.

Neuropsychological deficits in probands from multiply-affected schizophrenic families

This study was designed to determine if schizophrenics from families with more than one psychotic relative show more severe neuropsychological deficits than schizophrenics with only one psychotic relative, non-familial schizophrenics, and a group of matched normal controls. Eighty-one schizophrenic-spectrum patients were divided into three groups on the basis of the presence of psychotic disorder among first- and second-degree relatives. The three groups of schizophrenics and the normal controls were compared for differences on a brief neuropsychological testing battery. The four groups showed significant multivariate differences. Patients from multiply-affected families showed significantly greater neuropsychological dysfunction on measures of abstract concept formation, visuomotor-coordination, and attention than patients from families that had only one psychotic relative. Schizophrenics from low-density families showed more severe deficits in fine motor-control than non-familial schizophrenics. These data suggest that abnormalities in those frontal systems that are likely to mediate fine motor control and abstract concept formation may be related to the degree of familial loading for psychotic disorder.

The short-term course of familial and nonfamilial schizophrenic-spectrum disorder

This study was designed to determine if familial and nonfamilial forms of schizophrenia show a different short-term illness course. Sixteen familial and 22 nonfamilial schizophrenics were evaluated on three occasions at regular 6-month intervals over an 18-month period. The familial and nonfamilial groups were compared for differences in positive and negative symptoms of psychosis and interpersonal and occupational role functioning. The data show that familial schizophrenics experience significantly higher levels of positive symptoms of psychosis and significantly worse occupational role functioning. Significant time by family history interactions indicates that the negative symptoms and interpersonal role functioning of the familial schizophrenics changed over the course of follow-up while remaining stable over time in the nonfamilial group. These data provide preliminary support for the hypothesis that familial schizophrenics show a higher degree of impairment during follow-up than nonfamilial schizophrenics.

A family study of lithium-responsive psychosis

Psychiatric life histories of 487 first-degree family members of 24 lithium-responsive (mood-incongruent) psychotics, 54 lithium-nonresponsive (mood-incongruent) psychotics, and 18 lithium-responsive patients with bipolar (manic-depressive) disorder were contrasted. While the morbid risk of schizophrenic-spectrum was 11.1% in relatives of lithium-nonresponsive probands, the morbid risk for such disorders was only 2.4% in relatives of lithium-responsive (mood-incongruent) psychotics (P less than 0.05). This lithium-responsive illness appears to be familially, and perhaps genetically, distinct from the bulk of the schizophrenias.

The course of DSM‐III‐R schizophreniform disorder

This study compared the course of illness of 36 patients who received a diagnosis of either DSM-III-R schizophreniform disorder or schizophrenia. Approximately 3.5 and 4.0 years after their index hospitalization, the two groups were compared for differences in positive and negative symptoms of psychosis, interpersonal and occupational role functioning, and other aspects of the deficit state. Multivariate data analyses indicate that the course of illness of the two groups is significantly different (p < .007), and the data also indicate that patient symptoms and functioning changed significantly over time (p < .008). The schizophreniform patients showed a low level of negative symptoms at both follow-ups; schizophrenics initially showed a higher level of negative symptoms, but these symptoms decreased significantly over time (p < .04). These data indicate that the course of DSM-III-R schizophreniform disorder is distinct from the course of schizophrenia.