Catherine Gilvarry

Predicting violence in schizophrenia: a prospective study

BACKGROUND People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice. AIMS To estimate the risk factors for assault in patients with schizophrenia. METHODS Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up. RESULTS Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17-4.61), a previous violent conviction (OR 2.02, 95% CI 1.04-3.87), having received special education (OR 2.76, 95% CI 1.22-6.26) and alcohol abuse (OR 3.55, 95% CI 1.24-10.2). CONCLUSIONS Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Autoimmune diseases in the pedigrees of schizophrenic and control subjects

Autoimmune diseases aggregate in individuals and within pedigrees, and it has been postulated that autoimmune mechanisms may account for a proportion of schizophrenia. Structured questionnaires were used to interview the mothers of 121 DSM-III-R schizophrenic patients and the mothers of 116 controls in order to determine the prevalence of schizophrenia and of autoimmune diseases in their pedigrees. Patients with a schizophrenic first degree relative were significantly more likely to also have a parent or sibling with an autoimmune disease (60% vs. 20%, OR = 6.1, 95% CI = 2.3-6.5, p = 0.0003). A significant excess of insulin dependent diabetes mellitus (IDDM) was present in the parents and siblings of schizophrenic patients (OR = 9.65, 95% CI = 1.3-429.2, p = 0.009). These findings suggest that autoimmune mechanisms may play a role in the aetiology of schizophrenia, particularly familial schizophrenia. Associations have been established between autoimmune diseases and the HLA encoding genes of the major histocompatibility complex on chromosome six, and it may be that some of the genetic liability to schizophrenia involves these genes.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

Abstract Objectives: To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management. Design: Randomised controlled trial with two year follow up. Setting: Four inner city community mental health services. Participants: 708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group. Intervention: Intensive case management (caseload 10–15 per case manager) for two years compared with standard case management (30-35 per case manager). Main outcome measure: Physical assault over two years measured by interviews with patients and case managers and examination of case notes. Results: No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86). Conclusions: Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care. What is already known on this topic Psychosis and violence are known to be associated Community psychiatric interventions aimed at reducing the risk of violence have not been evaluated What this study adds Increasing the intensity of contact between patients and case managers does not reduce the prevalence of violent behaviour in patients with psychosis Younger age, learning difficulties, and a history of violence, drug misuse, and victimisation predict violent behaviour in psychotic patients

Schizophrenic patients and their first-degree relatives show an excess of mixed-handedness

An excess of mixed-handedness in schizophrenia has been reported. However, it is not established whether this excess is manifest in non-schizophrenic psychoses, nor whether the underlying etiology is genetic or environmental. We investigated these issues in a group of patients with schizophrenia (n=94), affective psychosis (n=63), other psychosis (n=26); their respective first-degree relatives (total n=183) and a control group (n=85). A narrow definition of mixed-handedness was used corresponding to groups 5 and 6 as defined by the Annett Handedness Questionnaire. We found an excess of mixed-handedness in the schizophrenic group compared with controls (OR=5.2, 1.4-18.6, p<0.006). There was no difference between the other psychotic groups and controls. There was a trend for an excess of mixed-handedness in the first-degree relatives (n=99) of schizophrenic patients (p=0.055), but not in the relatives of affective or other psychotic patients. There was a striking linear trend in the proportion of mixed-handedness between controls, the relatives and the schizophrenic patients (chi2=7.0, p=0.008). There was no association between mixed-handedness and a history of pregnancy or birth complications in the schizophrenic group. There was some evidence for impaired sociability in the mixed-handed schizophrenic patients. Our results indicate that the excess of mixed-handedness in schizophrenia may have a genetic basis.

Family history of autoimmune diseases in psychosis

The mothers of 101 psychotic patients and 116 normal controls were interviewed using a semi-structured questionnaire designed to determine the presence or absence of autoimmune disorders in first degree relatives of the probands. Thyrotoxicosis and insulin-dependent diabetes mellitus were significantly more common in the relatives of the psychotic patients than in the control relatives; in particular thyrotoxicosis was more frequent in the mothers of patients (11%) than the mothers of controls (2.6%). None of the examined characteristics of the patients, including RDC-diagnosis, family history of psychosis, age at onset of psychosis and winter birth, was predictive of thyrotoxicosis and insulin-dependent diabetes mellitus in relatives.

Obstetric complications and familial morbid risk of psychiatric disorders

Obstetric complications (OCs) have been found to occur in higher frequency in patients with schizophrenia. One explanation for this finding is that the genes that contribute to the schizophrenia phenotype also influence the likelihood to experience OCs. If this were true, morbid risk of psychiatric illness should be higher in the first-degree relatives of both schizophrenic and control probands exposed to OCs, compared to probands not exposed to OCs. We set out to test this hypothesis. Information on OCs, blind to family history of psychiatric disorder, was collected retrospectively through maternal interview in 151 psychotic patients and 100 controls. Family history (FH) in relatives of cases (n = 600) and controls (n = 461) was assessed with the FH-RDC and through personal interviews. Tests for associations between family history and OCs were conducted using Cox proportional hazard regression. In the cases, familial morbid risk of affective disorder was greater in those with a history of OCs (hazard ratio (HR) = 1.9, P = 0.007). Analyses examining individual complications revealed associations between FH of affective disorder and pre-eclampsia (HR = 2.9, P = 0.003) and FH of affective disorder and breech presentation (HR = 2.8, P = 0.02), especially when family history in the relatives was confined to affective illness in the mother (HR pre-eclampsia = 4.4, P = 0.009; HR breech-presentation = 4.2, P = 0.008). In controls, affective illness in the mother was not only associated with breech presentation (HR = 7.0, P = 0.01) and pre-eclampsia (HR = 4.4, P = 0.03) but also with other complications. Familial morbid risk of schizophrenia and related psychoses was not associated with OCs. The positive associations between OCs and familial morbid risk of affective disorder suggest that the factors that contribute to familial aggregation of affective symptoms in psychotic patients also influence the likelihood to experience OCs. Although the proportion of OCs that could be attributed to these factors was very small, part of the relationship between family history of affective disorder and psychosis may be mediated by OCs.

Premorbid IQ in patients with functional psychosis and their first-degree relatives

Numerous studies have found deficits in premorbid IQ in schizophrenic patients, but it is not clear whether this deficit is shared by (a) patients with other functional psychoses, and (b) relatives of these patients. Ninety-one schizophrenic patients, 66 affective psychotic patients (29 schizoaffective and 37 manic or depressed), and 50 normal control subjects were administered the National Adult Reading Test (NART) which provides an estimate of premorbid IQ. The NART was also completed by 85 first-degree relatives of schizophrenic patients and by 65 first-degree relatives of affective psychotic patients. After adjustments were made for sex, social class, ethnicity and years of education, schizophrenic patients had significantly lower premorbid IQ than their relatives, the affective psychotic patients and controls. Manic and depressed patients had significantly lower NART scores than their first-degree relatives, but schizoaffective patients did not, and neither group differed significantly from controls. There was no significant difference in premorbid IQ between patients who had experienced obstetric complications (OC+) and those who had not (OC-). Both OC+ and OC- schizophrenic patients differed significantly from their relatives, but the disparity was greatest between OC+ patients and their relatives. Relatives of OC+ schizophrenic patients had significantly higher IQ than relatives of OC- schizophrenic patients.

Comparison of the family history with the family study method: Report from the Camberwell Collaborative Psychosis Study

We assessed the accuracy of the family history (FH-RDC) and family study (SADS-L) methods for obtaining information about the presence of psychopathology in 274 first-degree relatives of patients with psychotic disorders. The family history method had only modest sensitivity, 40.8% for affective disorders and 58.6% for psychotic disorders, but high specificity, 94.1% for affective disorders and 98.7% for psychotic disorders. For both disorders, sensitivity was higher for relatives who had had previous psychiatric admissions. However, with the family study method, we found that relatives with affective disorder were more likely to be interviewed than those relatives with other disorders. Hence, the family study method may be prone to selection bias that distorts morbid risk estimates. We conclude that the best way of collecting information regarding family psychopathology is to interview directly as many relatives as possible and to collect supplementary family history information on unavailable relatives.

Does socioeconomic status predict course and outcome in patients with psychosis

Background We examined the relationship between socioeconomic status (SES) and course and outcome of patients with psychosis. Two hypotheses were examined: a) patients with higher best-ever SES will have better course and outcome than those with lower best-ever SES, and b) patients with greater downward drift in SES will have poorer course and outcome than those with less downward drift. Method Data were drawn from the baseline and 2-year follow-up assessments of the UK700 Case Management Trial of 708 patients with severe psychosis. The indicators of SES used were occupational status and educational achievement. Drift in SES was defined as change from best-ever occupation to occupation at baseline. Results For the baseline data highly significant differences were found between best-ever groups and negative symptoms (non-manual vs. unemployed – coef −10.5, p=0.000, 95 % CIs 5.1–15.8), functioning (non-manual vs. unemployed – coef −0.6, p=0.000, 95 % CIs 0.3 to −0.8) and unmet needs (manual vs. unemployed – coef 0.5, p=0.004, 95 % CIs 0.2–0.9). No significant differences between best-ever groups were found for days in hospital, symptoms, perceived quality of life and dissatisfaction with services. Significant differences for clinical and social variables were found between drift and non-drift SES groups. There were no significant findings between educational groups and clinical and social variables. Conclusions Best-ever occupation, but not educational qualifications, appeared to predict prognosis in patients with severe psychosis. Downward drift in occupational status did not result in poorer illness course and outcome.

Personality dimensions and neuropsychological performance in first-degree relatives of patients with schizophrenia and affective psychosis.

Several studies have found a significant increase in the prevalence of some personality disorders in the first-degree relatives of patients with schizophrenia; other studies have found subtle neuropsychological deficits in these relatives. However, little is known about the specificity of the personality traits reported or about the relationship between these traits and the neuropsychological deficits.One-hundred first-degree relatives of patients with schizophrenia (SR) and 88 first-degree relatives of affective psychotic patients (APR) completed the Eysenck Personality Questionnaire which measures extraversion, neuroticism, and psychoticism; they were also administered the National Adult Reading Test (NART), the Trail Making Test (TMT) and a Verbal Fluency Test (VFT). The male relatives of patients with schizophrenia scored significantly higher on the psychoticism scale than the male relatives of affective psychotic patients. In the SR group, there were significant correlations between the TMT performance and the extraversion scores and, between the IQ scores and the psychoticism scores. However, when logistical regression analyses were performed, none of the three personality scores predicted any of the neuropsychological performance in either the SR or the APR group. These results indicate some specificity as well as sex differences in the psychoticism dimension. Moreover, the relationship between the personality dimensions and the neuropsychological performance could indicate that psychoticism increases vulnerability to psychosis whereas extraversion decreases it.