Digby Tantam

Neurocognitive function and outcome in first-episode schizophrenia: a 10-year follow-up of an epidemiological cohort

The natural history of neurocognitive impairments in schizophrenia is unclear. We aimed to characterise this in an epidemiological first-episode cohort and relate it to long-term outcome. All but 1 of 112 first-episode psychosis cases ascertained from a geographical catchment area were traced at 10-12 years. Neurocognitive and multi-dimensional outcome assessments were made at interview in 49 cases with schizophrenia and related disorders. Twenty-four of these had completed the same neurocognitive battery at index admission. Comparisons with normative data showed impaired executive function in a proportion of the first episode (FE) sample at baseline. Significant deterioration was seen over the follow-up period in three of nine sub-tests: object assembly, picture completion and memory for designs. Neurocognitive impairments at outcome, but not baseline, correlated with clinical outcome. Poor outcome was associated with a decline in performance on visuo-spatial tasks and a failure to improve on frontal-temporal tasks during the follow-up period. Executive deficits may be present in the FE, but do not progress over 10-12 years. Visuo-spatial function is spared in the FE but may deteriorate over time. Changes in both these patterned deficits are predictive of clinical outcome.

Expressed emotion and early onset schizophrenia: a one year follow-up

Key relatives of 33 first or early admission psychotic patients (mainly schizophrenics) were interviewed to determine household levels of expressed emotion (EE). The patients were followed up for 12 months from index admission, during which time 13 (39%) experienced psychotic relapse. There was no association between relapse rate and household EE, but correlations between individual components of EE and pre-morbid measures suggest that level of criticism may be related to less acute onset of index episode, greater elapsed time since first signs of illness, and poor adjustment in the realm of work/study. The results are discussed in the context of continuing uncertainties about the precise nature of the relationship between EE and relapse.

Attitudes to self-injury within a group of mental health staff

BACKGROUND Self-wounding is a behaviour which remains poorly understood and which can evoke strong reactions from clinical staff. Such reaction may adversely influence treatment outcome and there have been calls for changes in the attitudes of professional staff towards this client group through improved training and awareness. There has, however, been little systematic study of how clinicians perceive those who self-injure or of how their attitudes are modified by training and other factors. METHOD This study aims to identify and explore factors governing professional attitude towards self-injury through postal survey of a large group of mental health staff. The survey assessed attitudes towards a representative case described in a vignette. RESULTS Five key factors were identified, with perception of control being the most dominant. Attitudes of clinical staff who had obtained additional qualification in counselling or psychotherapy differed significantly from those who had not. In contrast, no effect was found for specific training in handling self-injury. Attitude to the self-wounding woman was unaffected by gender, but was affected by age and work setting. The innate potential for the sample to self-polarize was examined statistically; a line of cleavage emerged between less tolerant staff who perceived her to have more control and to be more difficult to understand and those with opposing views. CONCLUSION Qualification in counselling or psychotherapy may modify attitude by reducing defensive attribution, allowing staff improved containment of their anxiety; alternatively, pre-existing attitudes may encourage certain staff to obtain such qualification.

Validating two survey methods for identifying cases of autism spectrum disorder among adults in the community.

BACKGROUND There are no tested methods for conducting epidemiological studies of autism spectrum disorders (ASDs) in adult general population samples. We tested the validity of the Autism Diagnostic Observation Schedule module-4 (ADOS-4) and the 20-item Autism-Spectrum Quotient (AQ-20). METHOD Randomly sampled adults aged ≥16 years were interviewed throughout England in a general population multi-phase survey. The AQ-20 was self-completed by 7353 adults in phase 1. A random subset completed phase 2, ADOS-4 assessments (n=618); the probability of selection increased with AQ-20 score. In phase 3, informant-based Diagnostic Interview Schedule for Social and Communication Disorders (DISCO) and Autism Diagnostic Interview-Revised (ADI-R) developmental assessments were completed (n=56). Phase 1 and 2 data were presented as vignettes to six experienced clinicians (working in pairs). The probability of respondents having an ASD was compared across the three survey phases. RESULTS There was moderate agreement between clinical consensus diagnoses and ADOS-4. A range of ADOS-4 caseness thresholds was identified by clinicians: 5+ to 13+ with greatest area under the curve (AUC) at 5+ (0.88). Modelling of the presence of ASD using 56 DISCO assessments suggested an ADOS-4 threshold in the range of 10+ to 13+ with the highest AUC at ADOS 10+ to 11+ (0.93-0.94). At ADOS 10+, the sensitivity was 1 [95% confidence interval (CI) 0.59-1.0] and the specificity 0.86 (95% CI 0.72-0.94). The AQ-20 was only a weak predictor of ADOS-4 cases. CONCLUSIONS Clinically recommended ADOS-4 thresholds are also recommended for community cases: 7+ for subthreshold and 10+ for definite cases. Further work on adult population screening methods is needed.

Case history of co-morbid Asperger's syndrome and paraphilic behaviour.

We report a case of a man with Aspergers syndrome, paraphilic behaviour and convictions for sexual offences. We describe his assessment within a secure mental health setting to determine issues of diagnosis, treatment and risk. We also highlight the difficulty in reducing the risk of further offending because of the apparent ineffectiveness of interventions for the small group with Aspergers syndrome and an offending history. Consequently, they are likely to face long periods in institutional settings.

Expressed emotion and schizophrenia: the ontogeny of EE during an 18-month follow-up.

Key relatives of 30 first or early admission psychotic patients (mainly with a diagnosis of schizophrenia) were interviewed (for a second time) 18 months after participating in an initial assessment of expressed emotion (EE). The patients were followed up throughout the interim period, during which time 17 experienced a psychotic relapse. Although there continued to be a negligible association between initial EE rating (established during the index admission) and relapse, a significant association between EE rating at 18 months and psychiatric status of the patient during the follow-up period emerged. Results are discussed in the context of recent interactional theories of the relationship between household EE and psychiatric morbidity.

Clinical management of women who self-wound : A survey of Mental Health professionals' preferred strategies

Aim: To evaluate professional opinion of various strategies advocated for the clinical management of self-wounding in female patients. Method: A postal survey of all 386 NHS staff working within multi-disciplinary teams in one English county using a specially developed questionnaire assessing preferred management of a case described in a vignette. Results: A return of 55% (n =213) was achieved, with 94% of respondents reporting direct clinical contact with women who had self-wounded. Responses were scored according to the extent to which respondents endorsed each of 19 management strategies. The strategies of maintaining regular discussion amongst involved staff and of encouraging the client to ventilate unexpressed feelings were seen as the most helpful, with medication and hospital admission regarded as unhelpful. Ambivalence and uncertainty were evident for many of the suggested strategies. Conclusions: A range of opinion has been demonstrated amongst a multi-disciplinary group of mental health profess...

Sleep, Scratching and Dreams in Eczema

6 patients with itching due to skin disorder and 6 student controls were studied in the sleep laboratory. It was found that some of the patients had personality characteristics consistent with

Report on a Systematic Review of the Efficacy and Clinical Effectiveness of Group Analysis and Analytic/Dynamic Group Psychotherapy

This article reports on a systematic review to assess the efficacy and clinical effectiveness of group analysis and analytic/dynamic (A/D) group psychotherapy. Systematic literature searches were undertaken; 34 primary studies and 19 reviews met the inclusion criteria and their data was extracted. Of the primary studies, the randomized controlled trials provided evidence for the efficacy and clinical effectiveness of group therapy approaches in a range of clinical problems, but not for specific benefits of any particular theoretical approach. The controlled studies and observational studies gave support for the use of group psychotherapy in a variety of conditions. The review of reviews confirms that group therapies in general are more effective than wait list or standard care controls. Methodological challenges encountered and recommendations for further research are presented, along with a more detailed discussion of the implications of the review for the research community.

Psychosis in autism: comparison of the features of both conditions in a dually affected cohort

Background There is limited information on the presentation and characteristics of psychotic illness experienced by people with autism spectrum disorder (ASD). Aims To describe autistic and psychotic phenomenology in a group of individuals with comorbid ASD and psychosis (ASD–P) and compare this group with populations affected by either, alone. Method We studied 116 individuals with ASD–P. We compared features of their ASD with people with ASD and no comorbid psychosis (ASD–NP), and clinical characteristics of psychosis in ASD–P with people with psychosis only. Results Individuals with ASD–P had more diagnoses of atypical psychosis and fewer of schizophrenia compared with individuals with psychosis only. People with ASD–P had fewer stereotyped interests/behaviours compared with those with ASD–NP. Conclusions Our data show there may be a specific subtype of ASD linked to comorbid psychosis. The results support findings that psychosis in people with ASD is often atypical, particularly regarding affective disturbance.