Eckhard Michael Steinmeyer

Diagnostic validity of basic symptoms

Although the Bonn Scale for the Assessment of Basic Symptoms (BSABS) [13] has come into use in several European countries, its diagnostic validity has not yet been sufficiently examined. That is why we have assessed BSABS items on a sample of 243 consecutive admissions to the Department of Psychiatry at the RWTH University, Aachen, and 79 psychologically healthy persons. Then, a cluster analysis was calculated to identify the empirical item-grouping. Five well-interpretable BSABS subsyndromes were found. In addition, uni- and multivariate analyses were computed to evaluate the diagnostic validity of these subsyndromes. We were able to show that every BSABS subsyndrome separates at least schizophrenic, organic mental and affective disorders from personality, neurotic and substance-induced disorders, as well as from psychological health. Furthermore, the subsyndrome “information processing disturbances” differentiates between schizophrenic and organic mental disorders, on the one hand, and affective disorders, on the other, and additionally, the subsyndrome “interpersonal irritation” between schizophrenics and all other persons examined.

Long-term outcome of schizoaffective and schizophrenic disorders: a comparative study

SummaryThe long-term outcome of 72 schizoaffective and 97 schizophrenic patients with a mean duration of illness of 25.6 years and 19.6 years respectively was investigated. The outcome was assessed using the WHO Disability Assessment Schedule (WHO/DAS), the Psychological Impairment Rating Schedule (PIRS) (also developed by the WHO), the Global Assessment Scale (GAS), and the Bonn Psychopathological Criteria of Outcome. The outcome of schizoaffective disorders was found to differ from that of schizophrenia in several ways: (a) schizoaffectives achieve a full remission significantly more frequently than schizophrenics (50% vs 10%); (b) the development of so-called characteristic schizophrenic residua is the exception in schizoaffective disorders, but is frequent in schizophrenia; (c) disability, psychological impairment and disturbances of the level of functioning are not only significantly less frequent in schizoaffective disorders but are also less intense than in the schizophrenic group. The factors influencing the outcome of the two disorders are different (see part 11), as are the social consequences (part III).

Experimenteller Nachweis mangelnder Affektregulation bei Patientinnen mit selbstschädigendem Verhalten

ZusammenfassungDie affektive Instabilität von Patienten mit Borderline-Persönlichkeitsstörung (BPS) wird im DSM-IV einer erhöhten Reaktivität der Stimmungslage auf Umweltereignisse zugeschrieben. Ziel der vorliegenden Studie war es, die affektive Reaktivität von abnormen Persönlichkeiten mit selbstschädigenden Impulshandlungen empirisch mit Hilfe von Affektinduktionsexperimenten zu untersuchen. Das erste Experiment beruhte auf der Präsentation einer Kurzgeschichte und ermöglichte, die Qualität, die Intensität und den zeitlichen Verlauf von affektiven Reaktionen auf vielfältige Reize zu erheben. Das zweite stellte eine typische Frustrationssituation dar, die spezifische Gefühle des Ärgers und der Enttäuschung provozierte. Die impulsiven Persönlichkeiten zeigten eine affektive Hyperreaktivität, die sich als herabgesetzte Affektschwelle, als überhöhte, im Zeitverlauf rasch wechselnde Affektintensität sowie als qualitativ wenig differenzierte Affektantworten manifestierte. Die Ergebnisse legen nahe, daß die affektive Instabilität von Patienten mit BPS von den autonomen Stimmungsauslenkungen affektiver Erkrankungen abgegrenzt werden muß und am ehesten als Teil eines persönlichkeitseigenen impulsiven Stils des Reagierens auf die Umwelt aufzufassen ist.SummaryAccording to DSM-IV affective instability in borderline personality disorder is due to marked reactions to environmental events. The aim of this study was to investigate affective responsiveness of abnormal personalities with self-harming impulsive behaviors by means of an affect-stimulation design. The first experiment was based on the presentation of a short story that allowed affective responses to various stimuli to be assessed in regard to quality, intensity, and alterations over time. The second one presented a typical frustration design, which provoked specific feelings of anger and disappointment. Impulsive personalities showed an affective hyperreactivity that was characterized by a decreased threshold for affective responses, as well as by intensive, rapidly changing affects. Furthermore, affect experiences turned out to be qualitatively diffuse and undifferentiated. Results support that affective instability of patients with borderline personality disorder should be differentiated from the autonomous deviations of mood typical of affective disorders. Their affective hyperreactivity is a crucial part of impulsive personality functioning.

Patterns of comorbidity among DSM-III-R and ICD-10 personality disorders as observed with a new inventory for the assessment of personality disorders

Although DSM-III-R and ICD-10 suggest the assignment of multiple personality diagnoses, a high degree of overlap may be an indicator of insufficiently distinct and too inclusive types of personality. We studied this problem with a new inventory in an unselected clinical sample. The Aachen List of Items for the Registration of Personality Disorders (AMPS) integrates the different types of disordered personality according to DSM-III-R, ICD-10, and four subaffective categories, which largely follow the typologies of Kracpelin, K. Schneider, and Kretschmer. The prevalence rate of each personality disorder was calculated in a consecutive group of 231 patients. Patterns of comorbidity were computed using odds ratios. More than one personality disorder was found in 41% according to DSM-III-R. ICD-10 showed a significantly higher degree of overlap. Interesting comorbidity patterns are discussed in comparison with several North American studies. Results indicate that clear-cut categorical personality diagnoses are not likely to be set up.

Positive or negative symptoms--which are more appropriate as diagnostic criteria for schizophrenia?

For over a decade there has been a consensus that the diagnosis of schizophrenia should rest upon the presence of positive symptoms. Recently it has been suggested to give negative symptoms, which have played a prominent role in research, more diagnostic importance again. This study investigated the usefulness of that suggestion. In a sample of 489 inpatients covering the whole range of psychiatric diagnoses, the frequencies and prevalences of positive and negative symptoms were determined. Analyses of variance were calculated to assess the diagnostic validity of the different classes of symptoms. The study demonstrates that positive symptoms are of much higher diagnostic value than negative symptoms. A change of diagnostic procedures giving more importance to negative symptoms is discouraged.

On the conceptualisation of subaffective personality disorders.

The reconceptualisation of German traditional constructs of subaffective personality disorders (PDs) was stimulated by clinical and some empirical evidence of mild and enduring alterations of mood and drive in patients who never developed one of the full-blown mood disorders. The aim of the study was to clarify the status of historical concepts of subaffective PDs (as there are the depressive, hyperthymic, cyclothymic, and asthenic type) in relation to the modern Diagnostic and Statistical Manual (DSM)-III-R conceptions of personality disorders and the five factor theory of personality. A consecutive psychiatric sample and a normal control sample were used to investigate these relationships. By means of a non-metric multi-dimensional scaling procedure, and facet theoretical interpretation, the depressive and asthenic PDs were demonstrated to correspond highly with the global construct of PD as well as with the personality factor neuroticism which proved to be elevated in most types of PDs within the clinical sample. The hyperthymic and cyclothymic categories displayed differences to most DSM-III-R constructs of PD in the clinical but not in the control sample. The findings may explain the chronic course of some depressive or somatization disorders that are difficult to influence by pharmacotherapy and that may require special treatment strategies.

Zur Frage des Einsamkeitserlebens Gesunder und Neurotiker

SummaryOne purpose of this study was to formulate definitions of “lone-liness”, “being alone”, and “isolation” as philosophical and sociological concepts; we made use of the relevant literature, devoting particular attention to work with an evaluative bias. The polarity profile was used to measure attitudes to loneliness. We found substantial differences in attitude between our sample of normal subjects and the sample of German subjects examined by Hofstätter in 1957: the attitudes of our normal subjects were more similar to those of the American subjects also examined by Hofstätter in 1957. This result is interpreted as an indication of adaptation to the times.The subjective experience of loneliness was also examined in 112 healthy and 56 neurotic subjects. It appeared to be possible to make a clear distinction between normal and neurotic subjects on the basis of the problems seen as inherent to loneliness in each group. Neurotic subjects suffer more deeply from loneliness and feel lonelier than normals, and this difference is highly significant; however they are less communicative and less willing to attempt new contacts.We concluded that the loneliness variables allowed the diagnosis of neurosis with 78% accuracy, which indicates that the problem of loneliness is relevant to neurosis.ZusammenfassungEine definitorische Abgrenzung der Begriffe „Einsamkeit“, „Alleinsein“ und „Vereinsamung“ unter philosophischem und soziologischem Aspekt wird anhand entsprechender Aussagen der Literatur — vor allem auch im Hinblick auf eine wertende Einstellung — versucht. In der mit dem Polaritätenprofil gemessenen wertenden Einstellung zur Einsamkeit ergeben sich bei unserem Normal-Personenkollektiv deutliche Unterschiede im Vergleich zur Einstellungsattitüdenposition des deutschen Hofstätterschen Kollektivs von 1957 einerseits bzw. eine Angleichung an die von ihm zum gleichen Zeitpunkt gemessene amerikanische Einstellung andererseits. Dieses Ergebnis wird auf dem zeitgeschichtlichen Hintergrund als Hinweis einer Anpassung an den Zeitgeist interpretiert.Des weiteren wurde nicht nur die Einstellung gegenüber der Einsamkeit, sondern auch das Einsamkeitserleben sowohl bei gesunden (112) Versuchspersonen als auch bei neurotischen (56) Versuchspersonen untersucht. Anhand der Klassifizierung der Einsamkeitsproblematik schien eine eindeutige Abgrenzung zwischen Gesunden und Neurotikem möglich. Es zeigt sich, daß Neurotiker höchst signifikant stärker unter Einsamkeit leiden und sich einsamer fühlen, jedoch weniger kommunikationswillig und kontaktfreudig sind als Gesunde.Hinsichtlich der nosologischen Zuordnung ergab sich anhand der Einsamkeitsvariablen eine diagnostische Trefferwahrscheinlichkeit von 78%, was dafür spricht, daß sich die Einsamkeitsproblematik als ein für das Ereignis Neurose relevanter Aspekt erweist.

Can self-experienced neuropsychological deficits indicate propensity to schizophrenic psychosis? Results of an 8-year prospective follow-up study

We investigated the potential predictive value of early self-experienced neuropsychological deficits for the subsequent development of schizophrenia. We re-examined 96 patients diagnosed, according to the third revised Diagnostic and statistical manual of mental disorders (DSM-III-R), with personality disorder or what were formerly called neurotic disorders, who had been examined for the presence of subjective experiences of deficits with the Bonn Scale for the Assessment of Basic Symptoms (BSABS), in order to determine whether they had undergone a transition to a schizophrenic disorder. Of these 96 patients, 78 (81%) had displayed basic symptoms at the initial assessment. After an average follow-up period of about 8 years, more than half of the patients (58%) had developed schizophrenia according to DSM-III-R criteria or defined by the presence of at least one component of the ninth version of the Present State Examination (PSE9) nuclear syndrome. In 77% the outcome, transition or absence of transition to schizophrenia was correctly predicted by the earlier presence or absence of self-experienced disturbances of thought, speech, memory, perception and action. Development of a schizophrenic psychosis was predicted with a specificity of 45% and a sensitivity of 100%. These findings suggest that certain self-experienced neuropsychological deficits are able to indicate a propensity to a schizophrenic psychosis.

Facettentheoretische Validierung des Konstrukts Lebensqualität bei depressiv Erkrankten

Die gesundheitsbezogene Lebensqualitatsforschung, die sich insbesondere aus dem Bedurfnis nach einem „weichen“ Therapieeffizienzkriterium motiviert, ist zur Zeit durch einen Zustand begrifflicher und empirischer Unklarheit charakterisiert, fur den das Motto der anarchistischen Erkenntnistheorie „anything goes“ (Feyerabend, 1983) eine adaquate Beschreibung liefert: Bereits nach Durchsicht weniger Standardwerke (Bowling, 1991; Walker und Rosser, 1988; Wenger et al., 1984) sowie des Programmes zum letzten „Quality of life “-Kongres in Wien (Association of European Psychiatrists, 1994) stost man auf nicht weniger als 104 Mesinstrumente, die alle in irgendeiner Weise vorgeben, Lebensqualitat (LQ) erheben zu konnen. Daruberhinaus scheint die Konzeptualisierung des Konstruktes LQ weitgehend der definitorischen Willkur eines jeden Autors uberlassen mit der Folge eines vorwiegend atheoretischen Aktivismus mit ebenso vielen in- und expliziten Modellierungen wie Operationalisierungen.

Über Störungen des räumlichen Wahrnehmungs- und Vorstellungsvermögens bei Schizophrenen

SummaryThirty-seven acute schizophrenics and 25 normal subjects were investigated with regard to their spatial perception, representation, and their spatial ability. Schizophrenics showed significantly poorer performances (in terms of quantity) in those variables, which characterized the ocular apprehension of structures and wholes, the relation of parts to a whole, or the analysis of a whole in its various components as well as the availability of visual engrams, partly in the sense of spatial representation, and the practical realization of imagined spatial configurations. On the other hand, in ocular apprehension, interpretation, and when necessary the practical realization of two-dimensional represented spatial symbols and configurations and perspective abilities there was only statistical trend for quantitatively poorer performances in schizophrenics compared with healthy persons.Factor analysis of the intercorrelation matrices for 14 variables separated out the same 4 factors in each group for space perception and spatial ability. In spite of the demonstrated “quantitative” differences for the single variables between the two groups a marked similarity in a “qualitative” sense was found, when the two-factor structures were compared mathematically (similarity coefficient: 0. 664).In order to specify these differences, 56 schizophrenics were classified as paranoid or nonparanoid and investigated in the above-mentioned manner. While these groups did not show any significant quantitative difference concerning their performances at variable level, they showed entirely different structures using factor analysis. Spatial perception of the paranoid schizophrenics seemed less structured and their perceptual conception less systematical. On the other hand, when factor structures from nonparanoids and healthy controls were compared mathematically, both groups showed a marked similarity (0. 783).An attempt was made to relate these results to other findings of literature and to theories of cognitive and perceptual dysfunctions of schizophrenics.Zusammenfassung37 akut Schizophrene und 25 gesunde Versuchspersonen wurden auf ihre räumliche Wahrnehmung und — Vorstellung hin untersucht. Für die Schizophrenen wurden signifikante Minderleistungen für die Variablen nachgewiesen, die das Erfassen von Gestalten und Ganzheiten bzw. das Verhältnis von Teilen zum Ganzen oder die Zergliederung eines Ganzen in einzelne Komponenten sowie die Verfügbarkeit visueller Gedächtnisinhalte, z. T. i. S. der räumlichen Vorstellungsfähigkeit und die praktische Realisierung vorgestellter räumlicher Gebilde charakterisierten. Hingegen zeigte sich bei den Aufgaben zur Erfassung, Interpretation und ggfs. praktischen Umsetzung zweidimensional dargestellter räumlicher Gebilde und Figuren sowie für die perspektivischen Fähigkeiten nur ein Trend für Minderleistungen der Schizophrenen im Vergleich mit Gesunden.Eine für beide Gruppen getrennt gerechnete Faktorenanalyse ergab eine ähnliche Faktorenstruktur (Ähnlichkeitskoeffizient: 0. 644) der räumlichen Wahrnehmungs- und Vorstellungsprofile mit einer 4-Faktorenlösung. Die “quantitativen” Unterschiede beider Gruppen auf Variablenniveau konnten auf Faktorenniveau, d. h. auf einer komplexeren “qualitativen” Ebene somit nicht mehr nachgewiesen werden.Um diese Unterschiede differenzierter zu erfassen, wurde die auf 56 Vpn erweiterte Gruppe der untersuchten Schizophrenen in paranoide und nonparanoide Vpn untergliedert. Auf Variablenniveau konnten keine signifikanten quantitativen Unterschiede zwischen diesen beiden Gruppen gefunden werden. Dagegen ergaben sich deutlich unterschiedliche Strukturen der räumlichen Wahrnehmungs- und Vorstellungsfähigkeit. Die paranoiden Schizophrenen zeigten eine geringere Strukturiertheit und unsystematischere Konzeptbildung der Wahrnehmungsorganisation, während die Faktorenstruktur der Nonparanoiden und der gesunden Vpn eine große Ähnlichkeit (0. 783) aufwies.Diese Ergebnisse werden zu den in der Literatur angegebenen Befunden und Theoriebildungen über Wahrnehmungsstörungen Schizophrener bzw. ihrer Raumerlebensstörungen in Beziehung gesetzt.