Gian Lippi

Schizophrenia in a member of the family : burden, expressed emotion and addressing the needs of the whole family

How often do we find ourselves concentrating so much on treating a patient with schizophrenia that we forget about the needs and difficulties of the family members who take care of that patient? This article highlights the global and specific difficulties that families and caregivers experience in having to care for chronically ill family members with schizophrenia with a backdrop of continuing global deinstitutionalisation of such patients. Matters such as burden and expressed emotion are explored, family-specific interventions are discussed and areas of service delivery and resource inadequacies are identified.

Psychiatric and other contributing factors in homicide-suicide cases, from northern Gauteng, South Africa over a six-year period

ABSTRACT Homicide committed by a person who subsequently commits suicide within one week of the homicide is a relatively rare event. The current study used an explanatory sequential design, including psychological autopsies, to identify psychiatric and other contributing factors in 35 homicide-suicide cases in northern Gauteng Province, South Africa. This research highlighted the complex multifactorial nature of these events. Identification of high-risk individuals and delineation of contributing factors is important. Early recognition and effective treatment of psychiatric illness, particularly depression and substance use problems, in people experiencing relationship issues (with pending/recent separations) and financial stressors, is an essential component in the prevention of homicide-suicide incidents. Evaluations should always include direct questioning about suicidal and homicidal ideations. Mental health practitioners have a definite role to play in offering comfort, support, and treatment to all those who remain behind after these devastating events. Urgent attention needs to be given to the availability of support and treatment for investigating police officers and surviving family and friends.

Neuropsychiatric symptoms and diagnosis of grey matter heterotopia: A case-based reflection

Neuropsychiatric symptoms can be related to less common underlying neuropsychiatric conditions – in this case report, the condition discussed is that of grey matter heterotopia (GMH). The patient presented with a history of prominent aggression, impulsivity and manipulative and attention-seeking behaviour. Episodes of depression and incidents of deliberate self-harm and suicide attempts had been reported. Neuropsychiatric symptoms included anxiety, a labile mood, delusional thinking and auditory hallucinations. Testing revealed some cognitive difficulties and severe impairment of frontal lobe functions. A magnetic resonance imaging (MRI) scan of his brain revealed the presence of GMH, which had previously been misdiagnosed as tuberous sclerosis. An MRI scan of the brain is the special investigation of choice for the correct diagnosis of GMH. The pathognomonic finding is that of heterotopic grey matter abnormally located within areas of white matter. Defective foetal neuronal migration between the third and fifth month of pregnancy can lead to GMH, which can present later on in childhood or adolescence with epilepsy, intellectual impairment or reading difficulties. During the late teenage years or early adulthood, a wide variety of neuropsychiatric symptoms may be present, which can lead to diagnostic difficulties.

Identifying factors associated with the discharge of male State patients from Weskoppies Hospital

Background Designated psychiatric facilities are responsible for the care, treatment and reintegration of State patients. The necessary long-term care places a considerable strain on health-care resources. Resource use should be optimised while managing the risks that patients pose to themselves and the community. Identifying unique factors associated with earlier discharge may decrease the length of stay. Factors associated with protracted inpatient care without discharge could identify patients who require early and urgent intervention. Aim We identify socio-economic, demographic, psychiatric and charge-related factors associated with the discharge of male State patients. Methods We reviewed the files of discharged and admitted forensic State patients at Weskoppies Psychiatric Hospital. Data were captured in an electronic recording sheet. The association between factors and the outcome measure (discharged vs. admitted) was determined using chi-squared tests and Fischer’s exact tests. Results Discharged State patients were associated with being a primary caregiver (p = 0.031) having good insight into illness (p = 0.025) or offence (p = 0.005) and having had multiple successful leaves of absences. A lack of substance abuse during admission (p = 0.027), an absence of a diagnosis of substance use disorder (p = 0.013) and the absence of verbal and physical aggression (p = 0.002 and p = 0.016) were associated with being discharged. Prolonged total length of stay (9–12 years, p = 0.031) and prolonged length of stay in open wards (6–9 years, p = 0.000) were associated with being discharged. A history of previous offences (p = 0.022), a diagnosis of substance use disorder (p = 0.023), recent substance abuse (p = 0.018) and a history of physical aggression since admission (p = 0.017) were associated with continued admission. Conclusion Discharge of State patients is associated with an absence of substance abuse, lack of aggression, multiple successful leave of absences and length of stay in hospital.

The use of cyproterone acetate in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning

Background Cyproterone acetate (CPA) is a steroidal anti-androgenic medication used in the field of psychiatry for the treatment of paraphilic disorders, hypersexuality, and inappropriate sexual behaviour which may be present in patients with disorders such as mild and major neurocognitive disorders. In the forensic psychiatric population, it is prescribed for these indications especially for patients with a history of committing a sexual offence or who are at moderate to high risk of recidivism. Objectives To investigate the use of CPA in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning. Methods Seventy-six forensic psychiatric patients from Weskoppies Hospital in Pretoria, South Africa, participated in the study which measured their sexual functioning. A specifically designed questionnaire was used to capture relevant background information. The use of CPA was studied. The Changes in Sexual Functioning Questionnaire, Male Clinical Version (CSFQ-M-C) was used to measure sexual functioning of participants. The CSFQ-M-C scores, and those of all its subscales, of participants on CPA were compared to those not on the drug. Relevant statistical analyses were performed. Results Thirteen out of the 76 participants were being treated with CPA (17.11%). In total, 53.85% of the participants on CPA and 65.08% not on CPA had scores indicating the presence of sexual dysfunction. The total CSFQ-M-C scores for participants on CPA (mean = 40.54; median = 42) were not statistically significantly lower than those not on the drug (mean = 41.22; median = 41). More notable is that the use of CPA in this population was associated with lower levels of desire, frequency of and pleasure from sexual activity. There was an association between having intellectual disability and being treated with CPA. Conclusion That all the participants were being treated with psychotropic medication could account for the high percentage of sexual dysfunction in any or all areas of sexual functioning and contribute to the small difference in CSFQ-M-C scores between the two groups. Only a tentative conclusion can be made that CPA may be more effective in decreasing levels of desire, frequency and pleasure related to sexual activity than other areas of sexual functioning. The indication for the use of CPA in this population should be assessed clinically according to patient circumstances and risk assessment.

Treated for psychosis and presenting with prominent speech and language abnormalities : a case report of an adult with a frontal lobe teratoma

We report on a rare case of an adult presenting with psychotic symptoms, including prominent thought form disorder and an aphasia. Further investigation revealed the presence of a mature teratoma in the left frontal lobe, which could have played a pathophysiological role in the development of both the psychosis and the language impairment.

Suicide risk in schizophrenia - a follow-up study after 20 years Part 1: Outcome and associated social factors

Objective. This study re-evaluated, after a period of 20 years, a cohort of patients with schizophrenia who had been considered to be at high risk for suicide. The outcome and social factors associated with their suicide risk were investigated over the two decades. Method. Subjects were contacted and interviewed face to face using a questionnaire devised for this purpose. The Beck Hopelessness Scale (BHS) was administered and ratings were compared with those from the original study. The Calgary Depression Scale for Schizophrenia (CDSS) was administered. Cross-tabulations were performed to identify factors associated with increased suicide risk. A psychological autopsy was performed for those subjects who had committed suicide since the original study. Results. Fourteen of the original 33 high-suicide-risk schizophrenia patients were traced. Three subjects had committed suicide during the 20-year period. Among the living subjects, risks for suicide were found to be lower than those 20 years earlier. Male gender, poor social support, early age of illness onset, current admission to or recent discharge from hospital, and a higher level of education were all factors associated with increased suicide risk. Conclusion. Demographic factors and those related to illness course found to be associated with suicide risk in patients with schizophrenia in this study are in accord with those reported in the literature.