Hanafy A. Youssef

Sequential cross-sectional and 10-year prospective study of severe negative symptoms in relation to duration of initially untreated psychosis in chronic schizophrenia

Current clinical correlates of duration of initially untreated psychotic symptoms were investigated in a cross-sectional analysis followed by a 10-year prospective study among 88 in-patients with a long-standing schizophrenic illness, many of whom had experienced prolonged periods of untreated psychosis due to illness onset and hospital admission in the pre-neuroleptic era. After controlling for the effects of age, and duration and continuity of subsequent neuroleptic treatment, the primary clinical correlate of duration of initially untreated psychosis was muteness. Over the subsequent 10-year-period, no new cases of muteness emerged and some existing cases of muteness partially resolved, though the speech that emerged remained very sparse and revealed generally gross cognitive debility. The pathophysiology underlying active, unchecked psychosis may also constitute an active morbid process that is associated with the further progression of severe negative symptoms and cognitive dysfunction in the long-term.

Cognitive dysfunction in chronic schizophrenia followed prospectively over 10 years and its longitudinal relationship to the emergence of tardive dyskinesia

Basic cognitive function was assessed at initial and at 5- and 10-year follow-up assessments among 41 primarily middle-aged in-patients manifesting the severest form of schizophrenia; additionally, the presence and severity of tardive dyskinesia was evaluated on each occasion. Overall, there was a modest but significant deterioration in cognitive function over the decade, particularly among older men. Longitudinally, patients with persistent tardive (orofacial) dyskinesia continued to show poorer cognitive function than those consistently without such movement disorder, though within neither group did cognitive function change over the decade. Those patients demonstrating prospectively the emergence of orofacial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, but this decline did not progress further thereafter. There appears to exist some modes, progressive deterioration in cognitive function even late in the chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de novo emergence of tardive orofacial dyskinesia.

Primitive (developmental) reflexes and diffuse cerebral dysfunction in schizophrenia and bipolar affective disorder: Overrepresentation in patients with tardive dyskinesia

Primitive (developmental) reflexes are present in fetal and infant life, but disappear in adulthood. Their elicitation in later life usually occurs in association with cortical or diffuse cerebral dysfunction and suggests a new approach to the issue of whether tardive dyskinesia is particularly likely to occur in patients with organic brain disorder(s). Sixty-six patients with schizophrenia (age range 50-86) and 18 with bipolar affective disorder (age range 40-77) were assessed for the presence of involuntary movements and for the release of the grasp, palmomental, snout, corneomandibular, and glabellar reflexes. In each diagnostic group, patients with involuntary movements showed a significant excess of primitive reflexes in comparison with otherwise indistinguishable patients without such movements. These results complement recent reports that similar patients with involuntary movements also show greater cognitive impairment and point anew to an association between the presence of tardive dyskinesia and of organic brain dysfunction. They raise again the issue of whether or not such dysfunction may be a consequence of neurodevelopmental abnormality rather than of neurodegenerative processes.

Cognitive dysfunction in schizophrenia followed up over 5 years, and its longitudinal relationship to the emergence of tardive dyskinesia

In this study, 51 chronic schizophrenic in-patients were evaluated for a range of demographic, clinical and medication variables, and followed up over five years. There was no significant overall change in cognitive function in this patient group as a whole, suggesting the absence of active disease at this stage of the illness. The only correlate of individual instances of cognitive deterioration over the study period was the emergence of new cases of tardive buccal-lingual-masticatory but not of limb-truncal dyskinesia, and the greater severity of such movement disorder. A positive family history was also identified prospectively as a predictor of the emergence of tardive dyskinesia in chronic schizophrenia.

Prospective analysis of premature mortality in schizophrenia in relation to health service engagement: a 7.5-year study within an epidemiologically complete, homogeneous population in rural Ireland

While premature death in schizophrenia is well recognised, mortality risk has received little longitudinal study in relation to population representativeness and patient engagement with health services. Within a rural Irish catchment area of socioeconomic, ethnic and geographical homogeneity and low residential mobility, an epidemiologically complete population of 72 patients with schizophrenia was followed up over 7.5 years in order to quantify mortality prospectively. Information was obtained in relation to 99% of the cohort, with 94% of those surviving retained in engagement with psychiatric care. There were 25 deaths (35% of cohort). A relative risk of 2.06 (95% CI, 1.40-2.80; P < 0.001) among this epidemiologically complete population may constitute an estimate of risk for mortality inherent to schizophrenia when disengagement from health services, residential mobility and socioeconomic, ethnic and geographical diversity are minimised. On long-term prospective evaluation, risk for death in schizophrenia was doubled on a background of enduring engagement in psychiatric care with increasing provision of community-based services and introduction of second-generation antipsychotics.

Familial psychosis and vulnerability to tardive dyskinesia.

The demography, course of illness, cognitive dysfunction and neurological consequences of long term treatment of 11 family pairs with long history of chronic schizophrenic illness were studied. There was concordance for the presence of tardive dyskinesia in 6 pairs; each of 2 brother-brother pairs; 3 brother-sister pairs and one of mother-daughter pair. There was concordance for the absence of tardive dyskinesia in 5 pairs, each of 3 father-son pairs and 2 brother-sister pairs. In schizophrenic patients the presence or absence of tardive dyskinesia in one member of the family is a risk factor for the development of the syndrome in another member with the same psychotic illness. Those pairs with tardive dyskinesia were characterized by negative symptoms of schizophrenia and evidence of intellectual deterioration.

Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset.

This study examined geographical variation in rate of occurrence of schizophrenia by place at birth vs place at onset, among a rural Irish catchment area population of unusual stability and socioeconomic homogeneity. Within a catchment area of 21,520 persons, all cases of schizophrenia were sought using current inpatient and outpatient records and key informants active in the community. Suspected cases were interviewed personally and diagnosed using DSM-III-R criteria. Place at birth and place at onset of psychosis were specified among the 32 District Electoral Divisions constituting the study region. For the 72 cases ascertained, an unremarkable overall prevalence rate/morbid risk obscured substantial and significant geographical variations therein between District Electoral Divisions. Particularly after controlling for high-density families, men demonstrated prominent geographical variation both by place at birth and by place at onset, with most men remaining unmarried and becoming ill at their place of birth; conversely, women demonstrated prominent variation by place at birth but more limited variation by place at onset, despite more frequent transitions from the parental home to the marital home before onset. Even when cases changed their location before the onset of psychosis, geographical variation in rate of occurrence of schizophrenia remained associated more strongly with factors related to the place of their birth.

Schizophrenia in East County Cavan: Spatial Variations in Prevalence and their Aetiological Implications

Schizophrenia prevalence rates in Ireland have been amongst the highest in (he world For over a century. These rates do not necessarily indicate a high risk of mental illness in the community, but they could reflect elevated risks associated with either genetic factors or unidentified factors associated with the Irish social or physical environment. This study examines spatial variations in prevalence in east County Cavan. By confining the study to a small area. The effects of nosocomial factors and diagnostic variability can be assumed to be minimal. Also, given that the study area receives few immigrants, drift processes, which complicate most other small-area studies, may be discounted. Various statistical tests indicate that the prevalence of schizophrenia in east Cavan is significantly uneven. After considering various alternative explanations, it is concluded that the observed spatial variations in prevalence possibly reflect the influence of unidentified environmental factors.

Characterization of abnormal respiratory movements in schizophrenic, bipolar and mentally handicapped patients with typical tardive dyskinesia.

A population of 76 patients with typical tardive orofacial dyskinesia, and from which cases of respiratory disease had been excluded, were evaluated for abnormal respiratory movements. Such abnormality was present in 34 patients (45%), and was unrelated to age, sex or smoking habits. However, patients with respiratory movement disorder showed more severe orofacial dyskinesia and higher blood pressure. Putative pathophysiological processes implicated in this often unappreciated component of the tardive dyskinesia syndrome are discussed.

The death of electroconvulsive therapy.

In Italy, where it began more than 62 years ago, ECT has almost been abolished. In some countries, however, ECT is still used inappropriately, particularly in elderly patients. There is no medical, moral, or legal justification for ECT, and the new requirements of modern psychiatric practice can all be achieved with-out it. Like prefrontal lobotomy and all previous shock treatments, ECT is nonviable. The death of ECT will help promote mental health and put the treatment where it belongs—in the archaeology of science.