José Cássio do Nascimento Pitta

Factor structure of the Positive and Negative Syndrome Scale (PANSS) in Brazil: convergent validation of the Brazilian version

OBJECTIVES The Positive and Negative Syndrome Scale (PANSS) was developed to assess the symptoms of schizophrenia dimensionally. Although it is widely used in clinical trials in Brazil, it is not fully validated. The aim of this study is to assess the factor structure of the Brazilian PANSS and generate validation data for its current version. METHODS A total of 292 patients diagnosed with schizophrenia were enrolled. RESULTS Principal component analysis suggested a forced five-factor final model that accounted for 58.44% of the total variance, composed of negative, disorganization/cognition, excitement, positive, and depression/anxiety. CONCLUSION The Brazilian PANSS has a similar factor structure and internal consistency compared to versions in several other languages.

Adesão ao tratamento clínico no transtorno de personalidade borderline

Compliance is a complex behavior, ranging from minor instances of treatment refusal to the inappropriate use of health services or even treatment abandonment. The study comprises a qualitative analysis of six patients with borderline personality disorder submitted to an open interview, a psychosocial questionnaire, a diagnostic classification through SCDI I and II and a clinical follow-up. Six behaviors made treatment compliance either difficult or impossible: impulsivity, manipulation, affective dissociation, attempted suicide, tendency to regression, and aggression. The participants who abandoned the treatment made the health team impotent, requiring social strategies to manage the situation. We hypothesized that healthy families are of great importance for compliance to treatment. For the cases in which treatment was not abandoned, non-compliance was manifested as attacks against the bonds and against the improvement, and aggression towards the health team and the institution.

Disorganized symptoms predicted worse functioning outcome in schizophrenia patients with established illness.

Most patients with schizophrenia will have subsequent relapses of the disorder, with continuous impairments in functioning. However, evidence is lacking on how symptoms influence functioning at different phases of the disease. This study aims to investigate the relationship between symptom dimensions and functioning at different phases: acute exacerbation, nonremission and remission. METHODS Patients with schizophrenia were grouped into acutely ill (n=89), not remitted (n=89), and remitted (n=69). Three exploratory stepwise linear regression analyses were performed for each phase of schizophrenia, in which the five PANSS factors and demographic variables were entered as the independent variables and the total Global Assessment of Functioning Scale (GAF) score was entered as the dependent variable. An additional exploratory stepwise logistic regression analysis was performed to predict subsequent remission at discharge in the inpatient population. RESULTS The Disorganized factor was the most significant predictor for acutely ill patients (p<0.001), while the Hostility factor was the most significant for not-remitted patients and the Negative factor was the most significant for remitted patients (p=0.001 and p<0.001, respectively). In the logistic regression, the Disorganized factor score presented a significant negative association with remission (p=0.007). CONCLUSIONS Higher disorganization symptoms showed the greatest impact in functioning at acute phase, and prevented patients from achieving remission, suggesting it may be a marker of symptom severity and worse outcome in schizophrenia.

What are the PANSS items most related with global improvements in patients with schizophrenia? Toward a reduced version of the PANSS.

The most commonly used response criteria in clinical trials for the treatment of schizophrenia is a combination of the percentage of decrease in the total score of the Positive and Negative Syndromes Scale (PANSS; Kay et al., 1987) and the Clinical Global Impression (CGI; Guy, 1976) scale (Leucht et al., 2007). The peak of effect of antipsychotics typically occurs within 2–4 weeks, which means that satisfactory subsequent clinical response is highly unlikely (Kinon et al., 2009). The PANSS consists of 30 items and generally produce a five-factor solution (Wallwork et al., 2012; Higuchi et al., in press), that are regarded as “symptom dimensions”, which are the positive, negative, cognitive/disorganized, mood/depression and excitement/hostility. However, few items poorly correlate to the factors (Lehoux et al., 2009). In addition, the PANSS demands carefully directed interviews lasting 40–60 min and, recent studies have proposed a modification to the PANSS in order to improve its application time and efficiency (Obermeier et al., 2010). Here, we compared reductions in the scores of each item of the PANSS with corresponding reductions in the CGI-S score after 4 weeks of treatment with antipsychotic medication to ascertain which items of the PANSS best explained global improvements. The sample comprised 106 inpatients with schizophrenia from the Inpatient Psychiatric Unit of Hospital das Clínicas Luzia de Pinho Melo (Mogi das Cruzes, Brazil) between 2011 and 2013. The inclusion criteria were: a diagnosis of schizophrenia as defined by the DSM-IV (American Psychiatric Association, 1994), age between 14 and 65 years and absence of demonstrable organic brain diseases assessed with computed tomography, or severe intellectual disability. Patients were assessed by the first author with the Structured Clinical Interview for DSM-IVAxis I Disorders (SCID-I) (First et al., 1996), the PANSS, and the CGI-S. The local ethic committee approved the study (2013/01), and all subjects and their relatives provided written informed consent for participation in the study. Each psychopathological dimension was disclosed by factor analysis. To estimate the association between each item of the PANSS and CGI-S scores, the baseline scores of each item and the scores of the CGI-S were subtracted from the 4th week scores. For a fair comparison between the items (positive symptoms respond better than negative symptoms), we performed an exploratory stepwise linear regression analysis for each dimension, in which the delta PANSS items were entered as the independent variables and the corresponding delta CGI-S score was entered as the dependent variable. To compare the variance explained by the final model with the traditional 30-item model, a linear regression analysis was performed for bothmodels with the delta CGI-S scores as the dependent variable. P-

A case report of Cotard’s syndrome with catatoniform symptoms

.Mrs. A, a 55 year-old woman, was brought to our psychiatric emergency service because she hadn’t eaten or drank for the last two days. Her depressive symptoms had began 18 months before: she presented sadness, anhedonia and easy crying, which got progressively worse, with apathy, restlessness, prejudice in her daily activities, insomnia, weight loss (went from 105 kg to 54 kg in one year) and delusional nihilistic thoughts. Outpatient care was initiated, but without result.During evaluation, the patient had no eye contact with the attending resident and re-mained stand, with slow pendulum movements, until finally felt down on the floor. She denied having any psychiatric disorder and repeated numerous times phrases like: “my throat is locked and nothing can be done about it”, “I have no blood in my veins or pulse in my arteries” and “the sun won’t rise up and the night won’t end”. After a complete clinical evaluation, in which any organic cause for the psychiatric symp-toms was discarded, patient was admitted on the psychiatric inpatient floor, under the diagno-sis of severe depression with psychotic symptoms, according to the world health organization’s tenth edition of the international classification of diseases (ICD-10)

Panorama nacional do ensino da psiquiatria nas escolas médicas brasileiras

OBJECTIVE: To determine the profile of psychiatric teaching in Brazilian medical schools, with a focus on the number of professors involved and their respective degrees, the number of disciplines devoted to psychiatry and the predominant approach (psychodynamic/clinical/other) adopted, the didactic materials employed and the teaching and learning facilities available. METHODS: The study was based on the collection of data via application of questionnaires at all medical schools registered with the Brazilian Association of Medical Education (Associacao Brasileira de Educacao Medica). RESULTS: Of the 119 Brazilian schools contacted, 85 (71%) returned the questionnaires. The number of professors graduated in psychiatry at each school varied from 1 to 5 (75.3%); of these, 1 to 2 (43.4%) had a PhD degree, 1 to 2 (45.8%) a masters degree, and 1 to 2 (57.3%) were specialists. The findings revealed that 41.2% of the schools offered two disciplines of psychiatry, with a predominantly psychodynamic/clinical approach (61.2%). At 52.9% of the schools, teaching of psychiatric topics was not restricted to the specific disciplines; 64.7% of the disciplines offered hands-on training in general clinical settings. Mean number of credit hours of psychiatric teaching along the medical program was 61-90 (26.2%), and 88.9% of the programs used books as the main choice for didactic purposes. At 83.3% of the medical schools, psychiatric teaching is graded by students at the end of each discipline. CONCLUSION: The present findings revealed an important heterogeneity in the geographic regions assessed, affecting at least 71% of the schools. New studies are warranted to advance the preliminary findings herein reported.

S129. DOES TREATMENT RESISTANT SCHIZOPHRENIA PRESENT A CHARACTERISTIC SYMPTOMATIC SIGNATURE

Abstract Background Treatment-resistant schizophrenia (TRS) may underlie a specific biological signature among patients with schizophrenia. The main lines of evidence suggest a glutamatergic rather than dopaminergic dysfunction in TRS, with lower levels of striatal dopamine and higher levels of glutamate in anterior cingulate. Whether this biological signature relates to a distinct symptomatic profile remains unclear. Our objective is to define a symptom profile of patients with TRS. Methods We used two samples of patients with schizophrenia. First, we followed a discovery sample of inpatients (n=203) to prospectively identify TRS predictors, then we tested the predictors in a replication sample of outpatients (n=207). The samples were collected independently. All patients were assessed with the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions-Severity Scale (CGI-S) and the Global Assessment of Functioning Scale (GAF). Diagnosis was confirmed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). TRS was defined according the criteria of the Schizophrenia Algorithm of the International Psychopharmacology Algorithm Project (IPAP). Initially, we tested if patients with disorganized subtype were more likely to be TRS, and grouped the patients into disorganized or non-disorganized schizophrenia according to SCID-I. Then, we checked which PANSS items at the baseline predicted TRS at the follow-up through multiple logistic regression analyses. A receiver operating characteristic (ROC) curve with the best items was performed at the follow-up. Results TRS was more common in disorganized schizophrenia in the inpatient sample (73.8% vs 22.4%, P < 0.001) and in the outpatient sample (68.2% vs 28.2%, P < 0.001) in comparison to non-disorganized schizophrenia. They also presented worse scores on PANSS, CGI-S and GAF (P < 0.001). In the second step, three PANSS items, P2 (conceptual disorganization), N5 (difficulty in abstract thinking) and G9 (unusual thought content), predicted TRS with 78.4% accuracy (P = 0.011, P = 0.010 and P <0.001). The ROC analysis using the sum of PE+N5G+G9 predicted TRS with a sensitivity of 72.3%, and a specificity of 82.4%. In the outpatient sample, logistic regression analysis of the model P2+N5+G9 discriminated TRS with 69.3% accuracy (P <0.001). Discussion Non-paranoid clinical presentations, specially disorganized characteristics, may consist in clinical markers of TRS. Further Cross-validation of such clinical findings and biological features may improve prediction of TRS

Comparing PANSS scores and corresponding CGI scores between stable and acute schizophrenic patients.

Universidade Federal de Sao Paulo, Dept Psychiat, Interdisciplinary Lab Clin Neurosci LiNC, BR-05039032 Sao Paulo, Brazil