Lewis A. Opler

Empirical Assessment of the Factorial Structure of Clinical Symptoms in Schizophrenia

The Positive and Negative Syndrome Scale (PANSS) is widely used as a method for the assessment of symptoms of schizophrenia but the most complete model of how symptoms are structured has not been determined. Using the methods of confirmatory factor analysis with a large sample of 1,233 of schizophrenic subjects this study examined the goodness of fit of 20 previously proposed models. None of these proposed models met criteria for adequate fit to the empirical data. The sample was then stratified and half of the data was used to calibrate a new model. The model was validated in the second half of the data. The new pentagonal model uses 25 of the 30 items of the PANSS in 5 factors: positive, negative, dysphoric mood, activation, and and autistic preoccupation. Patients who varied widely in age, severity, and chronicity of illness did not differ in their overall symptom structure. The results of this study also implicated some problems in the validity of the PANSS as currently configured when used to assess symptoms of schizophrenia.

Risk Factors for Long-Term Homelessness: Findings From a Longitudinal Study of First-Time Homeless Single Adults

OBJECTIVES We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. METHODS Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, symptoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. RESULTS Eighty-one percent of participants returned to community housing during the follow-up period; the median duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group P<.05) and arrest history (P<.01) were the strongest predictors of a longer duration of homelessness. CONCLUSIONS Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventions.

Risk factors for homelessness among schizophrenic men: A case-control study

OBJECTIVES To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. METHODS Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. RESULTS Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. CONCLUSIONS Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

Positive and negative syndromes in chronic schizophrenic inpatients.

This study considered whether chronic schizophrenics with positive and negative syndromes represent distinct subtypes. From a survey of 47 schizophrenic inpatients, 18 showed preponderance of productive or deficit features, and four were mixed. The discrete groups were compared on clinical symptoms, cognitive tests, demographic and historical data, and drug side effects. They were significantly distinguished on most criterion symptoms and affect scales but, otherwise, essentially comparable in psychopathology and extrapyramidal symptoms. The tests revealed similar levels of intellectual impairment and visual-motor deficit, yet the negative patients displayed more primitive cognitive mode and greater psychomotor retardation. They also proved older, less educated, more often born in wintertime, hospitalized later in life, and less heavily medicated. The results supported the validity of the positive-negative dimension for identifying schizophrenic subtypes and suggested etiological implications regarding developmental deficiency.

Neurological signs and the positive-negative dimension in schizophrenia

Schizophrenic patients have been observed to manifest a variety of abnormal neurological signs, but the nature of their association with differing clinical presentations is less well established. To address this issue, we administered a newly compiled neurological inventory to 28 well-characterized chronic schizophrenic inpatients and separately assessed them on the Positive and Negative Syndrome Scale and on control variables that included measures of global pathology, chronicity of illness, neuropsychological and intellectual integrity, and extrapyramidal dysfunction. We found, first, that our neurological battery provided statistically independent measures of apraxia, fine motor function, and prefrontal, parietal, and nonlocalizing signs. A significant association emerged between negative symptomatology and neurological signs of prefrontal impairment (p less than 0.01), which could not be accounted for by any of the control variables. Positive symptoms were associated with an absence of parietal and nonlocalizing signs; however, these correlations were mediated by higher neuroleptic doses in these patients. There was no association between any neurological sign and age, extrapyramidal symptoms, general neuropsychological integrity, education, IQ, or severity or chronicity of illness. We concluded that the negative syndrome in schizophrenia represents a distinct dimension of psychopathology that is related specifically to prefrontal deficit.

SIGNIFICANCE OF COCAINE HISTORY IN SCHIZOPHRENIA

Fifty-one schizophrenic inpatients were divided into two groups, those with and without history of cocaine use, and compared on historical, demographic, cognitive, and psychopathological measures. Patients with a cocaine history were found to be significantly more depressed, less socialized, and more impaired in conceptual encoding and verbal memory, while less disordered in attention. The two groups did not differ in severity of illness or positive and negative syndromes. There were also no differences in control variables such as age, gender, education, intelligence, premorbid adjustment, neuroleptic dose, onset and chronicity of illness, continuity of hospitalization, paranoid subtype, and psychiatric illness in the family. Cocaine history was associated with multiple illicit drug use, but for other substances there was no increased liability for depression or cognitive deficits. The results suggest that the clinical presentation in schizophrenia is significantly associated with prior cocaine experience

Positive and negative syndromes in schizophrenia as a function of chronicity

The construct validity and extended stability of positive and negative syndromes were studied via multidimensional cross‐sectional assessment of 134 schizophrenics in the acute, chronic, and long‐term chronic stages. For all groups the syndromes were internally reliable, not significantly intercorrelated, and of similar severity. The syndromal correlates with clinical, motor, historical, and genealogical dimensions, however, differed as a function of chronicity. In acute schizophrenics, a negative syndrome was associated with clinical and genealogical indicators of good prognosis, whereas the converse obtained for a positive syndrome in the acute stage and a negative syndrome in the chronic stage. The relationship of education, marital status, and attention disorder to the positive‐negative distinction also varied according to length of illness. Its meaning, therefore, appeared phase‐specific and subject to evolution, obviating generalizations across all phases. Implications for theory, prognosis, current research, and future study are presented.

Amantadine in the treatment of neuroendocrine side effects of neuroleptics.

An open-label reversal drug study was undertaken on 10 neuroleptic-treated schizophrenic inpatients to assess the impact of amantadine hydrochloride on presumed prolactin-mediated neuroendocrine side effects. Measures were conducted across 7 weeks, including a 2-week neuroleptic baseline, a 3-week neuroleptic-plus-amantadine phase, and a 2-week return to the baseline regimen. Significant reduction with amantadine was observed on all six indices of neuroendocrine side effects: serum prolactin levels, body weight, gynecomastia/galactorrhea, breast tenderness, decreased libido, and amenorrhea. Improvement on these parameters was noted for as many as nine or all 10 patients, while in no cases was there worsening. In terms of motor and clinical effects, significant diminution of extrapyramidal and psycho-pathological symptoms was also achieved during this phase. The results suggested that amantadine may be beneficial for the treatment of neuro-endocrine side effects of antipsychotic medication owing to its ability to reverse neuroleptic-induced hyperprolactinemia.

Positive and negative subtypes in acute schizophrenia

Abstract This study examined the validity of the positive-negative dimension for the subtyping of young acute schizophrenics with under two years of illness. From a survey of 37 consecutively admitted acute schizophrenic inpatients with a mean age of 23.6 years, 9 were classified as having a positive syndrome and 8 a negative syndrome. They were compared on multiple psychopathological ratings, an affect scale, a test of attention and psychomotor rate, demographic, historic, and treatment variables, and drug side effects. A significant inverse relationship between positive and negative symptoms was found. The two groups were reliably distinguished on most criterion symptoms. The positive schizophrenics more commonly carried a paranoid subdiagnosis and also rated higher on symptoms associated with paranoid status. The negative patients showed an accurnulation of deficit symptoms that included impairments in affect, social relations, spontaneous thinking, attention, and motorium. Premorbidly they had less education and poorer work adjustment. Demographic variables, age and mode of onset of illness, duration since onset, global psychopathology, prevalence of extrapyramidal symptoms, and neuroleptic doses were essentially comparable in both groups. The data supported the presentation of a negative syndrome among young acute schizophrenics and its distinction from the positive subtype. The negative syndrome apparently was not secondary to progression of the disorder, prolonged institutionalization, severity of illness, neuroleptic dosage, or drug side effects. Processes accounting for the differentiation of these two syndromes early in the course of illness were discussed in the relation to developmental and biochemical hypotheses.

A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms.

We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.