Linda S. Grossman

Sex differences in schizophrenia and other psychotic disorders: a 20-year longitudinal study of psychosis and recovery

This longitudinal study was designed to provide data on sex differences in the course of schizophrenia and other psychotic disorders. Ninety-seven participants (43 women and 54 men) were assessed during index hospitalization when they were in the acute phase of illness and then reassessed prospectively at 6 consecutive follow-ups over a 20-year period. Patients were evaluated by a series of standardized measures on many aspects of illness including the presence of psychosis, global outcome, and rate of recovery. When women were compared to men in this sample, the data demonstrated a lower percentage of psychotic activity for women over the course of illness (significant at the 7.5- and 20-year follow-ups), and a significant improvement in psychotic activity over 20 years for women (P < .05), but not for men. In addition, women showed significantly better global functioning (P < .05) at 3 of the 6 follow-ups (the 2-, 7.5-, and 10-year follow-ups). Significantly higher percentages (P < .05) of women were in recovery at 2 of the 6 follow-up years (the 2- and 10-year follow-ups). Cumulatively, 61% of the women with schizophrenia showed a period of recovery at some point during the 20-year period compared to 41% of the men. The sex difference patterns were similar for patients with schizophrenia and for those with other types of psychotic disorders. Sex differences in this sample were specifically not attributable to differences in age of onset or premorbid developmental achievements.

Psychological aspects of sexual functioning among cleric and noncleric alleged sex offenders.

Cleric sexual misconduct with minors is a problem receiving increased attention from the media, victims groups, and church authorities. Mental health professionals are increasingly being asked to assist church and civil authorities to help better understand the problem of cleric sexual misconduct with minors. In the current study we compared self-reported sexual functioning among cleric alleged child molesters, noncleric alleged child molesters, and normal control subjects. We hypothesized clerics would differ from nonclerics and normals in reported sexual functioning. Our sample included 30 Roman Catholic clerics and 39 nonclerics who were alleged to have engaged in sexual misconduct with minors, and 38 normal control subjects, all of whom took the Derogatis Sexual Functioning Inventory (DSFI) as part of their forensic psychiatric evaluation. Our results indicated clerics were more likely to report fewer victims, older victims, and victims of male gender than noncleric alleged child molesters. Clerics differed from nonclerics and normal control subjects on several dimensions of self-reported sexual functioning. Lower offense rate histories among clerics suggest that, as a group, clerics may be less seriously psychologically disordered than noncleric child molesters. Low DSFI scores among Roman Catholic clerics may be accounted for in part by their unique training and socialization process. Future studies should attempt to study the influence of social desirability on DSFI scores. Normative data from nonoffending celibate clergy are needed.

Psychopathology and denial in alleged sex offenders

To investigate whether patients accused of having committed acts of sex offense manifest symptoms of psychopathology and whether they minimize or deny such symptoms during clinical evaluations, we administered the MMPI to 53 alleged sex offenders. We compared patients along two dimensions: a) whether they admitted or denied deviant sexual behavior, and b) whether they faced legal charges for sex offenses. Results indicated the following: a) Patients who denied deviant sexual behavior were significantly more likely to minimize psychopathology than were those who admitted to deviant sexual behavior (p<.05). b) Patients facing no active legal charges showed significantly more psychopathology than did those facing legal charges (p<.05). c) The most frequent forms of psychopathology shown by these patients were antisocial attitudes, depression, somatization, and cognitive disorganization. These findings suggest that many alleged sex offenders may experience, and deny, severe psychopathology in addition to their sexual disorders. Clinicians should be alert to subtle signs of psychopathology when evaluating alleged sex offenders who deny deviant sexual behavior, because these patients may be especially likely to minimize symptoms.

Diagnostic and prognostic significance of Schneiderian first-rank symptoms: a 20-year longitudinal study of schizophrenia and bipolar disorder

OBJECTIVE This research addresses the following questions: what is the prevalence and severity of first-rank symptoms (FRS) during an extended period of time in patients with schizophrenia and bipolar disorder with psychosis? Are the specific FRS listed in Diagnostic and Statistical Manual of Mental Disorders DSM, Third Edition, Revised/Fourth Edition Criterion A for schizophrenia diagnosis (a voice keeping a running commentary or voices conversing) more prevalent and severe in patients with schizophrenia than bipolar disorder with psychosis? Lastly, do FRS at index hospitalization in patients with schizophrenia predict the absence of later recovery? METHODS This research follows a sample of patients with psychotic disorders who were evaluated at index hospitalization and then prospectively followed-up at 6 evaluations during next 20 years (n = 86). All patients were evaluated as part of a prospective research study designed to measure multiple factors of phenomenology, severity of illness, course of illness, prognosis, and global outcome. RESULTS First-rank symptoms are not exclusive to schizophrenia; they also occur in some bipolar patients. However, they are more frequent and more severe in patients with schizophrenia than bipolar disorder. Schizophrenia patients with FRS during the acute phase are more likely to have poorer long-term outcome than schizophrenia patients who do not have FRS during the acute phase. CONCLUSIONS Our results indicate FRS at the acute phase are not a clinicopathologic correlate specific to schizophrenia. However, the presence and severity of any FRS and specifically of the 2 FRS associated with Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised/Fourth Edition Criterion A are more prevalent and more severe in patients with schizophrenia than patients with bipolar disorder.

Denial and Social Desirability in Clinical Evaluations of Alleged Sex Offenders

Clinicians are increasingly being requested to evaluate alleged sex offenders. Denial of sex offenses and minimization of psychopathology is common in such patients. We studied the relationship between denial of deviant sexual behavior and minimization/exaggeration of problems (i.e., response bias) during clinical evaluations in 59 alleged sex offenders. The data indicated that patients who denied allegations of deviant sexual behavior showed significantly more minimization of problems than did admitters (p < .001), and patients who admitted allegations showed more exaggeration of problems than did deniers (p < .05). Response bias was significantly associated with a number of personality characteristics. In particular, alleged offenders who denied deviant sexual behavior were more likely to be defensive about undesirable personality characteristics and to minimize problems than were those who admitted to deviant sexual behavior. When defensive, alleged sex offenders were likely to minimize anxiety and personality disorders. The data support the forensic utility of psychological testing in the assessment of alleged sex offenders.

Denial of deviant sexual arousal and psychopathology in child molesters

To provide information about whether alleged sex offenders honestly report their patterns of sexual interest and whether this varies with self-report of symptoms of psychopathology, the present study assessed 75 alleged child molesters and 41 normal subjects using a subjective index of self-reported sexual, interest known as the Pictorial Sexual Interest Card Sort (PSICS) and the MMPI. Results indicated that child molesters who denied allegations reported significantly less sexual interest in children than did admitters or normal subjects. Self-report of low deviant sexual interest was associated with minimization of psychopathology for child molesters. Individuals who molested boys reported significantly more sexual interest in boys and men than did normal subjects or individuals who molested girls. Individuals who molested girls reported less interest in adult women than did normal subjects. Incestuous child molesters admitted to less sexual interest in children than did nonincestuous child molesters. The latter results further support the use of the PSICS as a subjective self-report measure of sexual interest. However, clinicians should be especially cautious about accepting self-reports of deviant sexual interest by child molesters who deny deviant sexual behavior and minimize psychopathology.

A 20-year multi-follow-up of hallucinations in schizophrenia, other psychotic, and mood disorders

BACKGROUND Hallucinations are a major aspect of psychosis and a diagnostic feature of both psychotic and mood disorders. However, the field lacks information regarding the long-term course of hallucinations in these disorders. Our goals were to determine the percentage of patients with hallucinations and the relationship between hallucinations and recovery, and work attainment. Method The present study was a prospective evaluation of the 20-year trajectory of hallucinations in 150 young patients: 51 schizophrenia, 25 schizoaffective, 25 bipolar with psychosis, and 49 unipolar depression. The patients were studied at an index phase of hospitalization for hallucinations, and then reassessed longitudinally at six subsequent follow-ups over 20 years. RESULTS The longitudinal course of hallucinations clearly differentiated between schizophrenia and bipolar disorder with psychosis, and suggested some diagnostic similarities between schizophrenia and schizoaffective disorder, and between bipolar disorder and schizoaffective disorder and depression. Frequent or persistent hallucinatory activity over the 20-year period was a feature of 40-45% of schizophrenia patients. The early presence of hallucinations predicted the lack of future periods of recovery in all patients. Increased hallucinatory activity was associated with reduced work attainment in all patients. CONCLUSIONS This study provides data on the prospective longitudinal course of hallucinations, which were previously unavailable to the field, and are one of the key features of psychosis in major psychiatric disorders. This information on the clinical course of major psychiatric disorders can inform accurate classification and diagnosis.

Profiling Psychological Distortion in Alleged Child Molesters

Sex offenders frequendy show denial and distortion during forensic psychological evaluations, but research into assessment of rationalizations and cognitive distortions among sex offenders has been limited We examined patterns of psychological distortion in 59 alleged child molesters. We compared fake-good and fake-bad orientations on the MMPI with psychological distortion on the Multiphasic Sex Inventory questionnaire which assesses various psychosexual characteristics among sex offenders. Analysis indicated that distortion on the Multiphasic Sex Inventory indices of minimization and exaggeration was significantly associated with response-bias on the MMPI. Cognitive-distortion indices were highly influenced by response-bias. Admitters differed from deniers on scales with items requiring admission or denial of offenses. Caution is warranted in clinical interpretation of the validity scales of this questionnaire, which are of limited utility for deniers. Subtle items on cognitive-distortion indices may be useful in assessment of those who deny and should be subjected to further research.

Temporal patterns of veterans' psychiatric service utilization, disability payments, and cocaine use.

This study examined temporal patterns of service utilization, disability benefits, and substance use. Specifically, it investigated whether the first day of the first week of each month (when disability payments are disbursed) was associated with increased emergency room (ER) use and more frequent cocaine use among psychiatric patients. All 1993 psychiatric ER presentations (n=1,448) at a Veterans Administration hospital were reviewed in order by the week of each month in which they occurred. A random subsample of only those admitted to an inpatient psychiatric service (n=143) was further assessed for amount of disability payments received and recent cocaine use. This study found that for the total population of patients utilizing the ER, most ER visits occurred during the first week, followed by weeks two, three, and four respectively. The highest percentage (49%) of patients who used cocaine were those admitted during the first week of the month, followed by week two (39%), week four (28%) and week three (25%). For the subsample of patients admitted to inpatient services, patients hospitalized during the fourth week of the month were those receiving the highest disability payments. This study found that cocaine users have the most ER visits during the first week of the month following receipt of benefits. Current data, if confirmed, would suggest public policy changes, such as payment of entitlement money to cocaine users through a third-party payee and stipulated treatment for psychiatric patients with substance use disorders as a condition of payment. Ethical and political issues, including confidentiality and patient autonomy, would need to be considered in any such policy changes.

Posttraumatic Stress Disorder Symptoms in Resident Physicians Related to Their Internship

To evaluate whether stresses experienced by physicians during internship are associated with posttraumatic stress disorder (PTSD) symptoms, the authors administered a standardized questionnaire to assess PTSD symptoms, depressive and anxiety symptoms, and social supports to 212 residents. Thirteen percent of residents met diagnostic criteria for PTSD, including 20% of the women and 9% of the men. PTSD symptoms were significantly more frequent in residents who were single or divorced at the time the questionnaire was administered. There were significant positive correlations between PTSD symptoms and symptoms of both current anxiety and depression, and a significant negative correlation existed between social support and PTSD symptoms. PTSD symptoms attributed to stresses associated with internship, which may be deleterious to physician well-being and potentially to patient care, and suggest the importance of making major changes in postgraduate medical training.