Piet Oosthuizen

Dysmorphic concern: Prevalence and associations with clinical variables

Objective: The aim of this paper is to describe the development of a questionnaire, the Dysmorphic Concern Questionnaire (DCQ), for the assessment of dysmorphic concern, and to establish correlations with clinical variables. Method: Consecutive admissions to a psychiatric hospital were surveyed. Results: The DCQ showed good internal consistency, with most of the variance being explained by a single factor. Strong correlations with distress and work and social impairment lend face validity to the questionnaire. Dysmorphic concern was not significantly influenced by the patients age, sex or diagnosis. In terms of specific psychotic symptoms, there were weak positive correlations with thought interference and persecutory ideation. However, the strongest correlations were with depressed mood, according to the Beck Depression Inventory (BDI) but not the Montgomery Asberg Depression Rating Scale; the discrepancy was largely accounted for by the “cognitive” depressive items on the BDI. In terms of objective assessment of dysmorphic features, ratings on the Waldrop scale for minor physical anomalies showed no correlation with concern expressed by the patient. Conclusions: The strong correlation with depressive cognitions suggests that dysmorphic concern is often a reflection of a depressive cognitive set rather than being a diagnosis in itself.

Linking posttraumatic stress disorder and psychosis: a look at epidemiology, phenomenology, and treatment.

Several recent studies have provided direct evidence for the link between posttraumatic stress disorder (PTSD) and psychosis. Patients with psychotic disorders are known to be at a higher risk of traumatization and PTSD. Additionally, preclinical and clinical data suggest that the effects of trauma exposure on neural networks may provide a common diathesis for disorders like PTSD and schizophrenia. This article reviews evidence on a) the magnitude of association between PTSD and psychosis, b) the causal mechanisms implicated, and c) treatment considerations relevant to this association. A comprehensive MEDLINE search was conducted, and articles pertinent to epidemiological, clinical, and treatment aspects of comorbid PTSD and psychosis were identified. High rates of PTSD characterize patients with severe mental illness. Psychotic phenomena may also be a relatively common manifestation in patients with chronic PTSD. However, in clinical settings, the diagnosis is often missed, and few systematic guidelines exist for the identification and treatment of these comorbidities. Future neurobiological and treatment studies may be useful in better informing the clinical management of these subgroups.

The effects of eicosapentaenoic acid in tardive dyskinesia: A randomized, placebo-controlled trial

OBJECTIVE Worldwide, conventional antipsychotic medication continues to be used extensively, and tardive dyskinesia (TD) remains a serious complication. The primary objective of the present study was to compare the efficacy of EPA versus placebo in reducing symptoms of TD. METHOD This was a 12-week, double-blinded, randomized study of ethyl-EPA 2g/day versus placebo as supplemental medication, in patients with schizophrenia or schizoaffective disorder, with established TD. RESULTS Eighty-four subjects were randomized, of whom 77 were included in the analysis. Both the EPA and placebo groups displayed significant baseline to endpoint improvements in Extrapyramidal Symptom Rating Scale dyskinesia scores, but there were no significant between-group differences (p=0.4). Response rates (>or=30% improvement in TD symptoms) also did not differ significantly between EPA-treated subjects (45%) and placebo-treated subjects (32%) (p=0.6). However, a post-hoc linear mixed model repeated measures analysis of variance indicated an effect for treatment group and duration of TD. The EPA-treated patients had significantly greater mean reductions in dyskinesia scores initially, although this was not sustained beyond 6 weeks. CONCLUSIONS This trial failed to demonstrate an anti-dyskinetic effect for ethyl-EPA 2g/day on the primary efficacy measure. However, a modest and transient benefit is suggested in patients with more recent onset of TD. The lack of clear-cut efficacy could be explained on the basis of the dose of EPA being too low, the study being underpowered, TD being too chronic in the majority of cases, differences in dietary fatty acid intake, or that EPA lacks an anti-dyskinetic action.

Clinical potential of omega-3 fatty acids in the treatment of schizophrenia.

The phospholipids in the neuronal membranes of the brain are rich in highly unsaturated essential fatty acids (EFAs). It has been hypothesised that abnormalities of phospholipid metabolism are present in patients with schizophrenia and that the EFAs omega-3 polyunsaturated fatty acids, and eicosapentaenoic acid (EPA) in particular, may have a role in treating this illness. Considerable preclinical and clinical evidence provides support for this proposal. An epidemiological study reported a better outcome for patients with schizophrenia in countries where the diet is rich in unsaturated fatty acids. Evidence of abnormalities of EFAs has been found in erythrocyte membranes and cultured skin fibroblasts of patients with schizophrenia, and abnormal retinal function and niacin skin flush tests (markers of omega-3 polyunsaturated fatty acid depletion) have also been reported. Case reports and an open-label clinical trial reported efficacy for EPA in schizophrenia. Four randomised, controlled trials of EPA versus placebo as supplemental medication have now been reported. Two of these trials showed significant benefit with EPA on the positive and negative symptom scale total scores, whereas the other two did not show any effects on this primary efficacy measure. One study also reported a beneficial effect on dyskinesia. In the only published trial in which EPA was used as monotherapy versus placebo in schizophrenia, some evidence was found to suggest antipsychotic activity. Taken together, there is considerable evidence to suggest abnormalities of EFAs in cell membranes of patients with schizophrenia, and there is preliminary evidence that EPA is an effective adjunct to antipsychotics.

Neurological abnormalities in first-episode schizophrenia : Temporal stability and clinical and outcome correlates

OBJECTIVE Neurological abnormalities in subjects with schizophrenia have been regarded as diagnostically non-specific and non-localising. This study assessed the temporal stability of neurological abnormalities in subjects with first-episode schizophrenia over the course of 12 months. We also examined their relationships with psychiatric symptoms, medication effects and treatment outcome. METHOD The sample comprised 66 largely medication-naive subjects who were treated according to a fixed protocol. We performed a factor analysis of the Neurological Evaluation Scale (NES) items, and relationships between the NES factors and various clinical and outcome measures were explored. RESULTS Five NES factors were identified, explaining 68.4% of the variance. While the NES total scores did not change significantly over time, poor performance on motor sequencing tests was related to longer duration of untreated psychosis, and showed a tendency to improve as psychiatric symptoms resolved. The most interesting finding was that high scores on the motor sequencing factor predicted the emergence of persistent dyskinesia at 24 months (ANCOVAR F(1, 20) = 19.287, p = 0.0002). CONCLUSIONS Two NES factors (motor sequencing and attention) are reasonably replicable across samples, and have potential relevance for the further exploration of the pathogenesis of schizophrenia, as well as possible clinical applications.

A randomized, controlled comparison of the efficacy and tolerability of low and high doses of haloperidol in the treatment of first-episode psychosis

While haloperidol is still widely used in the treatment of psychoses, the optimal daily dose remains a topic of controversy, particularly in first-episode psychosis. Previous studies have suggested that doses as low as 2 mg/d may be effective, whereas others have indicated superiority for higher over lower doses. This double-blinded, randomized controlled study compared the efficacy and tolerability of 2 vs. 8 mg/d of haloperidol over 6 wk in 40 subjects with first-episode psychosis. Both treatments were equally effective in reducing the PANSS Total and subscale scores. The low dose of haloperidol was better tolerated, with fewer extrapyramidal side-effects, less frequent use of anticholinergic medication and smaller elevations in prolactin levels. Using a low dose of haloperidol is at least as effective as, and better tolerated than a high dose of haloperidol in the treatment of first-episode psychosis.

Muscle dysmorphia : A South African sample

Abstract It has recently been suggested that muscle dysmorphia, a pathological preoccupation with muscularity, is a subtype of body dysmorphic disorder (BDD). There are, however, few studies of the phenomenology of this putative entity. Twenty‐eight amateur competitive body builders in the Western Cape, South Africa, were studied using a structured diagnostic interview that incorporated demographic data, body‐building activities and clinical questions focusing on muscle dysmorphia and BDD. There was a high rate of muscle dysmorphia in the sample (53.6%). Those with muscle dysmorphia were significantly more likely to have comorbid BDD based on preoccupations other than muscularity (33%). Use of the proposed diagnostic criteria for muscle dysmorphia indicated that this is a common and relevant entity. Its conceptualization as a subtype of BDD seems valid. The disorder deserves additional attention from both clinicians and researchers.

The factor structure for positive and negative symptoms in South African Xhosa patients with schizophrenia

Most studies investigating the symptom dimensions of schizophrenia utilising the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS) favour a three factor model. This study sought to investigate the factor structure of both the global and individual items of the SANS and SAPS in a large sample of South African Xhosa patients with schizophrenia. A total of 422 subjects participated. Both principal components and factor analytical procedures were applied. For the global items, a two-factor solution representing positive and negative symptoms accounted for 59.9% of the variance. Alternatively, the three-dimensional model of negative, psychotic and disorganisation factors was supported by a five-factor solution if the more heterogeneous items of attention and alogia were ignored. Analysis of the individual items yielded a five-factor solution with the negative symptoms splitting into diminished expression and disordered relating, and the positive symptoms separating into factors for psychosis, thought disorder and bizarre behaviour. Our findings are very similar to those from other parts of the world, providing evidence that the factor structure for the symptoms of schizophrenia is relatively resistant to cultural influences. This is particularly true for negative symptoms.

Depressive symptoms at baseline predict fewer negative symptoms at follow-up in patients with first-episode schizophrenia.

There is uncertainty regarding the prognostic value of depressive symptoms in schizophrenia, having previously been associated with both favourable and poor outcome. This study investigated the relationship between baseline depressive symptoms and treatment outcome at 6, 12 and 24 weeks in 80 subjects with first-episode schizophrenia or schizophreniform disorder in terms of PANSS total and subscale score changes. No significant association was found between baseline PANSS depression factor scores and PANSS total and subscore changes. However, a significant inverse correlation between baseline depression scores and negative scores at 6, 12 and 24 weeks was found (p=0.044, 0.023 and 0.012, respectively). Multiple regression analysis indicated that this finding could not be explained on the basis of age, gender or duration of untreated psychosis. These findings support previous work suggesting that high baseline depressive scores predict favourable outcome.

Pathways to care and treatment delays in first and multi-episode psychosis: Findings from a developing country

In contrast to findings from the developed world where general practitioners and mental health professionals are central in first episode psychosis pathways, studies from Africa have found GPs to play a less prominent role with other help providers such as traditional healers being more important. We compared pathways to care, treatment delays and gender differences in patients with first versus multi episode psychosis. Private sector GPs were first contacts in first episode patients in as many as 38% of patients and were significantly more likely to be the first contact (odds ratio = 4.5, 95% CI = 1.38–14.67) and final referring agent (odds ratio = 6.8, 95% CI = 1.56–25.12) in first episode patients. Female multi episode patients were significantly more likely to make first contact with primary care practitioners whereas male multi episode patients were more likely to first come into contact with the police (P = 0.003) and be admitted compulsorily (P = 0.009). Only 5.6% (n = 4) of patients contacted traditional healers at some point in their pathway to care. Treatment delays and DUP in first episode patients were longer and reached a median of 4.5 versus 2.5 months in multi episode patients. Treatment discontinuation of antipsychotics occurred in 82% of multi episode patients. Despite significantly longer overall treatment delays in first episode patients the distribution of treatment delays in multi episode patients followed a similar pattern to DUP in first episode patients with a subgroup having very long delays. Pathways to care in this treatment setting correspond more to findings from first world and newly industrialized countries. A subgroup of multi episode patients had very long periods of untreated illness. Limitations include small sample size and the retrospective nature of data collection.BackgroundIn contrast to findings from the developed world where general practitioners and mental health professionals are central in first episode psychosis pathways, studies from Africa have found GPs to play a less prominent role with other help providers such as traditional healers being more important.MethodsWe compared pathways to care, treatment delays and gender differences in patients with first versus multi episode psychosis.ResultsPrivate sector GPs were first contacts in first episode patients in as many as 38% of patients and were significantly more likely to be the first contact (odds ratio = 4.5, 95% CI = 1.38–14.67) and final referring agent (odds ratio = 6.8, 95% CI = 1.56–25.12) in first episode patients. Female multi episode patients were significantly more likely to make first contact with primary care practitioners whereas male multi episode patients were more likely to first come into contact with the police (P = 0.003) and be admitted compulsorily (P = 0.009). Only 5.6% (n = 4) of patients contacted traditional healers at some point in their pathway to care. Treatment delays and DUP in first episode patients were longer and reached a median of 4.5 versus 2.5 months in multi episode patients. Treatment discontinuation of antipsychotics occurred in 82% of multi episode patients. Despite significantly longer overall treatment delays in first episode patients the distribution of treatment delays in multi episode patients followed a similar pattern to DUP in first episode patients with a subgroup having very long delays.ConclusionsPathways to care in this treatment setting correspond more to findings from first world and newly industrialized countries. A subgroup of multi episode patients had very long periods of untreated illness. Limitations include small sample size and the retrospective nature of data collection.