Rachel Gittelman-Klein

Premorbid asocial adjustment and prognosis in schizophrenia

IN THE extensive literature concerning the personality characteristics of schizophrenics, major emphasis has been placed on the role premorbid asocial adjustment plays in the development of schizophrenia.l-I1 KRAEPELIN was one of the first to discuss the early childhood personality characteristics of dementia praecox patients. He emphasized a pattern, most frequently reported in men, who as children ‘exhibited a quiet, shy retiring disposition, made no friends, lived only for themselves’.’ HocH~J~ labeled such patients as having a ‘shut-in’ personality. BLEULER also described an early disturbance reflecting the child’s lack of interest in the environment.13 The concept that the childhood of the adult schizophrenic was often characterized by inadequate social interaction gained wide acceptance. 11 A variety of labels were used to refer to the shut-in premorbid personalities of schizophrenic patients, such as ‘schizophrenic constitutions’,10 ‘schizoid personalities’,293p6 ‘constitutional schizophrenia’,1 ‘introverted personalities’,14 and ‘process symptoms’.l” The qualitative referents of these terms unanimously reflected Hoch’s description. There was disagreement, however, as to what the shut-in, schizoid personality signified. Some clinicians, among them Kraepelin, Bleuler, and Kretschmer, felt that these early disturbances were the first signs of the disease. MEYER, on the other hand, felt that these early traits did not represent disease onset but were dynamic factors predisposing to schizophrenia.16J7 Although much was written in the early 1900’s regarding the childhood social inadequacies of adult schizophrenics, HOCH only was explicit about their prognostically negative role.12 In view of Hoch’s explicit statement regarding the relationship of premorbid adjustment to outcome, it is surprising that relatively little attention was given to this issue. Rather, the length of time during which the psychosis developed (i.e. insidious vs. acute onset) was considered by clinicians the major factor influencing the course of schizophrenia.18Js

School phobia: diagnostic considerations in the light of imipramine effects.

The results of a double blind, placebo-controlled study of the effects of imipramine among 35 school phobic children between the ages of 6 to 14 are reported. The children and families were given a multidiscipline treatment program concurrently with imipramine or placebo treatment. Imipramine, over a 6-week period, was found to be significantly superior to placebo in inducing school return and in global therapeutic efficacy. Doses of medication ranged from 100 to 200 mg/day after 6 weeks of treatment. It was found that imipramine effects could not be detected after 3 weeks of therapy but were clearly present after 6 weeks. Of 10 items rated by the psychiatrists at baseline and after 6 weeks of treatment, 4 items which reflect the severity of the childs phobic behavior, the childs venturesomeness from the mother, physical symptoms while going to school, and fear of going to school were significantly improved by imipramine treatment. Among 10 items rated by mothers, only 1 item reflecting depressive mood showed a significant drug effect. On the whole, side effects were not significant, and only one child required dosage alteration due to orthostatic hypotension. The diagnostic characteristics of this population are discussed. Further, the relevance of the findings to theories of school phobia is examined.

Imipramine side effects in children.

The incidence, range, and severity of side effects in 65 children and young adolescents receiving imipramine treatment are compared with those occurring in 37 children and young adolescents receiving placebo. Minor side effects occurred in 83% of the imipramine group and in 70% of the placebo group. Just under 5% of the children in the imipramine group had significant side effects but none were serious enough to necessitate drug withdrawal. The majority of side effects in both groups occurred during the first three weeks of treatment. However, there may be serious individual idiosyncrasies to high dosage of imipramine, as possibly suggested by the sudden death of one six year old girl during imipramine treatment.

Are Behavioral and Psychometric Changes Related in Methylphenidate-Treated, Hyperactive Children?

Improvement in psychometric test performance as well as in behavior has been consistently observed among hyperactive children treated with stimulants. In some publications there is either the expressed or implied opinion that the improved cognitive functioning is an end in itself, suggesting that the improvement is evidence of the drugs more general beneficial effects (Campbell, Douglas, & Morgenstern, 1971). More important, the positive effects of stimulants on psychometric test results have been used for deriving theories explaining how stimulants benefit the behavior of hyperactive children. It is argued quite convincingly that stimulants do not have a paradoxical effect on hyperactive children, but rather that they act as central nervous system (CNS) stimulants enhancing attention-arousal processes; this improvement enables the child to focus and attend. Secondary to improved attention, the child is more controlled and focused, less impulsive and distractible (Conners, 1973; Douglas, 1972; Ellis, Witt, Reynolds, & Sprague, 1974; Kinsbourne, 1974; Satterfield, Cantwell, Lesser, & Podosin, 1972). This change is interpreted by the caring adults as a reduction in hyperactivity. The hypothesis is that motor activity is not quantitatively reduced but qualitatively improved by the stimulants. The child does not stop moving, but his movements become goal directed and meaningful, rather than haphazard, unfocused, and purposeless. If the above interpretation is correct, one possible consequence would be that children who responded to stimulants would improve both in behavior and in test performance, so that those whose

Problems in the Diagnosis of Minimal Brain Dysfunction and the Hyperkinetic Syndrome

(1975). Problems in the Diagnosis of Minimal Brain Dysfunction and the Hyperkinetic Syndrome. International Journal of Mental Health: Vol. 4, Recent Advances in Child Psychopharmacology, pp. 45-60.

Clinical Pharmacological Management of Hyperkinetic Children

According to the classic description, children with the diagnosis f hyperkinetic reactions of childhoodtT display motor hyperactivity, impulsiveness, poor frustration tolerance, poor concentration, distractibility, and, frequently, immaturity and/or aggressiveness all in the absence of psychosis. Markedly increased motor activity may be an immediately obvious behavioral feature of the disorder; but the disabling aspect does not seem to be the level of activity per se, but the seeming lack of goal direction of the childrens behavior. The impulsive quality of their behavior and their poor concentration and easy distractibility contribute to an over-all impression of disorganization. These children are frequently immature; they communicate and behave like, and often associate with, children two to three years

Sex differences in the relationship between premorbid asociality and posthospital outcome.

To clarify the influence of the patients sex on the relationship between level of premorbid social functioning and posthospital outcome, the premorbid asocial adjustment during preadolescence and adolescence and the 3-year posthospital outcome of a group of 163 previously hospitalized psychiatric patients were determined. A significant relationship was found between premorbid asocial adjustment and both incidence of rehospitalization and sex (p < .005). The data indicate that a premorbid asocial adjustment scale (PAAS) score associated with good posthospital outcome among male patients was indicative of poor outcome for female patients. Thus the mean PAAS score for nonhospitalized males (4.97) is statistically similar to the mean PAAS score of rehospitalized females (5.30). Further, the relationship between PAAS and rehospitalization was limited to schizophrenic patients, indicating that the meaning of premorbid asocial adjustment is a function of diagnosis rather than a panpathological index. The findings were discussed in terms of differences in childrearing practices and social expectations for each sex group. The importance of comparing individuals on measures of premorbid social competence only within their own sex and diagnostic group was emphasized.

Ritalin effects in children with learning disability

321 Ritalin effects in children with learning disability DONALD F. KLEIN and RACHEL GITTELMAN-KLEIN Long Island Jewish-Hillside Medical Center, Glen Oaks, New York, U.S.A. Stimulants have been reported to ameliorate both the behavior of children with “emotional problems”, as well as their performance on various measures of intellectual functioning and learning. As a result there is a growing trend in the U.S.A. to view stimulants as useful for learning disability. However, so far all studies have been conducted with children selected because of behavior disorders. Therefore, it is not known whether stimulants are a relevant intervention among children who are poor achievers, but who have no significant psychopathology. This study tested the effects of methylphenidate on the intellectual functioning of children free of behavioral deviance, but with learning lags. Fifty children, 7-12, not hyperactive, with an I.Q. of at least 85,2 yr below their expected grade level in reading, and free of moderate to severe psychopathology, were randomly assianed to methvluhenidate or ulacebo for 12 weeks. A battery of achievement and cognitive tests was adni treatment, ripeated 4 and 12 weeks after treatment. The child was &en weekly by a psychiatrist, blind to the treatment. Results. On the Wide Range Achievement Test, both reading and arithmetic scores were significantly improved by methylphenidate after 4 weeks. Over the first month of methylphenidate treatment, the children gained 4 months in’ reading, 7 months in arithmetic, whereas the placebo treated group gained only 14 months in readine and showed no chance in arithmetic CD < 0.005). After 12 weekzof treatment the pi&e was considegably different. The methylphenidate and placebo groups were no longer significantlj different either on the reading or arithmet~cc‘scores of the WRAT. The Grav Oral Reading Test was not sensitive to drue effect at anv noint. Children’s uerformance on the Porteus Maze test showsd marked gain in favor of the &g-treated @up after 4 and 12tveeks of treatment. Comment. The above results indicate that methylphenidate does have a positive effect on cognitive function, independent of its clinical action in behavior disorders. However it may be unjustified to generalize about stimulant effects on learning from short-term studies. The current practice in American pediatric psychopharmacology of long-term treatment on the basis of short-term investigations should be reviewed by appropriate long-term studies. The validation of specific diagnostic criteria for primary affective disorder by means of a blind five year follow-up GEORGE E. MURPHY, ROBERT A. WOODRUFF and MARIJAN HERJANIC Department of Psychiatry, Washington University, School of Medicine, St. Louis, Missouri, U.S.A. One hundred fifteen patients admitted to Renard Hospital in 1962 and 1963 with depressive symptoms were interviewed systematically with a structured research protocol containing approximately 500 items of information. Each interview lasted l&4 hr. Clinical diagnoses were made on the basis of these interviews. Follow-up interviews were sought with these same patients 5 yr later, to test the validity (stability over time) of the original diagnoses. Each patient was interviewed blindly bv interviewers who had not narticipated in the original colikction of data and who had no knowledge of the patient’s index diagnosis.& Fifty-two patients met specific inclusion and exclusion criteria (no other psychiatric illness or atypical symptoms) for primary affective disorder at the initial interview and were so diagnosed. Of these, follow-up was obtained with 43 (83 per cent). Thirty-seven of the 43 patients (86 per cent) were diagnosed blindly at follow-up as having primary affective disorder. They had unequivocal primary affective disorder during the follow-up interval and no other psychiatric illness, or were well throughout the entire interval. Each of these circumstances satisfies the basic requirement for a legitimate diagnostic entity: that it remain the same or disappear, but that it not turn into something else. Six patients receiving an index diagnosis of primary affective disorder were given another diagnosis at follow-up. Four had developed interval conditions not ordinarily considered incompatible with primary affective disorder (alcoholism, organic brain syndrome,

RELATIONSHIPS OF THE MECHOLYL TEST, PREMORBID ASOCIAL FUNCTIONING, AND LONG TERM OUTCOME IN SCHIZOPHRENIA

This study addressed itself to the controversy whether magnitude of mecholyl response is related to premorbid characteristics and/or long term outcome in nonchronic schizophrenics. It was found that in a group of 46 schizophrenics the ratings of premorbid asocial functioning were correlated with outcome. However, both of these patient characteristics were independent of the magnitude of a mecholyl-induced drop in systolic blood pressure. Similar results were obtained when the schizophrenic sample was combined with 33 nonschizophrenic patients, thus suggesting that diagnostic variation among studies cannot account for contradictory results regarding the relationship between mecholyl response, process-reactive schizophrenia, and long term outcome.