Shmuel Fennig

The confusion between bipolar disorder and schizophrenia in youth : where does it stand in the 1990s ?

OBJECTIVEnTo determine whether the bias against diagnosing bipolar disorder in youth continues, and if so, why.nnnMETHODnSubjects are bipolar and schizophrenic patients taken from a county-wide sample of first admissions for psychosis. Patients are given structured interviews and consensus diagnoses at intake and 6 months. Age of onset of psychosis, gender, and 6-month consensus diagnosis between both groups are compared. To assess diagnostic bias, diagnostic stability and facility discharge diagnoses are examined in young (aged 15 through 20 years) versus adult (aged 30 through 40 years) patients.nnnRESULTSnBipolar disorder and schizophrenia are diagnosed at similar rates in younger age groups by 6-month consensus. However, bipolar disorder was underdiagnosed by Suffolk Countys psychiatric hospitals in the youth. The stability of both disorders in both age groups was similar and excellent. Schizophrenia had a slightly older age at first psychosis than bipolar disorder and an equal gender representation. Bipolar disorder in males was rare after age 30.nnnCONCLUSIONnCommunity psychiatrists no longer call young bipolar patients schizophrenic, but they underdiagnose bipolar disorder. The more complicated nature of early-onset bipolar disorder may be a contributing factor.

Best-estimate versus structured interview-based diagnosis in first-admission psychosis ☆

In a sample of first-admission psychotic patients, best-estimate diagnoses made by psychiatrists at entry to the study (N = 310) and 6 months later (N = 228) were compared with Structured Clinical Interview for DSM-III-R (SCID) algorithm diagnoses. Sensitivity, specificity, and agreement (kappa) at entry and at 6-month follow-up evaluation were satisfactory for schizophrenia (sensitivity, .89 and .98; specificity, .96 both times; kappa, .86 and .92) and bipolar disorder with psychosis (sensitivity, 1.00 and .94; specificity, .96 both times; kappa, .89 and .88), moderate for major depression with psychosis (sensitivity, .90 and .81; specificity, .94 and .95; kappa, .75 and .72), but mixed for the organic psychoses (sensitivity, .50 and .23; specificity, 1.00 both times; kappa, .66 and .36). Reasons for disagreement included the role of drugs and other organic factors in the etiology of the disorder, and clinical judgment versus the rules of the structured interview. We conclude that the SCID, when administered by closely supervised experienced nonpsychiatrist clinicians and incorporating information from other sources, can produce a reliable diagnosis of schizophrenia and bipolar disorder. However, the best-estimate procedure seems mandatory in studies investigating a broad range of psychoses, where the use of drugs is not an exclusion criterion.

Mood-congruent versus mood-incongruent psychotic symptoms in first-admission patients with affective disorder

The distribution of mood-congruent and mood-incongruent symptoms in 49 first-admission DSM-III-R psychotic bipolar and 35 psychotic depressed patients is presented. Most patients had mood-incongruent symptoms (77.4%). 73% of mood-incongruent bipolars and 32% of incongruent depressives had a combination of mood-congruent and mood-incongruent symptoms. Demographic and clinical variables were unrelated to incongruence. The only 24-month clinical outcome predicted by mood incongruence was poorer GAF rating. 15 of the 16 patients whose diagnosis was changed at follow-up from affective to nonaffective psychosis had mood-incongruent features initially. The findings raise questions about the general prognostic utility of mood congruence.

Bizarre delusions and first-rank symptoms in a first-admission sample: A preliminary analysis of prevalence and correlates

This report examines the prevalence and correlates of bizarre delusions and Schneiders first-rank symptoms (FRS) in a first-admission sample with psychosis. A total of 196 patients were assessed with the Structured Clinical interview for DSM-III-R (SCID) and given a consensus diagnosis. Project psychiatrists blind to the consensus diagnoses coded each delusion and hallucination in the sample for both FRS and DSM-III-R bizarreness. Interrater reliability of bizarreness was lower than that of FRS (kappa = .681 v 861). The majority of symptoms (72%) were neither bizarre nor FRS, and of the remainder, bizarre delusions that were not also FRS were extremely uncommon. The prevalence of FRS was 70% in schizophrenia, 29% in psychotic bipolar disorder, and 18% in psychotic depression. For seven schizophrenic patients (7.45%), diagnosis of that disorder depended on the presence of a DSM-III-R bizarre delusion to meet criteria. There was a trend for FRS to be associated with poorer prognostic features in the schizophrenic sample. We concluded that although the constructs of bizarre delusions and FRS overlap, FRS were a more important feature in schizophrenia than bizarreness. The rarity of bizarre delusions that were not FRS, combined with the lower reliability of their assessment as compared with that of FRS, raises questions about the continued emphasis on this phenomenon in the definition of schizophrenia.

Diagnosis and six-month stability of negative symptoms in psychotic disorders

Negative symptoms were examined in 150 primarily first-admission patients diagnosed with schizophrenia, schizoaffective disorder, psychotic depression, psychotic bipolar disorder, and ‘other’ psychoses. The analysis focused on patients who were rated on the Scale for the Assessment of Negative Symptoms (SANS) within 45 days of admission and at follow-up 6 months later. Significantly more schizophrenics had moderate to severe negative symptoms at each time point compared with other psychotic patients. The SANS scores were found to be relatively stable over time in all five diagnostic groups. Although the DSM-IV includes alogia, effective flattening, and avolition in the A criterion for schizophrenia, only alogia and affective flattening were found to be specific to this disorder. Our results point to the existence and enduring quality of negative symptoms in the early phase of psychosis and its specificity to schizophrenia even at this early stage.

Are diagnostic criteria, time of episode and occupational impairment important determinants of the female:male ratio for major depression?

This study addresses whether the female preponderance in the 1-year prevalence of major depressive disorder is associated with differences in reporting symptoms or underreporting remote episodes, or the inclusion of work impairment in the case definition. In a sample of 1870 professionals and managers, we find (1) a more restrictive cut-off point for women does not eliminate the differential; (2) males and females equally underreport symptoms for remote episodes; and (3) adding impairment to the case definition marginally affects the F:M ratio. Thus, the large F:M prevalence ratio is not an artifact of ascertainment method, case definition, or differential recall.

The consistency of DSM-III-R delusional disorder in a first-admission sample

The temporal consistency of the research diagnosis of DSM-III-R delusional disorder was assessed. Subsequent to their first psychiatric hospitalization, psychotic patients were diagnosed twice using a best-estimate procedure after 6- and 24-month follow-up. Only 57.1% of the 7 subjects diagnosed at the 6-month follow-up conference retained the diagnosis at the 24-month review. Conversely, 50.0% of the 8 subjects given this diagnosis at 24 months had different 6-month diagnoses. By contrast, 100% of a matched control group maintained the same diagnosis at both time points. Course and outcome in this sample varied considerably, with 2 of the subjects making severe suicide attempts. Longitudinal assessment in psychotic patients in their first episode is mandatory, and an initial diagnosis of delusional disorder has to be interpreted as provisional.