Thomas E. Gift

On the expression of psychosis in different cultures: Schizophrenia in an indian and in a Nigerian community

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and “self-centered” orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

The prediction of relapse of schizophrenic patients using emotional data obtained from their relatives.

The capacity of anxiety and hostility outward scores derived from the content analysis of 5-minute speech samples from the relatives of patients to predict relapse or nonrelapse was tested in three distinct groups of schizophrenic patients. Significantly correct predictions were made which compared favorably to the predictive capacity of ratings obtained by means of the Camberwell Family Interview. The latter requires 1 to 2 hours to administer and about 1 hour to score, whereas the former method requires a tape-recorded 5-minute speech sample and up to 0.5 hour to score.

A hostility measure for use in family contexts

A modification of the Gottschalk-Gleser standardized instructions for eliciting speech samples was developed and tested in ongoing family studies. This modification, the Wynne-Gift technique, allows the interviewer to focus on the speakers relationships with various family members. The usefulness and validity of the approach was assessed in a study of differences in attitudes toward the husband of 10 separated or divorced women as compared to the attitudes of 11 married women. Significant differences were found in the expected direction between mean hostility outward scores as well as hostility toward the spouse or ex-spouse of these two groups of women. The range of applications of this modification of eliciting speech samples is discussed.

How diagnostic concepts of schizophrenia differ.

How do various diagnostic definitions of schizophrenia compare? As part of a larger study of diagnosis and prognosis, nine different systems used for diagnosing schizophrenia were applied to a sample of patients (N=272) from two geographical catchment areas who had been hospitalized for the first time in their lives for functional psychiatric illness. The size and composition of the groups diagnosed schizophrenic by each set of criteria were then compared with respect to five clinical variables hypothesized to be important for differentiating the diagnostic systems. All data were collected with structured interviews of demonstrated reliability. Results showed that several of the variables tested distinguished schizophrenics diagnosed by some systems from those considered schizophrenic by other systems and from those patients in the sample not considered schizophrenic by any system. High levels of delusions of passivity characterized the patients classified as schizophrenic by three systems: Schneider, Langfeldt, and the Flexible System. High psychosis scores characterized the patients considered schizophrenic by the New Haven Schizophrenia Index. Increased chronicity and low levels of affective symptoms characterized the patients considered schizophrenic by the Feighner criteria. Poor work and social function characterized the patients considered schizophrenic by the hospital physician using DSM-II guidelines. These and other findings reported indicate that the various systems for diagnosing schizophrenia have both characteristic differences and overlap. Considering these can help to delineate the extent to which research findings or clinical experience based on the system can be generalized to findings based upon another.

IQ as a prognostic indicator in adult psychiatric first‐admissions

This study used IQ, along with measures of premorbid adjustment, health-sickness, symptom level, diagnostic severity and demographic data, to predict to 2-year outcome measures of level of functioning, health-sickness, and symptoms for a sample of 145 adult psychiatric first-admissions. It was hypothesized that IQ as an indicator of cognitive ability, or of general ability to adapt, would predict positively to improvement over the 2-year period. Data analysis was conducted with bivariate correlations and multiple regressions, using both absolute-level and residualized outcome variables. IQ showed modest, significant relationships with all absolute outcome indices and six of seven residualized measures, especially for a subsample of those with non-average IQ scores. Regressions showed that IQ provided independent prediction of symptom outcomes.

The severity of psychiatric disorder

Evaluating the severity of psychiatric illness is important, but it involves many implicit hypotheses and models. To investigate empirically characteristics entering into judgments of severity, a representative sample of 217 patients hospitalized for the first time for functional psychiatric illness was studied. Results indicated that psychotic symptoms and bizarre disturbed behavior were more associated with severity than were depression, anxiety, and other nonpsychotic symptoms. There was a strong relationship between severity and psychotic/nonpsychotic dichotomy, but relatively little relationship between severity and diagnostic categories. Severity was also related to certain measures of chronicity and social function.

Effects of subtype of attention-deficit/hyperactivity disorder in adults on lateralized readiness potentials during a go/no-go choice reaction time task.

We studied 40 young adults with attention-deficit/hyperactivity disorder (ADHD; 18 predominantly inattentive type, 22 combined type) and 38 demographically comparable controls in a go/no-go choice reaction time task with 2 levels of difficulty. The ADHD/combined group was less accurate and had more variable reactions than controls. The ADHD/inattentive sample was slower than controls and had smaller early lateralized readiness potentials (LRPs). Compared with controls, both subtypes had (a) smaller early LRPs for no-go stimuli and (b) relatively earlier LRP onsets for difficult no-go events. The ADHD/combined sample also had smaller late LRP waves than controls. The results suggest that adults with ADHD, particularly those with the combined subtype, exhibit weaker central preparation to respond to both stimuli requiring a motor response and those prompting response inhibition.

Predictors of outcome among adult psychiatric first‐admissions

This study comparatively evaluated the prognostic potential of 10 demographic and clinical factors previously associated with psychiatric outcome. The longitudinal design employed intensive, structured, reliable interview techniques. One hundred forty-five subjects from a representative sample (N = 217) of community mental health catchment area first lifetime admissions were assessed at hospitalization and at 2-year follow-up. Predictors examined included premorbid functioning, overall health-sickness, diagnostic severity, social class, sex, age, IQ, race, and life events. Outcome was assessed multidimensionally with absolute-level and residualized indices of functioning and symptomatology. Phillips Premorbid Status and social class emerged from correlation and multiple regression analyses as the best predictors of functioning level and overall clinical status, while IQ was the most prominent indicator of symptomatology changes. Results support the notion that a general social competence factor predicts to psychiatric outcome across the entire spectrum of severe disorders.

Effect of a drug holiday on plasma chlorpromazine levels in chronic schizophrenic patients.

Low chloropromazine (CPZ) levels have been measured in chronically treated schizophrenics. We tested six such patients to determine whether a 2-week CPZ-free period (drug holiday) would improve plasma CPZ levels. We also monitored psychiatric symptoms, autonomic function, and extrapyramidal signs. We found these patients to have low predose CPZ levels that did not change appreciably after the drug holiday. Peak levels following the holiday averaged 28 ±7 ng/ml higher than those measured prior to the holiday. Drug holidays are safe and should be examined more thoroughly as a means of improving plasma neuroleptic levels in chronically treated schizophrenics.

Sexual life events and schizophrenia

A large body of clinical literature would imply that life events in the sexual sphere are of major significance for schizophrenic patients. However, the best known reports of life events associated with the onset of schizophrenia do not seem to support the significance of life events in the sexual sphere in the onset, early course, or exacerbation of schizophrenia. Methodologically, however, these studies have focused on the precipitating event, rather than on the amount of life stress induced by the serial occurrence of life events. This suggests the possibility that if life events in schizophrenic patients are examined in their totality, conclusions as to the relationship between sexual life events and schizophrenia might be different. As part of an international collaborative study twenty subjects receiving an ICD-9 diagnosis of schizophrenia, hospitalized for the first time in their lives for functional psychiatric disorder, were evaluated on the basis of a structured interview to assess symptoms and psychiatric history, including life events. Almost half (920) of these schizophrenic patients were found to have experienced life events occurring in the sexual sphere. At the customary P < .05 level of significance, the presence of life events in the sexual sphere was independent of gender, marital status, and race, as well as age. If sexual sphere events were to be excluded completely from the ratings, 18 of 20 would still have had ratable life events. These data suggest the importance of relating specific categories of events to specific subject characteristics or to specific populations. They also point to the importance of life events in the sexual sphere as stressors for first-admission schizophrenic patients. Difficulties in more fully understanding the importance of life events in the sexual sphere can be approached via both a social model entailing prohibition of communication, and a psychopathological model involving the nature of the schizophrenic or preschizophrenic psychological processes.