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The prognostic value of psychopathometric data about the psychopathological state of schizophrenic patients on admission and discharge (author's transl)
Abstract
A psychopathometric study on the course of schizophrenic patients was carried out in order to analyse the long-term prognostic value of the psychopathological state on clinical admission and discharge. Eighty-one patients with schizophrenic or similar psychoses were rate three times using well-validated psychopathological scales ("Inpatient Multidimensional Psychiatric Scale", "Clinical Selfrating Scales"): in the beginning, at the end of clinical treatment and 5-6 years after discharge. As for differentiated or global outcome-criteria, the psychopathological state on discharge was of more prognostic importance than the psychopathological state on admission. There existed syndrome-specific relationships between discharge and follow-up, i.e., in general each syndrome correlated most closely with itself between the two times of measurement. As for global outcome criteria, depressive-apathetic symptoms were of more special importance than productive schizophrenic symptoms indicating a poor outcome. The stepwise multiple regression analysis gave prognostically optimal combinations of IMPS-syndromes at admission and discharge which were different for each outcome criterium. Nevertheless, some syndromes were repeatedly among the best predictors. The combination of best predictors explained a greater part of outcome-variance than one predictor alone. The prognostic value of the combination could be optimated by including the factors of the self-rating scales.
... possibilities (Wittenborn 1977;Mö ller et al. 1981;. A syndromatological classification with syndrome profiles on the basis of rating scales appears to be advantageous for various reasons: development of more precise algorithms, greater reliability, greater ability to differentiate through quantifying presentation of syndrome profiles. ...
Several methodological issues of classification of psychiatric disorders are addressed. Beside some historical aspects and basic characteristics of the classification of mental disorders, the advantages and disadvantages of the syndromatological and nosological classifications are broadly described. Finally the current situation of the international standardisation of psychiatric classification and particuarly the improvement of reliability by using operationalised procedures is discussed.
... The utilisation of average profiles facilitates the psychopathological comparison and syndromatological or nosological assignment of patient groups as well as the course analysis of single case evaluations and group statistical evaluations and improves their information content (Mombour et al. 1973; Wing et al. 1974). Furthermore, syndromes give rise to new prognostic possibilities (Wittenborn 1977; Mö ller et al. 1981; Mö ller and von Zerssen 1986). A syndromatological classification with syndrome profiles on the basis of rating scales appears to be advantageous for various reasons: development of more precise algorithms, greater reliability, greater ability to differentiate through quantifying presentation of syndrome profiles. ...
Major depression is associated with impairment of cognitive functions, and especially higher-order cognitive processes referred to as executive functions (EF). Whether this is a general finding is unclear. Patients without EF impairment may have different treatment needs than patients with EF impairment, and will probably have a better everyday functioning. Thus, it is important to identify the prevalence and characteristics of depressed patients without EF impairment. Forty-three patients with recurrent major depressive disorder (19-51 years) and 50 healthy controls were included in the study. The subjects were assessed with neuropsychological tests selected to measure central areas of EF, and screened on clinical and demographic variables. Within the depressed group, a total of 56% were defined as EF unimpaired. These patients were characterised by higher intellectual abilities and fewer depression episodes than the subgroup of patients with EF impairment. The subgroups were similar in age at debut of illness, severity of depression, general psychopathology and global level of functioning. In conclusion, about half of patients with recurrent major depression have normal EF. Since cognitive impairment and depressive symptomatology seem to be distinct dimensions, a neuropsychological investigation could help to ensure optimal treatment in patients with recurrent major depression.
... The utilisation of average profiles facilitates the psychopathological comparison and syndromatological or nosological assignment of patient groups as well as the course analysis of single case evaluations and group statistical evaluations and improves their information content (Mombour et al. 1973; Wing et al. 1974). Furthermore, syndromes give rise to new prognostic possibilities (Wittenborn 1977; Mö ller et al. 1981; Mö ller and von Zerssen 1986). A syndromatological classification with syndrome profiles on the basis of rating scales appears to be advantageous for various reasons: development of more precise algorithms, greater reliability, greater ability to differentiate through quantifying presentation of syndrome profiles. ...
A large number of neurological and psychiatric diseases like Morbus Parkinson, amyotrophic lateral sclerosis, dementia, schizophrenia and probably also affective disorders show an enhanced production of reactive oxygen species. Moreover, alterations of antioxidative systems and beneficial effects of antioxidative substances including steroid compounds such as estrogens have been described in several of these diseases. This review focuses on alterations of antioxidative systems in the course of neurological diseases and psychiatric disorders and on the differential effects of steroids on these systems in the central nervous system. Moreover, a possible clinical relevance of alterations of circulating steroids and of steroid treatment under these conditions is discussed.
... possibilities (Wittenborn 1977;Mö ller et al. 1981;. A syndromatological classification with syndrome profiles on the basis of rating scales appears to be advantageous for various reasons: development of more precise algorithms, greater reliability, greater ability to differentiate through quantifying presentation of syndrome profiles. ...
Transcranial magnetic stimulation (TMS) is a patient-friendly stimulation technique of the brain with interesting perspectives. In clinical psychiatry, limited data are available on activity in psychosis and anxiety, but much research has been done in depression. Major concerns on published papers are the inconsistency of used parameter settings, the restraint numbers of patients in randomised trials, the lack of real sham controlled studies and the quasi inexistent reproducibility of results. The most stringent meta-analysis of TMS in affective disorders found a modest, statistically significant antidepressant effect after 2 weeks of daily treatment of high frequency repetitive left dorsolateral prefrontal cortex stimulation. Although most results are rather weak and not convincing enough to promote TMS as evidence-based antidepressive therapy, they show a measurable action that should not be ignored. Preclinical and clinical effects were observed analysing heterogeneous data, and results comparing TMS to electroconvulsive therapy (ECT) in affective disorders are encouraging. Efforts should continue with emphasis on increasing homogeneity and reproducibility in data. Further refinement of stimulation parameters should be established, so that new and large double-blind, long-term, sham-controlled trials can bring us to better understanding and standardising TMS procedure, finally leading to definitive conclusions about its efficacy in psychiatry.
In a 5 year follow-up study of 81 patients suffering from schizophrenic or similar psychoses many of the predictors known from the literature concerning the outcome of schizophrenia were confirmed. In accordance with the results of the follow-up study on patients from the International Pilot Study of Schizophrenia (IPSS), long lasting professional disintegration and psychiatric hospitalisation preceding index-admission were of special prognostic importance. However in contrast to this follow-up study, other psychopathological data, especially minus symptoms proved to be of considerable prognostic significance. As a result of stepwise multiple regression analyses, combinations of the 5 best characteristics for each outcome-criterion have been found which explain a significantly greater part of the variance than single characteristics.
This paper describes basic principles of systematics for psychiatric disorders such as the categorical and dimensional approach. It summarises validity aspects of the traditional psychiatric nosology and syndromatology. The importance and limitations of the dichotomy of schizophrenia and affective disorders, first suggested by Kraepelin, is reviewed in the light of results from modern research in the field of classification, follow-up and neurobiological studies, especially neurochemical, neurogenetic and neuroimaging studies. Current developments towards DSM-V and ICD-11 are critically reflected. The conclusion is reached that there might be insufficient data to establish a new systematics of psychoses. Therefore it might be premature to leave the Kraepelinian dichotomy totally although it has to be modified in the light of new research.
This study was designed to assess the relative prognostic importance of patient factors, therapist characterists, and treatment mode. The sample was 100 schizophrenic outpatients referred to a community mental health center following psychiatric hospitalization. Patients were randomly assigned to either group (N=50) or individual (N=50) psychotherapy. Criteria were rehospitalization and two clinician ratings--adjustment and social effectiveness--at a two-year follow-up. The best predictor of rehospitalization was the number of previous hospitalizations. The best predictor of adjustment status at two years was pretreatment adjustment level. Also, patients with good prognostic indices made relatively large gains. Predictors of outcome for group-treated patients did not differ from those for individually treated patients. Controlling for initial status, treatment mode was almost as good as predictor of adjustment gains as were other patient factors.
• The long form of the Wittenborn Psychiatric Rating Scale was used every six months to rate the symptoms of a sample of 75 schizophrenic men during the 24-month period following their admission to the hospital. The greatest diminution of symptoms assessed in this manner occurred during the first six months of treatment, and rated symptom severity at the time of admission showed relatively little predictive promise for ratings of the respective symptoms at the end of six months. After the initial six-month period, however, the symptoms became increasingly stable and symptom ratings at 12 and 18 months had substantial predictive implications for respective symptom ratings for 24 months.
Factor analyses of the intercorrelated scores showed that two transcending patterns were conspicuous throughout the 24month period.
Psychopathological syndromes, as originally revealed by clinical observation, can also be detected by multivariate statistical analyses of symptom ratings. Changes in the course of psychiatric syndromes may be rated simply by improvement scales or by consecutive quantifications of symptoms and their comparison in chronological order. For the latter approach, which is less liable to bias, clinical ratings of psychopathology by staff members, self-ratings by the patients, analyses of patients' overt behavior (including video and speech records), or objective measurements of psychological and/or physiological variables can be used. Advantages and limitations of these different methods are discussed and illustrated by examples from ongoing clinical research in affective disorders. Generally, the combined use of different rating procedures is recommended. Self-ratings are economical, but they may represent aspects of psychopathology other than clinical ratings. In endogenous depression, mood scales are valid (supplementary) tools for the quantification of long-term as well as short-term changes, including diurnal variations. In severe conditions of mania, however, clinical rating has been--until now--the only valid basis for quantifying the degree of psychopathology and its changes with time. Precise evaluation of changes in psychopathology is essential in longitudinal investigations of endogenous affective disorders, since psychopathology up to now seems to have been the most sensitive and the most specific indicator of the hypothetical underlying abnormalities of cerebral functioning.
Despite the established efficacy of neuroleptics for maintaining schizophrenics in the community, there are data suggesting that those with very good prognostic signs may do as well without drugs. In testing this, we find no evidence that patients with good signs are not in need of drugs; instead they profit most from drug treatment. Patients who benefit little (1) are men whose families were disrupted earlier in their lives, (2) live alone or with extended families whose attitudes toward the study are not positive, and (3) are irregular in taking their medication. The practical implication is that the drug nonresponder can be helped by some means to ensure regularity of medication taking, such as a visiting nurse or long-acting medication. A second research question is whether major role therapy (MRT, a combination of social casework and vocational rehabilitation) can lengthen the time until relapse. Major role therapy affected time to relapse in a disordinal manner; asymptomatic patients benefited from MRT, while in patients with greater symptom severity MRT- suprisingly--hastened relapse. It is hypothesized that symptomatic patients are suffering from an inability to manage an expanded and enriched cognitive field; MRT, a therapy that urges the patient to become more responsible and to expand his horizons, may actually induce a state with which the patient cannot cope. It is recommended that a therapy such as MRT be deferred until the patient is essentially asymptomatic.
Recent studies of schizophrenia have begun to demonstrate the complex nature of its outcome characteristics and their predictors. However, generalization of findings has been limited by methodological problems such as relatively short-term follow-up the use of retrospective data, or employment of evaluation techniques without demonstrated reliability. This report describes a prospective, five-year follow-up using reliable evaluation techniques to determine whether specific relations between predictors and outcome variables represent behavior patterns persisting over an extended period. Results demonstrate the prognostic importance and specificity of certain predictors over five years. These results support the view that outcome function is comprised of persisting open-linked systems of behavior.
The Global Assessment Scale (GAS) is a rating scale for evaluating the overall functioning of a subject during a specified time period on a continuum from psychological or psychiatric sickness to health. In five studies encompassing the range of population to which measures of overall severity of illness are likely to be applied, the GAS was found to have good reliability. GAS ratings were found to have a greater sensitivity to change over time than did other ratings of overall severity or specific symptom dimensions. Former inpatients in the community with a GAS rating below 40 had a higher probability of readmission to the hospital than did patients with higher GAS scores. The relative simplicity, reliability, and validity of the GAS suggests that it would be useful in a wide variety of clinical and research settings.
Poor outcome has been considered by many psychiatrists as intrinsic to the concept of schizophrenia. A major issue has been whether a diagnostic concept of schizophrenia, based on symptoms alone, can identify patients who will have the poor outcome considered by many to be the validating criterion of 'true' schizophrenia. The strongest evidence that poor outcome schizophrenia can be identified by symptoms alone has come from studies using Langfeldt's symptom criteria of schizophrenia. The present investigation uses methodological controls not employed in earlier studies to evaluate the relationships between symptoms and outcome. Results show that the symptom criteria of Langfeldt do not discriminate selectively a poor outcome category of schizophrenia. This challenges the major empirical basis for the view that symptom criteria alone can account for a poor outcome concept of this disorder.
This report describes the characteristics of outcome and its predictors in a group of patients evaluated in the Washington Center of the International Pilot Study of Schizophrenia. Part I, focusing on the characteristics of outcome, suggested that outcome consists of several semi independent processes. The second part focuses on the nature of predictor outcome relationships in this group of patients. Results demonstrate that employment function and social relations in the past were each the best predictor of its respective outcome function. Established chronicity of illness predicted outcome in all areas. The findings support the view that outcome is not a single process but is comprised of several semi independent processes best conceptualized as open linked systems. Each system must be considered in understanding, evaluating, and treating the different areas of outcome disability in schizophrenia.
Although numerous studies of prognosis in schizophrenia exist, most have been biased by retrospective design and limited by short follow-up. There is no well-documented method for predicting on admission the longterm clinical course of schizophrenics. However, there are three studies 3,10,13 that have been well-enough designed to merit clinical confidence.
Wittman used her Elgin Prognostic Scale13 prospectively and in 83% of cases correctly predicted clinical course in schizophrenia. Her studies suffered from a follow-up period of only a year, and although her scale proved reliable in her own hands, it has proved unwieldy and subjective (21 weighted items) in the hands of subsequent investigators.
Stephens and Astrup10 examined 178 admission charts and decided which patients represented "process" and "non-process" (remitting) schizophrenia. They were able to obtain 5-13 year follow-ups on 80% of these patients. Ten per cent of the "recovered" and