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Taking up the Bleulerian view of a clinical description based on a pathogenic model, we propose a rating scale for the assessment of communication disorders in schizophrenic patients. The scale consists of clinical items that could be the direct expression of the three hypotheses of cognitive dysfunction which have been postulated to explain communication dysfunction in these patients. We assessed the frequency of the 16 items in the scale in a total of 80 subjects (43 schizophrenic subjects, ten manic subjects, 17 depressive subjects and ten normal control subjects). The results of this study showed that this item schedule was specific to schizophrenic patients and, in particular, could statistically significantly discriminate schizophrenic patients from psychotic patients with affective disorder. The methodological qualities of the scale were explored and proved accurate, except for the reliability which is too low for some items and the item-to-total correlation which is too low for one item of the scale.
The purpose of this study was to demonstrate the usefulness of multi-group piece-wise latent growth curve models (LGCM) in clinical research, particularly for assessing and comparing treatment effects. As an empirical example, this analytic technique was used to compare the effectiveness of Guided Self-Change (GSC) and Cognitive Behavioral Therapy (CBT) treatments for bulimia nervosa.
Sixty-two female patients (M age = 28.1, SD = 8.00) with bulimia nervosa were randomly assigned to a) a GSC treatment involving a self-care manual plus 8 bi-weekly sessions of CBT or b) 16 weekly sessions of CBT.
Both groups showed significant improvements in treatment outcomes across the treatment period, although the CBT group showed greater improvements. However, the GSC group evidenced more continued improvement post-treatment. CBT showed greater variability in effectiveness during the treatment period, while GSC showed greater variability during follow-up. For GSC patients, baseline levels on some treatment outcomes were related to follow-up improvement levels.
LGCM provided a rich analysis of these data, and addressed important questions regarding differences in the effectiveness of the two treatment programs. For example, CBT tended to show greater improvements during treatment, while GSC evidenced more continued improvements during follow-up.
This study was designed to evaluate the effect of semantic priming with a lexical decision task in 22 depressed patients (DSM-III-R, 1987) and 30 control subjects. These patients were evaluated twice: first when they arrived at the hospital, and secondly, after clinical improvement. Clinical improvement was evaluated using standard depression rating scales. A lexical decision task involving semantic relations (related vs. unrelated, e.g., apple-pear) was used to evaluate the processing of semantic information. The results showed that, for the first evaluation, the depressives presented similar semantic priming to control subjects. When we compared semantic priming in the first and the second passes, we observed that its amplitude was identical. The sole difference between the two passes concerns the global reaction time in the depressive group. This last result suggested that, with clinical improvement, the characteristic psychomotor retardation declines. One of the major results concerns the fact that severe depressive patients (first pass) exhibit normal semantic priming in a lexical decision task. These results indicate, in this clinical population, the preservation of controlled processes implicated in this lexical decision task.
This objectives of this study were three-fold: retrospectively evaluate anxiolytic/hypnotic consumption by psychiatric inpatients, identify the risk factors of prolonged intakes, and prospectively measure the impact of hospitalisation on the use of those drugs. Three hundred and seventy-six patients hospitalised in 11 psychiatric departments in the Paris region were studied using a structured interview for the anxiolytic/hypnotic treatments, DSM-III-R criteria, GHQ-12, HAD, Spiegel's questionnaire, COVI's anxiety scale and the CGI. Eighty-five per cent of the patients had taken one anxiolytic/hypnotic or more in the 3 months preceding hospitalisation. Hospitalisation induced little change in anxiolytic/hypnotic use: dosage frequency increased from 77% to 84% between the week preceding hospitalisation and that preceding discharge; 26% of consumers were taking at least two anxiolytics or two hypnotics in the first period vs. 23% in the second. The absence of withdrawal during hospitalisation was related to the high age and a diagnosis of depression rather than schizophrenia, to the existence of continuous intake over the 3 months preceding hospitalisation and to higher drug doses during the 7 days preceding hospitalisation. Prescription of treatment at the end of hospitalisation in previously non-user subjects was related to a higher HAD anxiety score at discharge.
Shared Mental Health care between Psychiatry and Primary care has been developed to improve the care of common mental health problems. Following a consultation-liaison intervention, this study evaluated one-year outcome for patients following the intervention to obtain objective data reflecting the “real-world” of shared mental health care.
95 patients from September 2006 to September 2007 (follow-up rate: 66%) were invited one year after the intervention to complete a paper questionnaire and a telephone short questionnaire about their mental health status, their care during the last year and their satisfaction with care.
89% of patients evaluated their current mental health as better then in the previous year. 44.5% were still managed by their GP as the psychiatric care provider (13.8% with a psychologist), 27.8% by a private psychiatrist, 11.1% by public psychiatry and 16.7% had no care anymore. 78.3% of patients evaluated the intervention as helpful for them.
The intervention was helpful for primary care patients with common mental health problems, supporting primary care without GPs’ de-motivation or disqualification. This study conducted among patients confirmed a previous study conducted among GPs.
Since reports have underscored that panic attacks (PA) may be an identifiable state occurring in schizophrenia, we studied the symptomatology of PA in a group of schizophrenic patients. Of 40 patients (21 males and 19 females) attending a clinic for maintenance therapy of schizophrenia, 19 (36.8%) had a lifetime history of PA. Seven among those 19 patients (36.8%) had or had had spontaneous panic attacks, not related to phobic fears or delusional fears, and for the 12 remaining patients, the PA were related to paranoid ideas. Moreover, the paranoid subtype of schizophrenia tends to be more often associated with a history of panic attack than other subtypes of schizophrenia (52.6% vs 23.8%; χ2 = 3.5, P = .06). It seems that there are at least two types of PA in schizophrenic patients. The first one could be independent from the psychotic feature, with no psychopathological link. The second kind of PA could be directly related to a schizophrenic disorder, and found in patients with the paranoid subtype.
Lexical decision tasks were used in 17 schizophrenic subjects and 11 control subjects, to evaluate the so-called automatic priming of semantic links, and the controlled processes which involve longer lexical anticipation strategies. In this type of trial, inhibition in the recognition of the target word, when the preceding priming word is not semantically linked to it, indicates the activation of such controlled processes. Postulating that patients in the schizophrenic group were heterogeneous in terms of cognition, we compared the resultant scores in two subtypes of schizophrenic patients: paranoid and hebephrenic (CIM-9 criteria). The study demonstrated that there was a difference in performance between the schizophrenic subtypes. Although these findings need to be confirmed, they demonstrate the necessity of determining individual profiles of patients entering the trial, to take into account those of their phenomenological differences that may correspond to differences in cognitive functioning. The results indicate an absence of inhibition, but only in the paranoid group. In these subjects, results were consistent with the hypothesis of a failure to set up controlled processes rather than a stronger “automatic” activation of the semantic links. However, as the results were not significant, the hypothesis remains open to further investigation. The reasons for the nonsignificance of the results and alternative hypotheses are discussed.
The purpose of the present study was to investigate whether deficits of behavioral or/and N400 semantic priming (SP) effect observed in patients with schizophrenia is a stable cognitive feature of the disorder or whether it may be influenced by the severity of the actual symptomatology that may fluctuate over time.
A Test-Retest one year study was conducted on fifteen patients with schizophrenia and 10 healthy participants who performed a SP task. Both behavioral measures and Event-related potentials (ERPs) of SP were recorded twice (Test and Retest sessions).
At Test, patients exhibited a deficit of SP as revealed by both the behavioral and the ERP measures (the amplitude of the N400 component). At Retest, behavioral SP remained impaired in contrast to the N400 SP which was significantly improved in relation probably to the patients' clinical improvement.
The results conveyed evidence that the N400 SP impairments in schizophrenia may not be considered as stable cognitive markers of the disorders. Significance: The behavioral and the N400 measures of SP had different level of sensitivity to subtle cognitive and brain processes which were subjected to change over the clinical course of schizophrenic disorder.
Insurance benefits which are dependent on the joint mortality of two lives, typically a married couple, form an important part of many insurance portfolios. In this chapter we develop the concepts and models from previous chapters to examine joint life insurance policies. There are also important applications in pension design and valuation, as spousal benefits are a common part of a pension benefit package.
We describe typical benefits offered and introduce standard notation for actuarial functions dependent on two lives. We develop an approach for pricing and valuing these policies, based on the future lifetime random variables, and making the strong assumption that the two lives are independent with respect to mortality.
Next, we show how joint life mortality can be analyzed using multiple state models. This creates a flexible framework to introduce dependence between lives, and we can apply the methods of Chapter 8 to calculate probabilities and value benefits.
In this chapter we represent the future lifetime of an individual as a random variable, and show how probabilities of death or survival can be calculated under this framework. We then define the force of mortality, which is a fundamental quantity in mortality modelling. We introduce some actuarial notation, and discuss properties of the distribution of future lifetime. We introduce the curtate future lifetime random variable, which represents the number of complete years of future life, and is a function of the future lifetime random variable. We explain why this function is useful and derive its probability distribution.
In this chapter we introduce equity-linked insurance contracts. We explore deterministic emerging costs techniques with examples, and demonstrate that deterministic profit testing cannot adequately model these contracts.
We introduce stochastic cash flow analysis, which gives a fuller picture of the characteristics of the equity-linked cash flows, particularly when guarantees are present, and we demonstrate how stochastic cash flow analysis can be used to determine better contract design.
Finally we discuss the use of quantile and conditional tail expectation reserves for equity-linked insurance.
In this chapter we introduce emerging costs, or cash flow analysis for traditional insurance contracts. This is often called profit testing when applied to life insurance.
We introduce profit testing in two stages. First we consider only those cash flows generated by the policy, then we introduce reserves to complete the cash flow analysis.
We define several measures of the profitability of a contract: internal rate of return, expected present value of future profit (net present value), profit margin and discounted payback period. We show how cash flow analysis can be used to set premiums to meet a given measure of profit.
We restrict our attention in this chapter to deterministic profit tests, ignoring uncertainty. We introduce stochastic profit tests in Chapter 15.
In this chapter we introduce some actuarial approaches to estimation and inference used to construct the life tables and survival models that we have been using in previous chapters. We start with a discussion of typical characteristics of lifetime data for actuarial applications. We then show how to use lifetime data to fit survival models, including parametric and non-parametric approaches.
We next move to the Markov models from Chapter 8. Starting with the alive--dead model, and assuming a piecewise constant force of mortality, we derive the maximum likelihood estimator for the force of mortality for each age year. We then extend the methodology to multiple state models with piecewise constant transition intensities.
In this chapter we develop formulae for the valuation of traditional insurance benefits. In particular, we consider whole life, term and endowment insurance. For each of these benefits we identify the random variables representing the present values of the benefits and we derive expressions for moments of these random variables. The functions we develop for traditional benefits will also be useful when we move to modern variable contracts.
We develop valuation functions for benefits based on the continuous future lifetime random variable and the curtate future lifetime random variable from Chapter 2. We introduce a new random variable, the 1/m-thly curtate future lifetime, which we use to value benefits which depend on the number of complete periods of length 1/m years lived by a life age x. We explore relationships between the expected present values of different insurance benefits.
We also introduce the actuarial notation for the expected values of the present value of insurance benefits.
In this chapter we lay out the context for the mathematics of later chapters, by describing some of the background to modern actuarial practice, as it pertains to long term, life contingent payments. We describe the major types of life insurance products that are sold in developed insurance markets, and discuss how these products have evolved over the recent past. We also consider long term insurance that is dependent on the health status of the insured life, rather than simply survival or death. Finally, we describe some common pension designs.
We give examples of the actuarial questions arising from the risk management of these contracts.