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Attention-deficit hyperactivity disorder (ADHD) and hyperkinetic disorder are well-established diagnoses in children, with estimates of prevalence in pre-adolescent children from 3 to 5%. Until recently ADHD was not thought to persist beyond adolescence, but results from long-term prospective outcome studies indicate that 30–70% of children with ADHD exhibit some symptoms as adults. Recognition of this disorder is important as the persistence of ADHD symptoms has been shown to be associated with academic and occupational failure and high rates of psychiatric comorbidity. With the establishment of a UK support group (LADDER) and increasing media attention highlighting this problem it is likely that there will be an increased demand for psychiatric assessment of adult ADHD in the next few years.
The association between temporal lobe epilepsy and schizophrenia suggests that the critical abnormality may be pathology within the temporal lobes. People with schizophrenia-like psychosis of epilepsy (SLPE) provide a useful group in which to examine the importance of temporal and frontal lobe dysfunction in schizophrenia.
A verbal fluency activation paradigm and a 99mTc HMPAO SPET were used to study frontotemporal function in people with SLPE (n = 12), schizophrenia (n = 11) and epilepsy (n = 16).
People with SLPE differed from both other groups by showing lower blood flow in the left superior temporal gyrus during performance of a verbal fluency task compared with a word repetition task (F=5.4, P=0.01). During the verbal fluency task people with primary schizophrenia showed a greater increase in blood flow in anterior cingulate (F=4.5, P=0.02) than the other two groups. There were no between-group differences in frontal brain regions.
Our findings support an association between left temporal lobe abnormality and SLPE. The different patterns of activation observed in people with primary schizophrenia and SLPE suggests that different pathophysiological mechanisms may operate in these two groups. In SLPE the pathophysiology may be relatively confined to the dominant temporal lobe.
It has been suggested that the dimensions of cerebral ventricles are a risk factor for poor outcome in psychotic illness.
A cohort of 140 patients with functional psychoses of recent onset who had undergone CT scanning, were followed up for an average of 46 months and assessed on six dimensions of course and outcome of illness.
Left and right sylvian fissure volumes and, to a lesser extent, third ventricular volume predicted negative symptoms and unemployment over the course of follow-up, the latter association being mediated by poor cognitive functioning. There was a significant linear trend in risk over the distribution of sylvian fissure volumes in the cohort, and associations were especially evident in schizophrenic patients. No associations were found with global severity of illness, duration of hospital stay, homelessness, or affective symptoms.
These findings support the notion that dimensions of the cerebral ventricles are a continuous risk factor for some measures of outcome in the functional psychoses.
Although a genetic component in schizophrenia is well established, it is likely that the contribution of genetic factors is not constant for all cases. Several recent studies have found that the relatives of female or early onset schizophrenic patients have an increased risk of schizophrenia, compared to relatives of male or late onset cases. These hypotheses are tested in the current study.
A family study design was employed; the probands were 195 patients with functional psychosis admitted to three south London hospitals, diagnosed using Research Diagnostic Criteria (RDC), and assessed using the Present State Examination (PSE). Information on their relatives was obtained by personal interview of the mother of the proband, and from medical records. Psychiatric diagnoses were made using Family History – Research Diagnostic Criteria (FH-RDC), blind to proband information.
There was a tendency for homotypia in the form of psychosis within families. The lifetime risk of schizophrenia in the first degree relatives of schizophrenic probands, and the risk of bipolar disorder in the first degree relatives of bipolar probands, were 5–10 times higher than reported population risks. Relatives of female and early onset (<22 years) schizophrenic probands had higher risk of schizophrenia than relatives of male and late onset schizophrenic probands. However, this effect was compensated in part by an excess of non-schizophrenic psychoses in the relatives of male probands.
These results suggest a high familial, possibly genetic, loading in female and early onset schizophrenia, but do not resolve the question of heterogeneity within schizophrenia.
Low birth weight has been postulated to be a risk factor for schizophrenia.
Obstetric history, premorbid adjustment, and cognitive function during admission were assessed in 167 patients with DSM–III schizophrenia or affective psychosis.
A birth weight of less than 2500 g was significantly more common in patients with schizophrenia than in those with affective psychosis. Schizophrenic patients as a group had significantly lower mean birth weight, a finding which was particularly marked after controlling for sociodemographic confounders. In schizophrenic men, lower birth weight was highly significantly correlated with poorer premorbid social and cognitive ability, and with impairment of adult cognitive function.
Neurodevelopmental impairment may cause poor foetal growth, and schizophrenia in adult life.
Data from the Camberwell Collaborative Psychosis Study were used to examine the proposition that there is an excess of life events preceding the onset of psychoses of all types. Of 97 patients from the study who had episodes within the past year that were datable, 51 had developed psychotic symptoms from an essentially symptom-free state, 29 had been suffering only from neurotic symptoms, and 17 had experienced a marked exacerbation of psychotic symptoms. DSM–III diagnoses were collapsed into three major groups: 51 cases of schizophrenia; 31 cases of mania; and 14 cases of depressive psychosis. Life-event histories were taken for the six months before onset, and when these were compared with equivalent histories from a psychiatrically healthy sample from the local general population, there was a significant excess of life events, particularly in the three months before onset of psychosis. This was apparent in all groups, and remained even when events were restricted to the independent category. The excess of events began rather earlier than has been found in previous studies. In our view, this study provides some of the strongest evidence for a link between life events and the emergence of psychotic symptoms.
The significantly favourable changes in medical students' general attitudes to psychiatry which we found after their 8-week clerkship in psychiatry and at the end of their clinical curriculum were not maintained at the end of their first post-graduate year. Three of their specific attitudes to psychiatry changed significantly in an unfavourable direction over this 2-year period. Our findings suggest that, while favourable changes in students' specific attitudes to psychiatry can be found following a clerkship, these attitudes do not seem to endure and, in some cases, they later become less favourable. The results are discussed with reference to the relationships between undergraduate medical training in psychiatry, attitudes to psychiatry, and subsequent career choice, particularly general practice.
Thirty patients who fulfilled DSM–III criteria for schizophrenia but who were within 2 years of presentation were compared with 26 age–matched normal volunteers with respect to CT scan appearances. In the index group the ventricle–brain ratio (VBR) was significantly greater. The VBR values were positively correlated with average alcohol intake and with early physical trauma, and negatively correlated with a family history of schizophrenia. The implications of these findings are discussed in the context of the present uncertainty about the meaning of CT scan findings in schizophrenia.
Sixty-nine patients, each with a combined diagnosis of epilepsy and psychosis, were compared with 53 patients with a diagnosis of functional psychosis. The epileptic affective patients often lacked convincing psychotic features; ECT and lithium were rarely prescribed; only three showed evidence of bipolarity. The epileptic schizophrenic patients were judged to have the better premorbid personality, experienced more paranoid delusions and delusions of reference, and showed less catatonic features than the functional schizophrenic patients. The course of the epileptics' illness was more variable.
The concept that the schizophrenia-like psychosis associated with epilepsy is a distinct nosological entity is supported, but not the suggestion of a relationship between affective psychosis and epilepsy.
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