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Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.
The Cavan–Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.
Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.
There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.
The potential of first-episode studies in schizophrenia is maximised through systematic epidemiological, clinical and biological comparisons between homogeneous populations of the psychoses.
To conduct prolonged accrual of ‘all’ cases of non-affective and affective psychotic illness on an epidemiologically complete basis.
Within the region covered by Cavan–Monaghan psychiatric service (population 102 810), all putative cases of first-episode psychosis were diagnosed using DSM–IV.
From 1995 to 2000, 69 cases of psychosis were ascertained, the incidence being 2.3-fold lower in females than in males. On resolving the ‘core’ diagnoses of schizophrenia and bipolar disorder, incidence of schizophrenia among women was 7.5-fold lower than among men whereas incidence of bipolar disorder among women was 6.6-fold lower than among men.
This homogeneous population, which eliminates factors associated with urbanicity and minimises confounding factors such as socioeconomic, ethnic and geographical diversity, shows a markedly reduced incidence among females both of schizophrenia and of bipolar disorder.
While executive (frontal lobe) dysfunction appears to be a core feature of schizophrenia, its relationship to psychopathology, age and duration of illness has yet to be explored systematically between the genders.
Executive dysfunction, positive and negative symptoms were evaluated in 27 male and 21 female in-patients who were unusually well-matched on numerous demographic and clinical measures.
Measures of executive dyscontrol and negative symptoms were highly associated in both genders. However, while both executive dyscontrol and negative symptoms increased prominently with age/duration of illness among women, no such relationship was evident among men.
The similarly prominent levels of current executive dyscontrol and negative symptoms in male and female patients appear to have emerged via processes that differ fundamentally between the genders; among males these deficits appear to emerge and become ‘locked in’ earlier in the course of illness and to show little subsequent increase, while among females these same deficits appear to be less evident early in the course but to increase in prominence thereafter.
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