Showing papers in "Schizophrenia Bulletin in 1992"

A Neurodevelopmental Approach to the Classification of Schizophrenia

Abstract: The conventional distinction between schizophrenia and manic depression has received little objective support from recent studies of phenomenology, outcome, or familial homotypy. Instead, much clinical, epidemiological, and morphological evidence suggests that within the broad range of Schneiderian schizophrenia there exists one form (congenital schizophrenia) that can be distinguished from other types, the manifestations of which are confined to adult life. We hypothesize that congenital schizophrenia is a consequence of aberrant brain development during fetal and neonatal life. Such patients show structural brain changes and cognitive impairment, and in their male predominance, early onset, and poor outcome, they reflect Kraepelin's original description of dementia praecox. We contend that adult-onset schizophrenia is itself heterogeneous. One important component is a relapsing and remitting disorder that is more frequent in females than in males, exhibits positive but not negative symptoms, and has much in common etiologically with affective psychosis. There also exists a very-late-onset group in which degenerative brain disorder is implicated.

Developmental Processes in Schizophrenic Disorders: Longitudinal Studies of Vulnerability and Stress

Abstract: The Developmental Processes in Schizophrenic Disorders project is a longitudinal study of schizophrenic patients who have recently had a first episode of psychosis. The project focuses on discriminating characteristics of schizophrenic patients that are "stable vulnerability indicators," "mediating vulnerability factors," and "episode indicators" by comparing normal subjects to schizophrenic patients assessed in clinically remitted and psychotic states. A parallel project goal is to identify predictors of relapse, social and work impairment, and illness course among potential psychobiological vulnerability factors and environmental potentiating factors. Hypothesized vulnerability factors and potential environmental stressors are examined first under standardized maintenance antipsychotic medication conditions for at least 1 year. Patients showing stable remission of psychosis after 1 year of maintenance antipsychotic medication are invited to enter drug crossover and withdrawal protocols to determine the need for continuous antipsychotic medication. Vulnerability and stress factors are again assessed. A summary of results to date is presented. Deficits in early components of processing visual arrays and in sustained discrimination of successive ambiguous perceptual inputs are relatively stable across psychotic and clinically remitted states in the schizophrenic patients. Performance on a vigilance task demanding active, working memory also remains abnormal during clinical remission but covaries significantly with psychotic state and is a candidate for a mediating vulnerability factor. Autonomic activation level does not appear to be an enduring vulnerability factor, but it predicts the extent of short-term symptomatic recovery and may mediate the impact of stressors. Under conditions of standardized, injectable antipsychotic medication, independent stressful life events and highly critical attitudes toward the patient in the social environment predict relapse risk. Prospective data suggest that signs and symptoms prodromal to psychotic relapse may be present in about 60 percent of patients.

Intellectual Deficits in First-Episode Schizophrenia: Evidence for Progressive Deterioration

Abstract: The developmental processes leading to neuropsychological deficits in schizophrenia are poorly understood. Both early developmental defects and subsequent deterioration may occur. Intelligence test profiles are often used to estimate premorbid ability and deterioration from prior levels of functioning. These characteristics were assessed in samples of firstepisode (« = 51) and chronic (« = 50) schizophrenic patients. Although the groups showed few differences on tests to estimate premorbid intellectual ability, the chronic group performed worse on measures considered sensitive to deterioration. Dextral (right-handed) patients tended to have better performance; this effect was marked in the firstepisode sample, especially on verbal tests. Male patients showed more evidence of deterioration than female patients. Subgroups differing in the time course of premorbid social dysfunction also differed in intelligence test profiles, suggesting that estimates of social and cognitive deterioration may have concurrent validity. The results support the hypothesis that patients differ in the course of cognitive decline and suggest that deterioration of function may follow the onset of overt psychosis in some patients. Prospective longitudinal studies of first-episode schizophrenic patients could directly test this hypothesis.

Treatment of the Neuroleptic-Nonresponsive Schizophrenic Patient

Abstract: The treatment and management of neuroleptic-resistant schizophrenic patients, who comprise 5 to 25 percent of all patients with that diagnosis, are major problems for psychiatry. In addition, another large group of schizophrenic patients, perhaps 5 to 20 percent, are intolerant of therapeutic dosages of neuroleptic drugs because of extrapyramidal symptoms, including akathisia, parkinsonism, and tardive dyskinesia. Because about 60 percent of neuroleptic-resistant schizophrenic patients respond to clozapine and a large percentage of neuroleptic-intolerant patients are able to tolerate clozapine, it should be considered the treatment of choice for such patients until other therapies are proven to be superior. A trial of clozapine alone should usually be continued for up to 6 months before it is terminated or supplemental agents are tried. Plasma levels of clozapine may be useful to guide dosage. The major side effects of clozapine are granulocytopenia or agranulocytosis (1%-2%) and a dose-related increase in the incidence of generalized seizures. Psychosocial treatments such as education of the patient and the family about the nature of the illness, rehabilitation programs, social skills training, and assistance in housing are generally needed to obtain optimal benefit from clozapine, as with other somatic therapies. If clozapine is unavailable, unacceptable, or not tolerated, a variety of approaches may be employed to supplement typical antipsychotic drugs for patients who do not respond adequately to these agents alone. These include lithium; electroconvulsive therapy; carbamazepine or valproic acid; benzodiazepines; antidepressant drugs; reserpine; L-dopa and amphetamine; opioid drugs; calcium channel blockers; and miscellaneous other pharmacologic approaches. The evidence for the efficacy of these ancillary somatic therapies in treatment-resistant patients is relatively weak. Polypharmacy should be tried only for discrete periods and with clear goals. If these are not achieved, supplemental medications should be discontinued. Psychosurgery is not a recommended alternative at this time.

Gender Differences in Tardive Dyskinesia: A Critical Review of the Literature

Abstract: We analyzed data from 76 selected studies on prevalence of tardive dyskinesia (TD), published through 1989. The primary focus was on gender differences. The overall prevalence of TD in the 39,187 patients included in these reports was 24.2 percent, and prevalence was significantly higher in women (26.6%) than in men (21.6%). The gender difference in TD prevalence appeared to narrow intriguingly in more recent studies. Overall, the TD prevalence seemed to reach its peak in the 50-70-year-old age group in men and continued to rise after age 70 in women. Also, women tended to have more severe TD than men. Spontaneous dyskinesia too was found to be more common in women. The material was also analyzed for cultural differences by comparing studies in four continents: North America, Europe, Africa, and Asia. Although grouping together studies from different countries in a continent into a single group is somewhat problematic, we found that Asian patients had lower prevalence of TD than North American, European, and African patients. Limitations of our review (including differences among studies in diagnostic criteria, observer bias, etc.) as well as possible explanations for the reported differences in the risk for TD are discussed.

The Significance of Age of Onset for Schizophrenia

Abstract: Age of onset is the single most important characteristic of schizophrenia that could yield clues to its origin. To identify the age of onset, however, the onset of the pathological process must be determined. This process may have more than one component occurring at distinctly different times in the life of an individual. Nevertheless, many studies, using either the first appearance of psychosis or the age of first hospitalization, have found gender, familial, and other "age of onset" differences among patients with schizophrenia. These differences may aid in examining genetic mechanisms for schizophrenia.

Treatment of Cognitive Dysfunctions and Behavioral Deficits in Schizophrenia

Abstract: Integrated Psychological Therapy (IPT) is a structured intervention program that prescribes steps to remediate cognitive and behavioral dysfunctions that are characteristic of the psychopathology of schizophrenia. Evaluative studies of IPT indicated that the program improved schizophrenic patients' elementary cognitive processes such as attention, abstraction, and concept formation but that patients' performance was still below the normal range. The clinical utility of IPT will depend on studies that document the hierarchical generalization of improvements from the cognitive to the social and symptomatic levels of functioning.

Relapse of paranoid psychotic state in methamphetamine model of schizophrenia

Abstract: The study of the clinical course of methamphetamine (MAP) psychosis yields insights into the biological aspect of the relapse of the paranoid psychotic state with hallucination in schizophrenia. A series of MAP psychosis studies in Japan conducted over a period of more than four decades revealed three types of clinical courses of MAP psychosis after discontinuation of MAP: transient type, prolonged type, and persistent type. Identification of the latter two indicates a lasting change in the brain that produces and maintains a schizophrenia-like paranoid psychotic state without MAP. The characteristic course seen in the transient type is acute recurrence of the psychotic state after a long remission period, almost identical to the initial episode, due to reuse of MAP or to psychological stressors. Such lasting vulnerability of the brain to schizophrenia-like psychotic symptoms may be caused by a lasting sensitization of the brain to the psychotogenic action of MAP resulting from its chronic abuse. Experimental studies using animals sensitized to MAP-induced stereotypy suggest that lasting enhancement of MAP-induced dopamine release in the striatum and nucleus accumbens is related to the development and expression of brain vulnerability to schizophrenic symptoms.

When Assessing Twin Concordance, Use the Probandwise Not the Pairwise Rate

Abstract: Geneticists and twin researchers have long debated the relative merits of two alternative measures of twin concordance: the pairwise and probandwise concordance rates. The results of this debate are now quite clear, for almost every application the probandwise rate is preferred over the pairwise rate. In a recent review of schizophrenia twin studies, however, Torrey (1992) chose to analyze pairwise rather than probandwise rates. Torrey's use of pairwise rates led him to conclude that the monozygotic twin concordance for schizophrenia is weaker than what is widely accepted, and that, by implication, the magnitude of the genetic contribution to schizophrenia has been overestimated. In this brief commentary, we review the relative strengths and weaknesses of the pairwise and probandwise rates and show that Torrey's conclusion is based upon his incorrect use of pairwise rates. Twin studies of schizophrenia continue to support the existence of a strong genetic influence on the development of schizophrenia.

Premorbid and onset features of first-episode schizophrenia

Abstract: Most descriptive studies of the psychopathology of schizophrenia have focused on the period following illness onset. Little attention has been paid to the assessment of psychopathology before onset of psychotic symptoms. In this study, 71 first-hospitalization patients diagnosed with schizophrenia, schizoaffective, or schizophreniform disorder using DSM-III-R criteria were assessed on measures of premorbid adjustment, clinical history, and presenting symptomatology. A pattern of progressive decline was characteristic of 21 percent of the cases--primarily males with a long-term history of psychotic symptoms before first hospitalization and a trend for more severe negative symptoms at hospital admission. Patients who had a stable pattern of good premorbid adjustment experienced symptom onset and first hospitalization at a later age than those with a chronically poor premorbid adjustment. Time from onset of first psychotic symptom to first hospitalization varied from less than 1 month to over 20 years and was not associated with symptom severity or age of first psychotic symptoms. Systematic characterization of the earliest manifestations of schizophrenia may be important in identifying subgroups of patients with a similar course of illness, and may ultimately facilitate diagnosis, treatment, and understanding of the pathophysiology of schizophrenia.

The natural course of schizophrenia: a review of first-admission studies.

Abstract: In this article, research on the natural course of illness among first-admission schizophrenic patients is reviewed from an epidemiological perspective. Three types of studies are considered: statistical reports dating primarily from the preneuroleptic era; long-term followback studies; and more recent prospectively designed cohort studies. Although relatively more first-admission patients have a positive course than do multiple admissions patients, the findings confirm the substantial heterogeneity in course and outcome. Methodological improvements in first-admission research are suggested, including separating the analyses of first-episode patients from those with past psychotic experiences; employing longitudinal methods for deriving diagnosis; including patients with drug and alcohol problems where appropriate; enlarging the samples either by multisite or multicenter collaborations or by pooling data across studies; and obtaining better data on treatment experiences in naturalistic research.

Long-term course of hospitalization for schizophrenia: Part I. Risk for rehospitalization.

Abstract: The probability of rehospitalization following the initial discharge on which a diagnosis of schizophrenia was made is described using data from psychiatric case registers in Victoria, Australia; Maryland, U.S.A.; Denmark; and Salford, England. The percentage eventually rehospitalized, after followup intervals as long as two decades, varies from about 50 to 80 percent in the four service systems. Survival curves for duration in the community without rehospitalization bend sharply in the period between 2 and 3 years following discharge in all four cohorts and are almost flat after 20 years. Early age of onset predicts higher risk for rehospitalization in multivariate proportional hazards models in each cohort. When age of onset is included as a covariate, neither gender nor marital status has consistent or statistically significant effects on risk for rehospitalization.

Prospective Study of Psychobiology in First-episode Schizophrenia at Hillside Hospital

Abstract: Heterogeneity has been a consistent problem in the research and treatment of schizophrenia. Despite marked variation in the onset, phenomenology, treatment response and outcome of schizophrenic patients, our ability to identify subtypes is remarkably limited. A major problem in schizophrenia research has been the use of cross-sectional study designs and heterogeneous patient samples at different stages of the illness and who have been previously exposed to neuroleptics which have potentially confounding effects on the disease. This study intends to identify biologic correlates of the phenomenology and course of schizophrenia by using a prospective, longitudinal, repeated measures design assessing biologic and clinical parameters including measures of psychopathology, side effects, and social adjustment to examine clinical variables of treatment response, illness course, and outcome; measures of central nervous system dopamine activity and brain morphology in patients, from the onset of their illness. Patients were ascertained at hospital admission and assessed with a battery of clinical, neuropsychologic, and biologic measures before undergoing standardized treatment for the acute and maintenance phases of the illness. Upon completion, approximately 120 first-episode patients will have entered the study and will have been followed prospectively for up to 5 years and assessed at specific time intervals. Preliminary results reveal significant abnormalities in brain morphology, growth hormone secretion, eye movement function, and psychotogenic response to dopamine agonists in first-episode, treatment-naive patients which are associated with treatment response and outcome. This article describes the study's rationale, design, and methods, and a summary of the published results to date. These are discussed in terms of their significance for putative clinical subtypes and pathophysiological models of schizophrenia.

Anomalous Lateral Sulcus Asymmetry and Cognitive Function in First-episode Schizophrenia

Abstract: This study examines the cognitive functioning of first-episode schizophreniform patients within several weeks of hospitalization and at 2 years into the illness. Differences between patients and controls are also reported for measurements of the length of the lateral sulcus, which borders the planum temporal, an area of the brain integral to language function. Neuropsychological test results are also correlated to magnetic resonance imaging structural variables at the time of first hospitalization. Findings on neuropsychological summary scales reveal a diffuse pattern of cognitive impairment in schizophreniform patients compared to controls, which appears to improve over time. An atypical pattern of anatomic lateral symmetry is found in female schizophreniform patients, with female appearing to have a reduction in the normally occurring left greater than right length of the lateral sulcus. Such atypical asymmetry of the lateral sulcus is also associated with better cognitive function, particularly in schizophreniform patients. These findings suggest that atypical lateralization in an area critical to language function may be related to cognitive function in schizophreniform illness.

Homovanillic Acid Measurement in Clinical Research: A Review of Methodology

Abstract: Despite its serious limitations, measuring the concentrations of homovanillic acid (HVA) in body fluids is perhaps the most direct method currently available to assess the changing activity of central dopamine (DA) neurons in living humans. The concentrations of HVA in body fluids are determined not only by the activity of central DA neurons but also by a number of unrelated factors such as the other sources of HVA and the elimination of HVA from the body. This article reviews many factors that help to determine the concentrations of HVA in body fluids and therefore must be considered in studies employing HVA as a possible index of central DA neuronal activity. The need for further methodological work is indicated to improve the use of body fluid HVA measurements in clinical research.

The Epidemiology of Psychosis: The Suffolk County Mental Health Project

Abstract: This article describes the rationale, aims, and methodology of an epidemiological study of psychosis being conducted in Suffolk County, New York. A sample of first-admission patients is drawn from 10 inpatient and 25 outpatient facilities. Diagnostic psychosocial interviews are conducted shortly after admission to treatment, and at 6- and 24-month followup. Consensus diagnoses are made after each interview. Demographic and clinical background characteristics of the first 250 subjects enrolled over a 2-year period are presented here. The response rate was 76 percent. Based on the initial interview, 75 percent of subjects received a diagnosis involving psychosis. The three most common diagnoses were schizophrenia, bipolar disorder with psychotic features, and major depression with psychotic features. Among subjects with psychosis, 58 percent of males and 29 percent of females had a history of substance abuse/dependence. Gender differences were found on several background and clinical characteristics. Males were somewhat younger, less likely to have ever married, and had less education. Although the median length of hospitalization was the same for females and males (27 days), females were more likely to be hospitalized within 1 month of the occurrence of their first psychotic symptom (60% of females compared to 37% of males). Subjects with schizophrenia-related disorders were significantly more impaired on an assessment of negative symptoms than were affectively ill subjects, but clinical ratings of depression were not significantly different across diagnostic groups.

First-episode studies in schizophrenia : criteria and characterization

Abstract: Studies of early schizophrenia offer several advantages for efforts to unravel the biology, treatment, and outcome of this disorder. A review of available first-episode studies, however, suggests marked variability in findings, frequently attributed to the presumed heterogeneity of the disorder. Another cause may be variation in definitions and criteria used. Thus, attention has turned to the study of patients experiencing their first episode of psychosis. Although this strategy will not control for the true underlying heterogeneity of the illness, it provides a valuable method for homogenizing variability due to course. For this strategy to be effective, definition and operationalization of criteria for such studies are crucial. In this article, we reviewed assessment methods used in first-episode studies in the recent literature and found marked inconsistencies. We offer a framework for definition of patient populations for studies of early schizophrenia and outline some key variables that may serve as the basis for fuller characterization of the disorder. It is important to provide data on such variables to enhance comparability among studies of early schizophrenia and to facilitate meaningful interpretation of data.

Are We Overestimating the Genetic Contribution to Schizophrenia

Abstract: That genetic factors contribute to the etiology of schizophrenia is no longer debated; the nature and magnitude of that contribution, however, are still open for discussion. In this article, concordance rates for twin studies of schizophrenia are reviewed as one means of assessing the magnitude of the genetic contribution. Using only those studies in which representative samples were used and zygosity was determined with reasonable certainty, the pairwise concordance rate for schizophrenia was found to be 28 percent for monozygotic (MZ) and 6 percent for dizygotic (DZ) twins. Review of twin studies of other central nervous system diseases reveals that schizophrenia is most similar to multiple sclerosis (MZ concordance rate 27%). Although genetics remains as the single most clearly defined etiological factor in schizophrenia, the question remains whether we are overestimating the magnitude of the genetic contribution.

The McLean First-episode Psychosis Project: Six-month Recovery and Recurrence Outcome

Abstract: The McLean First-Episode Psychosis project began in 1989. The authors describe the study design, diagnostic distribution, and recovery and relapse data on the first 102 recruited subjects. Fifty-nine percent of the subjects had a diagnosis of bipolar disorder, 15 percent psychotic depression, 10 percent schizophrenic spectrum, 9 percent delusional disorder, and 8 percent other psychotic disorders. By 6 months, 80 percent recovered syndromically but only 55 percent recovered functionally, and only 50 percent recovered both functionally and syndromically. Non-white and male patients were more likely to have a recurrence. Men were less likely and bipolar patients were more likely to recover functionally. Patients with nonaffective psychosis had longer hospitalizations and lower rates of functional recovery 6 months after discharge.

Phenomenology and Functioning in First-Episode Schizophrenia

Abstract: One current view of schizophrenia is that its clinical and functional features show a deteriorating course, particularly for negative symptoms. However, this is difficult to study in chronic patients who have been exposed to pharmacologic treatment and institutionalization. Examining first-episode (FE) patients can help clarify which symptoms are present initially and how the symptom pattern is linked to functioning. We evaluated a sample of 37 FE patients with schizophrenia and compared them to 70 other schizophrenia (OS) patients on standard clinical scales, measures of premorbid functioning, and quality of life. FE patients showed a symptom profile similar to OS patients; in particular, there was no evidence that negative symptoms are less severe in the FE group. Analysis of the clinical data led us to the conclusion that the symptom profile of schizophrenia exists at the outset, that negative symptoms are associated with poor premorbid and current functioning, but that the role of positive symptoms is more complex and may vary in subtypes.

Cognitive Rehabilitation for Schizophrenia: Is It Possible? Is It Necessary?

Abstract: Limitations of available psychosocial interventions combined with the increasing evidence that schizophrenia is characterized by diverse deficits in information processing has stimulated great interest in the possibility of cognitive rehabilitation. However, the current optimism seems unjustified. The precise role of information processing in the behavioral handicaps evidenced by schizophrenic patients is not clear, and the neuropsychologic and experimental psychopathology tasks used to assess information processing generally cannot specify precisely which cognitive functions are deficient. Thus, the choice of cognitive targets for rehabilitation is arbitrary. The strategies currently employed for rehabilitation emphasize an exercise model of treatment and the use of complex mnemonics. Neither approach has been successful in rehabilitating brain-injured patients, and preliminary results with schizophrenic patients are not very promising. It is concluded that the field might be better served by focusing on environmental change and compensatory strategies until we determine how and why schizophrenic patients fail.

Exploratory Eye Movements and Neuropsychological Tests in Schizophrenic Patients

Abstract: Exploratory eye movements in schizophrenic and nonschizophrenic subjects were examined with an eye mark recorder while the subjects viewed geometric figures. Elementary components of eye movements and the responsive search score (RSS), a function of the number of sections on which the subjects fixated, were measured by means of an eye movement analyzer and slow motion replay. The schizophrenic group and the depressed patient group had fewer eye fixations than the normal control group and the obsessive-compulsive disorder group. The schizophrenic group had a lower RSS average than patients with depression, patients with obsessive-compulsive disorders, or subjects in the normal control group. These results in conjunction with those of our previous studies suggest that a low RSS is specific to schizophrenia. We examined the relationship between these eye movements and neuropsychological tests and also investigated the relation between the eye movements and clinical symptoms by means of the Brief Psychiatric Rating Scale, Schedule for Affective Disorders and Schizophrenia, and the Scale for the Assessment of Negative Symptoms. The RSS correlated positively with the performance IQ and Wechsler's Maze test, but not with the Wisconsin Card Sorting Test or the verbal IQ result. The RSS also correlated negatively with negative symptoms. These results suggest that the RSS has two characteristic features: it is strongly associated with the interpersonal response and it may be connected with visuospatial and visuomotor functions including attention.

Long-term Course of Hospitalization for Schizophrenia: Part II. Change With Passage of Time

Abstract: This analysis examines the notion of progressive deterioration in schizophrenia, using long-term followup data on hospital episodes in defined cohorts from psychiatric case registers in Victoria, Australia; Denmark; and Salford, England. The analyses differentiate heterogeneity existing at the first hospitalization for schizophrenia, which produces a widely varying natural course, from heterogeneity that develops over time, as episodes of hospitalization occur. Episodes of hospitalization for schizophrenia tend to cluster earlier rather than later in the treatment career, suggesting a progressive amelioration rather than deterioration. When overall chronicity is adjusted, each additional episode of hospitalization lowers the risk for a further hospitalization by about 10 percent.

Neuropsychological and Eye Movement Abnormalities in First-episode and Chronic Schizophrenia

Abstract: It is well known that neurobehavioral deficits are associated with schizophrenia. Little is known, however, about whether these disturbances become more severe over the course of the illness. In the present study, 101 patients with schizophrenia, of whom 45 were firstepisode cases, performed pursuit eye tracking tasks. A subset of 60 of these patients, including 27 firstepisode cases, were administered a battery of neuropsycholo gical tests. Patients with a history of prior psychotic episodes demonstrated more severe pursuit eye movement dysfunction than first-episode patients and more severe disturbances on neuropsychological tests sensitive to prefrontal and left temporal cortical dysfunction. Longitudinal studies of patients ascertained close to the point of illness onset are needed to determine whether these findings reflect a progressive deterioration In neurobehavioral functioning over the course of schizophrenia . The classic Kraepelinian notion of dementia praecox (Kraepelin 1896) proposed that a progressive deterioration in brain function was an integral part of the illness. This notion is compatible with clinical studies demonstrating that some patients show serious deterioration in role functioning over the course of schizophrenia

Where Are the Women in First-Episode Studies of Schizophrenia?

Abstract: Almost all investigations of first-episode schizophrenia uncover more male than female subjects. Two possible explanations for this observation are (1) first-episode investigations suffer more or less consistent methodologic biases or (2) the incidence of schizophrenia is higher in men than in women. Data from the markers and predictors of schizophrenia (MAP) project, a community-based first-episode study, permitted an investigation of the two alternatives. The results suggest that neither recruitment nor diagnostic vagaries explain the excess of males. Instead, the MAP results, consistent with other recent investigations, suggest that the incidence of schizophrenia is lower in women than in men. The findings are consistent with the literature on gender differences in schizophrenia, which indicates that schizophrenia in women is a less severe disorder than in men. The report includes recommendations for future first-episode investigations to ensure adequate representation of women.

Whither Cognitive-behavioral Therapy for Schizophrenia?

Abstract: Clinical studies of cognitive therapy and rehabilitation for persons with schizophrenia have generated promising findings of improvements in patients' cognitive and clinical status. However, the results do not appear to be specific to a particular form of intervention, and long-term evaluations of cognitive therapy, as an element in a comprehensive system of care, need to be conducted for clinical validation. Rehabilitation efforts should be congruent with laboratory findings of specific cognitive deficits, including those that are "vulnerability indicators" and endure beyond symptomatic episodes. With the demonstration that chronic schizophrenic patients can learn a variety of cognitive and behavioral skills through Integrated Psychological Therapy and other psychosocial treatments, the future appears bright for a profusion of new modalities aimed at cognitive-behavioral rehabilitation, especially those that emerge from what is known about information-processing deficits in schizophrenia.

Electrodermal Anomalies in Recent-onset Schizophrenia: Relationships to Symptoms and Prognosis

Abstract: Electrodermal activity was measured in recent-onset schizophrenic patients (n = 98) and matched normal control subjects (n = 40) as part of an ongoing longitudinal study. Results at the initial inpatient test were generally consistent with the current consensus in the literature. A large subgroup of the patients was found to be nonresponsive with the phasic skin conductance orienting response measure, whereas the remaining subgroup of patients was found to be electrodermally tonically hyperaroused. Heightened electrodermal activity at the inpatient test was associated with a number of symptoms in male patients and with poor recovery from the acute schizophrenic episode. Followup tests conducted when the patients were in states of remission and psychotic relapse revealed that tonic electrodermal arousal measures qualify as state-sensitive episode indicators, whereas phasic nonresponding may qualify as an atypical vulnerability indicator. Moreover, preliminary data from three patients suggest that increases in tonic electrodermal arousal may temporally precede psychotic relapses. The principal findings are consistent with a vulnerability/stress model that posits that electrodermal hyperarousal is part of a transient intermediate state that may lead to a psychotic episode in a vulnerable individual.

The Role of the Family in Psychiatric Rehabilitation

Abstract: This article describes the multiple roles that families can play in the psychiatric rehabilitation process and suggests ways for professionals to collaborate with them. The authors discuss the family's experience of loss and their process of recovery; their caregiving role; their role in supporting other families; their teaching and educational role; their advocacy role; their role as researchers and research subjects; and some suggestions for supporting family roles.

Cognitive remediation in schizophrenia: proceed ... with caution!

Abstract: The apparent neglect of neuropsychologic deficits in schizophrenia as the basis for therapeutic intervention, together with only isolated attempts at remediating them, probably reflect the nature of impairments, the functional significance of which is uncertain. A critique of the limitations inherent in the appealing cognitive remediation of the closed-head injured is followed by positive suggestions for the restructuring of cognitive schema that appear to underlie schizophrenic disability in social and vocational functioning.