Sleep disturbances in patients with schizophrenia : impact and effect of antipsychotics.
TL;DR: It appears possible that the high-potency drugs exert their effects on sleep in schizophrenic patients, for the most part, in an indirect way by suppressing stressful psychotic symptomatology.
Abstract: Difficulties initiating or maintaining sleep are frequently encountered in patients with schizophrenia. Disturbed sleep can be found in 30–80% of schizophrenic patients, depending on the degree of psychotic symptomatology. Measured by polysomnography, reduced sleep efficiency and total sleep time, as well as increased sleep latency, are found in most patients with schizophrenia and appear to be an important part of the pathophysiology of this disorder. Some studies also reported alterations of stage 2 sleep, slow-wave sleep (SWS) and rapid eye movement (REM) sleep variables, i.e. reduced REM latency and REM density. A number of sleep parameters, such as the amount of SWS and the REM latency, are significantly correlated to clinical variables, including severity of illness, positive symptoms, negative symptoms, outcome, neurocognitive impairment and brain structure. Concerning specific sleep disorders, there is some evidence that schizophrenic patients carry a higher risk of experiencing a sleep-related breathing disorder, especially those demonstrating the known risk factors, including being overweight but also long-term use of antipsychotics. However, it is still unclear whether periodic leg movements in sleep or restless legs syndrome (RLS) are found with a higher or lower prevalence in schizophrenic patients than in healthy controls. There are no consistent effects of first-generation antipsychotics on measuresof sleep continuity and sleep structure, including the percentage of sleep stages or sleep and REM latency in healthy controls. In contrast to first-generation antipsychotics, the studied atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, ziprasidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity, with an increase in either total sleep time (TST) or sleep efficiency, and individually varying effects on other sleep parameters, such as an increase in REM latency observed for olanzapine, quetiapine and ziprasidone, and an increase in SWS documented for olanzapine and ziprasidone in healthy subjects. The treatment of schizophrenic patients with first-generation antipsychotics is consistently associated with an increase in TST and sleep efficiency, and mostly an increase in REM latency, whereas the influence on specific sleep stages is more variable. On the other hand, withdrawal of such treatment is followed by a change in sleep structure mainly in the opposite direction, indicating a deterioration of sleep quality. On the background of the rather inconsistent effects of first-generation antipsychotics observed in healthy subjects, it appears possible that the high-potency drugs exert their effects on sleep in schizophrenic patients, for the most part, in an indirect way by suppressing stressful psychotic symptomatology. In contrast, the available data concerning second-generation antipsychotics (clozapine, olanzapine, risperidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity in patients and healthy subjects, with an increase in TST and sleep efficiency or a decrease in wakefulness. Additionally, clozapine and olanzapine demonstrate comparable influences on other sleep variables, such as SWS or REM density, in controls and schizophrenic patients. Possibly, the effects of second-generation antipsychotics observed on sleep in healthy subjects and schizophrenic patients might involve the action of these drugs on symptomatology, such as depression, cognitive impairment, and negative and positive symptoms. Specific sleep disorders, such as RLS, sleep-related breathing disorders, night-eating syndrome, somnambulism and rhythm disorders have been described as possible adverse effects of antipsychotics and should be considered in the differential diagnosis of disturbed or unrestful sleep in this population.
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TL;DR: Insight is provided into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold‐standard treatments for chronic insomnia.
Abstract: Insomnia is a prevalent experience for individuals with serious mental illness, and is one of the most common reasons for mental health referrals in the Veterans Health Administration. Insomnia also critically impacts psychiatric, cognitive and somatic outcomes. However, there is limited information about how people with serious mental illness (i.e. schizophrenia spectrum, bipolar, or major depressive disorders, with serious functional impairments) understand and respond to problems with their own sleep. Bringing this information to light will yield novel methods of research and treatment. The purpose of this study was to examine reactions to insomnia among veterans with serious mental illness and insomnia. An inductive phenomenological approach was used to collect data from 20 veterans with serious mental illness and insomnia using semi‐structured interviews. Six themes were identified: Becoming Aware that Insomnia is a Problem; Response to and Dissatisfaction with Medications; Strategies to Get Better Sleep: Contrary to Usual Guidelines; Personal Responsibility for Getting Sleep; Resigned and Giving Up; and Acceptance and Persistence. These results provide insight into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold‐standard treatments for chronic insomnia. Clinical implications and recommendations for improving treatment efficacy are discussed.
TL;DR: In this paper , the authors performed a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia, and found that insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28-2.65, P < 0.01) and suicide attempt or death.
Abstract: Purpose of review Insomnia is common in schizophrenia. Insomnia has been associated with suicidal ideation and behavior, as well as greater severity of psychopathology, in schizophrenia. This review performs a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia. Recent findings We searched major electronic databases from inception until November 2022 for studies of insomnia, suicide, and psychopathology in patients with schizophrenia. Random effects meta-analysis calculating odds ratios (ORs, for suicide) and effect sizes (ESs, for psychopathology) and 95% confidence intervals (CIs) were performed. Ten studies met the inclusion criteria, comprising 3428 patients with schizophrenia. Insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28–2.65, P < 0.01) and suicide attempt or death (OR = 5.83, 95% CI 1.61–2.96, P < 0.01). Insomnia was also associated with total (ES = 0.16, 95% CI 0.09–0.23, P < 0.01), positive (ES = 0.14, 95% CI 0.08–0.20, P = 0.02), and general (ES = 0.17, 95% CI 0.08–0.27, P < 0.01) psychopathology. In meta-regression analyses, BMI was negatively associated with suicidal ideation. Otherwise, age, sex, and study year were all unrelated to the associations. Summary Insomnia is associated with suicide and psychopathology in schizophrenia. Formal assessment and treatment of insomnia appears relevant to the clinical care of schizophrenia.
Journal Article•
TL;DR: Sleep disturbance is a core feature of schizophrenia and sleep disturbance can indicate exacerbation of schizophrenia c) sleep disturbance is secondary to psychotropic medications d) all of the above The authors' observations Sleep disturbances occur in 16% to 30% of patients with schizophrenia and are associated with reduced quality of life and poor coping skills.
Abstract: Psychotic, sleepless, and depressed, Mr. F decides to make a new start in another country. When his travel plans are interrupted, his psychosis worsens. What could be exacerbating his symptoms? CASE Psychotic and sleepless Mr. F, age 30, is referred to our psychiatric outpatient clinic for follow-up care after hospitalization to treat a psychotic episode. His psychotic symptoms started 2 years ago without an identifiable trigger. Mr. F complains of episodic mood symptoms, such as depression, irritability, and angry outbursts; persistent auditory hallucinations (voices calling him names); and persecutory delusions. While in the hospital he was diagnosed with psychotic disorder not otherwise specified and started on olanzapine titrated to 30 mg/d. During evaluation, Mr. F is depressed and exhibits motor retardation, slow speech, bland affect, impaired short-term memory, and auditory hallucinations. He describes social anxiety and has ideas of reference and problems interpreting facial expressions. He is guarded and suspicious. Although auditory hallucinations and depression affect Mr. F's daily activities, he is attempting to find a job. Mr. F has used alcohol since age 16 to escape social difficulties. He says he last used alcohol 1 year ago, but refuses to provide details about how much alcohol he typically consumed. Sporadic cannabis use also started when Mr. F was in his teens. Mr. F's symptoms improve with olanzapine, but he complains of weight gain and sedation, so we switch him to aripiprazole, 10 mg/d. Two weeks later he reports feeling jittery and anxious, so we discontinue aripiprazole and start loxapine, 25 mg/d at night, and propranolol, 60 mg/d, for residual akathisia. Despite limited clinical improvement, Mr. F irrationally says he wants to join the Navy. After a week, his psychotic symptoms improve but anxiety persists, so we start clonazepam, 1 mg/d, and oxcarbazepine, 600 mg/d. After 2 weeks he says he feels calmer, but has gained 20 lbs and is constantly tired. Against our advice, Mr. F decides to discontinue loxapine and propranolol, but continues clonazepam and oxcarbazepine. At his next visit 4 weeks later, Mr. F is in good spirits. He says he is looking for a job as a dental assistant, and shows no apparent signs of psychosis. Mr. F misses his next appointment but returns 3 months later with evident deterioration in his general appearance. He says he is having difficulty sleeping and is depressed, stating "I just lay in bed; I don't want to deal with life." He is withdrawn and unwilling to elaborate on his personal problems but asks for a refill of clonazepam and oxcarbazepine, which we provide. What is the significance of Mr. F's sleep disturbance? a) sleep disturbance is a core feature of schizophrenia b) sleep disturbance can indicate exacerbation of schizophrenia c) sleep disturbance is secondary to psychotropic medications d) all of the above The authors' observations Sleep disturbances, including poor sleep efficiency, increased sleep-onset latency, decreased rapid eye movement (REM) sleep latency, and decreased stage 4 of non-REM sleep, occur in 16% to 30% of patients with schizophrenia and are associated with reduced quality of life and poor coping skills. (1) Sleep-onset and sleep maintenance problems and sleep-wake reversal generally persist despite antipsychotic treatment. (2), (3) Slow-wave sleep deficiency can lead to negative symptoms and memory deficits in patients with schizophrenia because (4): * declarative and procedural memory consolidation are associated with slow-wave and stage 2 sleep, respectively * procedural learning and visual spatial memory are correlated with delta power in slow-wave sleep. (3), (8) Acute psychosis exacerbations are associated with restless, agitated sleep. Insomnia often is an early warning sign of clinical relapse. …
TL;DR: In this paper , the authors analyzed 19 precedents of crimes with mental disorders and found that the frequency of injured area was highest in the face, neck, and head; perpetrator's body (hands/feet) and knife were used the most as tools of assault; premeditation was revealed in eight cases, and crimes with active intention of harming and impulsive crimes happened at a similar frequency; schizophrenics usually committed crimes between 03:00-06:00, which is related to sleep disturbance in schizophrenia; in five cases, criminal acts such as murder, arson, and rape were committed under the influence of alcohol; and homicide is related more frequently to schizophrenia, personality disorder, and intellectual disability.
Abstract: Crimes committed by the mentally ill may initially be mistaken as unmotivated or hate crimes, which may cause public anxiety and conflict between social classes. In this context, special attention is needed to secure social safety and to effectively respond against crimes committed by the mentally ill. For these purposes, comprehensive analysis of the details of such crimes, including the type of crime, the content of criminal behavior, the tool of crime, unusual behavior before and after the crime, and the triggering factor of the crime, can provide valuable information. If specific tendencies or common characteristics shared in criminal acts related to mental illness can be found, they would assist criminal investigations and determination of criminal responsibility. The authors analyzed 19 precedents of crimes with mental disorders. The results of the analysis are as follows: frequency of injured area was the highest in the face, neck, and head; perpetrator’s body (hands/feet) and knife were used the most as tools of assault; premeditation was revealed in eight cases, and crimes with active intention of harming and impulsive crimes happened at a similar frequency; schizophrenics usually committed crimes between 03:00-06:00, which is related to sleep disturbance in schizophrenia; in five cases, criminal acts—violent crimes such as murder, arson, and rape—were committed under the influence of alcohol; and homicide is related more frequently to schizophrenia, personality disorder, and intellectual disability.
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TL;DR: Review of five studies involving the PANSS provided evidence of its criterion-related validity with antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.
Abstract: The variable results of positive-negative research with schizophrenics underscore the importance of well-characterized, standardized measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale (PANSS) for typological and dimensional assessment. Based on two established psychiatric rating systems, the 30-item PANSS was conceived as an operationalized, drug-sensitive instrument that provides balanced representation of positive and negative symptoms and gauges their relationship to one another and to global psychopathology. It thus constitutes four scales measuring positive and negative syndromes, their differential, and general severity of illness. Study of 101 schizophrenics found the four scales to be normally distributed and supported their reliability and stability. Positive and negative scores were inversely correlated once their common association with general psychopathology was extracted, suggesting that they represent mutually exclusive constructs. Review of five studies involving the PANSS provided evidence of its criterion-related validity with antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.
18,358 citations
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01 Jan 1968
11,993 citations
TL;DR: The Brief Psychiatric Rating Scale (BRS) as mentioned in this paper was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change, and it is recommended for use where efficiency, speed, and economy are important considerations.
Abstract: The Brief Psychiatric Rating Scale was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change. Sixteen symptom constructs which have resulted from factor analyses of several larger sets of items, principally Lorr's Multidimensional Scale for Rating Psychiatric Patients (MSRPP) (1953) and Inpatient Multidimensional Psychiatric Scale (IMPS) (1960), have been included for rating on 7-point ordered category rating scales. The attempt has been to include a single scale to record degree of symptomacology in each of the relatively independent symptom areas which have been identified. Some of the preliminary work which has led to the identification of primary symptom constructs has been published (Gorham & Overall, 1960, 1961, Overall, Gorharn, & Shawver, 1961). While other reports are in preparation, applications of the Brief Scale in both pure and applied research suggest the importance of presenting the basic instrument to the wider scientific audience at this time, together with recommendations for its standard use. The primary purpose in developing the Brief Scale has been the development of a highly efficient, rapid evaluation procedure for use in assessing treatment change in psychiatric patients while at the same time yielding a rather comprehensive description of major symptom characteristics. It is recommended for use where efficiency, speed, and economy are important considerations, while more detailed evaluation procedures, such as those developed by Lorr (1953, 1961) should perhaps be wed in other cases. In order to achieve the maximum effectiveness in use of the Brief Scale, a standard interview procedure and more detailed description of rating concepts are included in this report. In addition, each symptom concept is defined briefly in the rating scale statements themselves. Raters using the scale should become thoroughly familiar with the scale definitions presented herein, after which the rating scale statements should be sufficient to provide recall of the nature and delineation of each symptom area. , To increase the reliability of ratings, it is recommended that patients be interviewed jointly by a team of two clinicians, with the two raters making independent ratings at the completion of the interview. An alternative procedure which has been recommended by some is to have raters discuss and arrive at a
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TL;DR: Among the newer antipsychotic agents, clozapine appears to have the greatest potential to induce weight gain, and ziprasidone the least, and the differences among newer agents may affect compliance with medication and health risk.
Abstract: OBJECTIVE: The purpose of this study was to estimate and compare the effects of antipsychotics—both the newer ones and the conventional ones—on body weight. METHOD: A comprehensive literature search identified 81 English- and non-English-language articles that included data on weight change in antipsychotic-treated patients. For each agent, a meta-analysis and random effects metaregression estimated the weight change after 10 weeks of treatment at a standard dose. A comprehensive narrative review was also conducted on all articles that did not yield quantitative information but did yield important qualitative information. RESULTS: Placebo was associated with a mean weight reduction of 0.74 kg. Among conventional agents, mean weight change ranged from a reduction of 0.39 kg with molindone to an increase of 3.19 kg with thioridazine. Among newer antipsychotic agents, mean increases were as follows: clozapine, 4.45 kg; olanzapine, 4.15 kg; sertindole, 2.92 kg; risperidone, 2.10 kg; and ziprasidone, 0.04 kg....
2,271 citations
TL;DR: A method of gravimetric planimetry by standard photographs offers a means to study the course of surface wounds more accurately than by clinical observation or by the pictorial record alone.
Abstract: obtain their surface in square centimeters. This simple method provides a means by objective measurements to make evident changes in the surface of wounds that are not apparent to the naked eye. Figure 1 shows the observations recorded with this method in a man of 42 years of age with hemiplegia and a decubital ulcer over the right buttock. The clinicians who had observed this wound daily had not noticed any remarkable change; however, it is quite obvious that the wound grew larger each time the treatment was changed, and that the use of an antibiotic was followed by a particularly striking enlargement of the lesion. In this instance the procedure of projection and gravimetric planimetry was repeated by different operators and a variation of ±5% was found (indicated by a cross-hatched area on Fig. 1). Figure 2 shows the same type of observation in a woman with hemiplegia and a decubital ulcer. This patient died from septicemia, and the decubital ulcer worsened with the general condition of the patient. A method of gravimetric planimetry by standard photographs offers a means to study the course of surface wounds more accurately than by clinical observation or by the pictorial record alone. References
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