- Email: [email protected]
Abortive forms of the neuroleptic malignant syndrome: Four case reports
s223
P2 Psychotic disorders and antipsychotics
was collected on all patients treated with Clozapine and Risperidone.
References
[l] CirauloD and Shader R: Fluoxetinedrug-druginteractions:Antidepressants The Subjective Well-being under Neuroleptic Treatment Scale (SWN) and antipsychotics..I.Clin. Psychopharmacol1990, 10:4X-50 lp.2.036(
Suicidal risk in patients treated with the novel antipsychotic olanzapine
M. Fung, P Tran, C. Beasley Jr., G. Tollefson, A. Crawford, W. Brookfield. Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, 46285, USA
and Befmdlichkeits Scale (Patients Subjective State Assessement, BfS) were used to assess the patients self rating of well-being. The Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale (CGI) were used to assess the psychopathology of the subjects. Results: Of the total patients observed, 59 were included in the following study: Clozapine (22 male/l2 female), Risperidone (5 male/20 female). The baseline and endpoint-scores for the different scales are listed in table 1. Table 1*
Introduction: The longitudinal course of schizophrenia is complicated
by a high incidence of self-harmful behaviors. Approximately 40% of schizophrenic patients attempt suicide; about 10% complete suicide. It has been observed that atypical antipsychotic agents may lead to a reduction in the incidence of suicidal behavior. In controlled clinical trials, olanzapine was found to be associated with a numerically lower incidence of suicide attempts than placebo and haloperidol. Completed suicides associated with olanzapine were numerically comparable to those associated with haloperidol and less than with placebo. We have attempted to evaluate whether this reduction has been observed in the post-marketing database. Methodology: The spontaneous safety database for olanzapine was searched during the first 12 months of marketing to determine the number of cases of attempted suicide. All cases generated were reviewed individuaIy to evaluate demographics of the patients, method of attempted suicide, and outcomes. A crude incidence was calculated and adjusted to per 100,000 patient-years using the estimated worldwide patient exposure. Results: A total of 134 unique reports of attempted suicide were identified after elimination of duplicate reports and cases of non-suicidal behaviors. There were 52 males (39%), 72 females (54%) and 10 unknown gender (7%) among these patients with the age range from 18 to 64 years old (mean 32.6). The methods of the suicide were: drug overdose (86%), laceration (2%), impact-related injury (3%), gun-shot (1.5%), hanging (1.5%) and unknown (6%). Outcomes of the suicides were death (14%), hospitalized and recovered (69%), and unknown (17%). Dividing these 134 cases of suicide by the patient number of 688,000 yields a crude incidence of 0.02%. The estimated total patient exposure during this first year period was 156,986 patientyears of therapy. This yields a suicide attempt rate of 85/100,000 patient-years. Eleven studies suggest a completed suicide rate between 35(r-600/100,000 patient-years. Given an estimate of 24 attempts per completed suicide, the suicide attempt rate among schizophrenics will be 70~2,400/100,000 patient-years, which is higher than our reported rate. However, if a 10 fold potential under-reporting factor (suggested for serious adverse events reporting in the literature) is considered, our adjusted rate will be 850/100,000 patient-years, which is still at the low end of the estimated rate from the literature. Conclusions: The estimated rate of suicide attempts is lower or at the low end of the range suggested by the literature. This is consistent with the observation in the clinical trial data with regard to suicidal behavior. lp.2.0371
Clozapine versus risperidone: An open, comparative and prospective study on efficacy, tolerability and quality of life
F.-G. Pajonk, S. Tiessen, R. Holzbach, D. Naber. Department of Psychiatry and Psychotherapy University -Hospital Hamburg - Eppendoti Germany Objekdve: The application of Clozapine and Risperidone in a controlled group of psychiatric patients within a clinical environment was observed and investigated with reference to the efficacy, tolerability and quality of life. The aim of our investigation was to clear up whether one of these drugs has an considerable advantage. Method: Within one year time period information pertaining to patient history, accompanying therapeutic intervention and demographical data
_ CGI
PANSS BL
EP
Clozapine (n = 34)
93.6 fl8.9
14. I 6.4 ~t21.9~ ik1.0
Risperidone (n = 25)
83.8 15.5 5.5 +19.1 k20.9 10.7
* BL,
baseline;EP,endpoint.
BL
SWN
BfS
EP
BL
EP
5.0 f1.2’
135.9 f34.2
148.9 29.9 22.4 +30.3+ zk13.4 f13.7
BL
5.0 150.6 156.1 28.1 11.25+ f29.8 f29.3 ztl4.1
EP
23.1 zt14.3’
’ p < 0.05. z p < 0.005
With the exception of a raised CGI and a higher rating for general symptoms (PANSS) within the Clozapine group there was no significant statistical difference in the severity of illness of both groups. There was however no comparable difference in the chronicicity of illness with specific reference to the duration of the pre-study treatment of patients with neuroleptics, number of inpatient admissions and patients age, but between gender. Risperidone patients were significantly earlier treated and discharged. The average dose prescribed was 242 * 138 mg/d (Clozapine) and 4.8 & 1.5 mg/d (Risperidone). It was found at the completion of the study that patients treated with Risperidone had a significant reduction in positive symptoms (PANSS), in the CGI and the BR. Patients treated with Clozapine demonstrated a significant Iowering of both positive and negative symptoms (PANSS). This reduction appeared in the CGI but not however in BfS. In the Clozapine group a significant improvement in SWN was demonstrated. Conclusion: Clozapine and Risperidone were both effective and proved good tolerance. However the relatively short time period for the clinical observation possibly inhibited the recording of reduced negative symptoms in Risperidone treated patients. The quality of life rose in both patient groups. However the selected test instruments rated the values differently.
[p.2.038/
Abortive forms of the neuroleptic syndrome: Four case reports
malignant
0. Zivanovic, Lj. Borisev, V Borisev. Psychiatric clinic, Institute fir neurology, psychiatry and mental health, Clinical center, Nooi Sad, Yugoslavia
Background: The clinical features of the neuroleptic malignant syndrome (NMS) can vary. Several sets of diagnostic criteria for NMS that are proposed include fever, clouding of consciousness, various combination of different extrapyramidal symptoms (EPS), signs of vegetative disturbances and laboratory abnormalities. However, the agreement between different recommended sets of criteria is poor. A considerable numbers of patients present with a combination of symptoms and signs of NMS, but don’t meet any of the proposed criteria, because of the lack of certain characteristics. These conditions, often labeled as the abortive or incomplete forms of NMS, are frequently unrecognized or misdiagnosed. We report about four cases of abortive forms of the NMS. Cases: From 205 female inpatients treated with neuroleptics during one year, four (2%) developed some of the symptoms and signs of the NMS. The common characteristics in all patients were worsening of the initial mental status shortly after the exposure to neuroleptic: clouding of consciousness or the emergence of catatonia, and signs of autonomic disregulation (labile TA, tachycardia, pallor or diaphoresis). At this point of time fever was present in only one of the patients.
s224
I?2 Psychotic disorders and antipsychotics
During the development of the disorder, different combinations of EPS were registered. In three cases, the elevation of the serum creatinine phosphokinase (CPK) preceded the occurrence of muscular hypertonus. Further treatment of these patients included a discontinuation of the neuroleptic (except for one who continued to receive low doses of clozapine), administration of lorazepam, bromocriptine and Supportive measures. This led not only to resolving of EPS and vegetative abnormalities, but in the tirst place, to amelioration of the mental status: improving of the state of consciousness, reducing psychomotor agitation and disappearing of catatonic features. The observed clinical recovery was followed by the gradual normalization of CPK levels. Subsequently, all patients were treated with clozapine, while the doses of bromocriptine and lorazepam were gradually tapered. Conclusion: We wanted to point out the possibility of the occurrence of the abortive forms of NMS, and stress the importance of monitoring the patients exposed to neuroleptic. Early recognition, prompt therapeutic intervention and prevention of recurrences of the NMS could be encouraged by the adoption of the less restrictive diagnostic criteria of this disorder for clinical practice. References [l] Gwera, R.J., Chang, S.S., Romero, J.A. A comparisonof diagnosticcriteria for neuroleptic malignant syndrome. J Clin Psychiatry 1992, 53: X%62. [2] Shalev, A., Monk H. The neuroleptic malignant syndrome: agent and host interaction. Acta psychiatr Stand 1986, 73: 337-47.
[p.2.0391
Substance abuse and axis I comorbidity in psychotic disorders
S. Pini, L. Dell’Osso, C. Mastrocinque, C. Manzi, M. Saettoni, S. Vignoli, A. Papasogli, G. Marcacci, G.B. Cassano. Department ofPsychiae, Neurobiology, Pharmacology and Biotechnology University of Piss, via Roma 67, 56100 Pisa, Italy
Several studies reported that substance abuse has a negative impact on phenomenology of psychosis. However, no studies, at our knowledge, have investigated the differential impact of substance abuse on psychotic phenomenology when it occurs alone with psychotic illness as compared to when it occurs concomitantly with other Axis I disorders. Method: The method of this study has been described in detail elsewhere’, One hundred ninety eight consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-IIIR (SCID-P). Psychopathology was assessed by the Brief Psychiatric Rating Scale (BPRS) and the Hopkins Symptoms Checklist (HSCL-90). Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders (SUMD). Results: Of the entire cohort of 198 consecutively hospitalized patients with psychotic features, 125 (63.2%) received a diagnosis of bipolar I disorder with psychotic features, 27 (13.6%) of unipolar major depression with psychotic features and 46 (23.2%) of schizophrenia spectrum disorders. The total cohort was categorized into four groups according to patterns of comorbidity. The first group was composed by 14 (7.1%) patients with substance abuse disorder without any other axis I comorbidity (S/nA); the second group was constituted by 29 (14.7%) patients with substance abuse plus at least one other Axis I comorbid disorder (A/S); the third group of 81 (40.1%) patients had at least one Axis I disorder without substance abuse (A/nS); the four group of 74 (37.4%) patients had neither substance abuse nor other Axis I comorbidities (nA/nS). The age at onset of psychotic disorder was found to be significantly earlier in A/S (21 f 4.7 years) group as compared to nA/nS group (26.5 f 8.7 years) (F = 3.192, p. < 03). As to level of patient’s awareness of current episode of illness, this was found to be significantly better in A/nS group that in nA/nS group (2.6 f 1.5 vs 3.4.1.5, F = 4.616, p < .004), while such a difference was not found for SInA or S/A as compared to nA/nS. The BPRS anxiety/depression subscale (2.9 f 1.3 vs 2.2 1.1, F = 5.287, p < ,002) and HSCL-90 total score (120.2 f 64.6
vs 92.3 & 55.7, F = 2.944, p < .05) were significantly higher in the A/nS group than in nA/nS group. Conclusions: Our findings suggest that substance abuse is associated with an earlier age at onset of psychosis as compared to patients without any comorbidity and that such a difference is significantly more pronounced when it is associated with other Axis I disorders. Conversely, Axis 1 comorbidity in the absence of substance abuse is associated with more subjective distress and higher level of anxiety/depression. References [I] Cassano GB, Pini S, Saettoni M, Rucci P, Dell’Osso L (1998) Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders. Journalof ClinicalPsychiatry59, 6&668.
-1
Application of the factor pyramidical model in diagnosing and treating schizophrenia
G. Tacchini, J. Sironi, S. Charitos, 0. Fusi, G. Penati. Institute of Psychiatry, University of Mlano, IRCCS Ospedale Maggiore Policlinico ofhlilano, Via I? Sforza 35, 20122 Milan. Italy In 1987 Kay and co-workers introduced a new scale for the assessment of the positive and negative symptoms - the Positive And Negative Syndrome Scale (PANSS) for schizophrenia. The scale includes 30 items, 18 of which from the Brief Psychiatric Rating Scale (BPRS), and 12 from the Psychopathology Rating Scale (PRS). The use of the PANSS led to the following conclusions: . the inter-rater reliability was quite satisfactory for the positive and the general psychopathology scales, however some problems remained with the inter-rater reliability of the negative scale; ?? seven factors emerged from factor analysis and the first four factors (positive, negative, excited and depressed) were retained and included in a four factor pyramidical model. Later, Kay himself introduced the Structured Clinical Interview for the PANSS (SCI-PANSS), and demonstrated a considerable increase in the inter-rater reliability of the negative scale. The multifactor pyramidical model of schizophrenia, developed by Kay and Savy, was afterwards extended by Lindstrom and Von Knorring, who described five factors: negative, positive, excited, anxious/depressive and cognitive; each of them was distributed to an angle of a hypothetical pyramid. The negative factor includes: motor retardation, lack of spontaneity, poor relationship, blunted affect, emotional withdrawal and passive social withdrawal. The positive factor includes: delusions, grandiosity, hallucinatory behaviour, and unusual thought content. The cognitive factor includes: disorientation, preoccupation, poor attention, conceptual disorganisation and difficulties in abstract thinking. The anxious/depressive factor includes: anxiety, depression, guilt feelings and somatic concerns. The excited factor includes: poor impulse control, hostility, excitement and uncooperativeness. It could be demonstrated that all these factors are sensitive to the action of the selective 5-HTz/D2 antagonists such as risperidone or zotepine that determine a direct action on the negative symptoms, but also indirect on the same symptoms through a preceding action on the positive and extrapyramidal symptoms. In our study 86 patients were selected by means of the PANSS and were followed during the hospitalisation with the SCI-PANSS. We propose to evaluate, through the use of the pyramidical model, whether: . the negative symptoms, i.e. the target of the new antipsychotic drugs, can be placed on the peak of the pyramid and therefore considered the dominant factor of schizophrenia, even if sometimes they are “hidden” compared to the others; on the contrary other factors can lie in the four angles of the base, as symbols of their essential contributions to diagnosis; . the modem therapy is effective because: a) has a direct action on the peak and on the four angles of the base, and b) has an additional effect on the “dominant” factor through the above-mentioned direct action on the four “subordinate” factors.
P2 Psychotic disorders and antipsychotics
was collected on all patients treated with Clozapine and Risperidone.
References
[l] CirauloD and Shader R: Fluoxetinedrug-druginteractions:Antidepressants The Subjective Well-being under Neuroleptic Treatment Scale (SWN) and antipsychotics..I.Clin. Psychopharmacol1990, 10:4X-50 lp.2.036(
Suicidal risk in patients treated with the novel antipsychotic olanzapine
M. Fung, P Tran, C. Beasley Jr., G. Tollefson, A. Crawford, W. Brookfield. Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, 46285, USA
and Befmdlichkeits Scale (Patients Subjective State Assessement, BfS) were used to assess the patients self rating of well-being. The Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale (CGI) were used to assess the psychopathology of the subjects. Results: Of the total patients observed, 59 were included in the following study: Clozapine (22 male/l2 female), Risperidone (5 male/20 female). The baseline and endpoint-scores for the different scales are listed in table 1. Table 1*
Introduction: The longitudinal course of schizophrenia is complicated
by a high incidence of self-harmful behaviors. Approximately 40% of schizophrenic patients attempt suicide; about 10% complete suicide. It has been observed that atypical antipsychotic agents may lead to a reduction in the incidence of suicidal behavior. In controlled clinical trials, olanzapine was found to be associated with a numerically lower incidence of suicide attempts than placebo and haloperidol. Completed suicides associated with olanzapine were numerically comparable to those associated with haloperidol and less than with placebo. We have attempted to evaluate whether this reduction has been observed in the post-marketing database. Methodology: The spontaneous safety database for olanzapine was searched during the first 12 months of marketing to determine the number of cases of attempted suicide. All cases generated were reviewed individuaIy to evaluate demographics of the patients, method of attempted suicide, and outcomes. A crude incidence was calculated and adjusted to per 100,000 patient-years using the estimated worldwide patient exposure. Results: A total of 134 unique reports of attempted suicide were identified after elimination of duplicate reports and cases of non-suicidal behaviors. There were 52 males (39%), 72 females (54%) and 10 unknown gender (7%) among these patients with the age range from 18 to 64 years old (mean 32.6). The methods of the suicide were: drug overdose (86%), laceration (2%), impact-related injury (3%), gun-shot (1.5%), hanging (1.5%) and unknown (6%). Outcomes of the suicides were death (14%), hospitalized and recovered (69%), and unknown (17%). Dividing these 134 cases of suicide by the patient number of 688,000 yields a crude incidence of 0.02%. The estimated total patient exposure during this first year period was 156,986 patientyears of therapy. This yields a suicide attempt rate of 85/100,000 patient-years. Eleven studies suggest a completed suicide rate between 35(r-600/100,000 patient-years. Given an estimate of 24 attempts per completed suicide, the suicide attempt rate among schizophrenics will be 70~2,400/100,000 patient-years, which is higher than our reported rate. However, if a 10 fold potential under-reporting factor (suggested for serious adverse events reporting in the literature) is considered, our adjusted rate will be 850/100,000 patient-years, which is still at the low end of the estimated rate from the literature. Conclusions: The estimated rate of suicide attempts is lower or at the low end of the range suggested by the literature. This is consistent with the observation in the clinical trial data with regard to suicidal behavior. lp.2.0371
Clozapine versus risperidone: An open, comparative and prospective study on efficacy, tolerability and quality of life
F.-G. Pajonk, S. Tiessen, R. Holzbach, D. Naber. Department of Psychiatry and Psychotherapy University -Hospital Hamburg - Eppendoti Germany Objekdve: The application of Clozapine and Risperidone in a controlled group of psychiatric patients within a clinical environment was observed and investigated with reference to the efficacy, tolerability and quality of life. The aim of our investigation was to clear up whether one of these drugs has an considerable advantage. Method: Within one year time period information pertaining to patient history, accompanying therapeutic intervention and demographical data
_ CGI
PANSS BL
EP
Clozapine (n = 34)
93.6 fl8.9
14. I 6.4 ~t21.9~ ik1.0
Risperidone (n = 25)
83.8 15.5 5.5 +19.1 k20.9 10.7
* BL,
baseline;EP,endpoint.
BL
SWN
BfS
EP
BL
EP
5.0 f1.2’
135.9 f34.2
148.9 29.9 22.4 +30.3+ zk13.4 f13.7
BL
5.0 150.6 156.1 28.1 11.25+ f29.8 f29.3 ztl4.1
EP
23.1 zt14.3’
’ p < 0.05. z p < 0.005
With the exception of a raised CGI and a higher rating for general symptoms (PANSS) within the Clozapine group there was no significant statistical difference in the severity of illness of both groups. There was however no comparable difference in the chronicicity of illness with specific reference to the duration of the pre-study treatment of patients with neuroleptics, number of inpatient admissions and patients age, but between gender. Risperidone patients were significantly earlier treated and discharged. The average dose prescribed was 242 * 138 mg/d (Clozapine) and 4.8 & 1.5 mg/d (Risperidone). It was found at the completion of the study that patients treated with Risperidone had a significant reduction in positive symptoms (PANSS), in the CGI and the BR. Patients treated with Clozapine demonstrated a significant Iowering of both positive and negative symptoms (PANSS). This reduction appeared in the CGI but not however in BfS. In the Clozapine group a significant improvement in SWN was demonstrated. Conclusion: Clozapine and Risperidone were both effective and proved good tolerance. However the relatively short time period for the clinical observation possibly inhibited the recording of reduced negative symptoms in Risperidone treated patients. The quality of life rose in both patient groups. However the selected test instruments rated the values differently.
[p.2.038/
Abortive forms of the neuroleptic syndrome: Four case reports
malignant
0. Zivanovic, Lj. Borisev, V Borisev. Psychiatric clinic, Institute fir neurology, psychiatry and mental health, Clinical center, Nooi Sad, Yugoslavia
Background: The clinical features of the neuroleptic malignant syndrome (NMS) can vary. Several sets of diagnostic criteria for NMS that are proposed include fever, clouding of consciousness, various combination of different extrapyramidal symptoms (EPS), signs of vegetative disturbances and laboratory abnormalities. However, the agreement between different recommended sets of criteria is poor. A considerable numbers of patients present with a combination of symptoms and signs of NMS, but don’t meet any of the proposed criteria, because of the lack of certain characteristics. These conditions, often labeled as the abortive or incomplete forms of NMS, are frequently unrecognized or misdiagnosed. We report about four cases of abortive forms of the NMS. Cases: From 205 female inpatients treated with neuroleptics during one year, four (2%) developed some of the symptoms and signs of the NMS. The common characteristics in all patients were worsening of the initial mental status shortly after the exposure to neuroleptic: clouding of consciousness or the emergence of catatonia, and signs of autonomic disregulation (labile TA, tachycardia, pallor or diaphoresis). At this point of time fever was present in only one of the patients.
s224
I?2 Psychotic disorders and antipsychotics
During the development of the disorder, different combinations of EPS were registered. In three cases, the elevation of the serum creatinine phosphokinase (CPK) preceded the occurrence of muscular hypertonus. Further treatment of these patients included a discontinuation of the neuroleptic (except for one who continued to receive low doses of clozapine), administration of lorazepam, bromocriptine and Supportive measures. This led not only to resolving of EPS and vegetative abnormalities, but in the tirst place, to amelioration of the mental status: improving of the state of consciousness, reducing psychomotor agitation and disappearing of catatonic features. The observed clinical recovery was followed by the gradual normalization of CPK levels. Subsequently, all patients were treated with clozapine, while the doses of bromocriptine and lorazepam were gradually tapered. Conclusion: We wanted to point out the possibility of the occurrence of the abortive forms of NMS, and stress the importance of monitoring the patients exposed to neuroleptic. Early recognition, prompt therapeutic intervention and prevention of recurrences of the NMS could be encouraged by the adoption of the less restrictive diagnostic criteria of this disorder for clinical practice. References [l] Gwera, R.J., Chang, S.S., Romero, J.A. A comparisonof diagnosticcriteria for neuroleptic malignant syndrome. J Clin Psychiatry 1992, 53: X%62. [2] Shalev, A., Monk H. The neuroleptic malignant syndrome: agent and host interaction. Acta psychiatr Stand 1986, 73: 337-47.
[p.2.0391
Substance abuse and axis I comorbidity in psychotic disorders
S. Pini, L. Dell’Osso, C. Mastrocinque, C. Manzi, M. Saettoni, S. Vignoli, A. Papasogli, G. Marcacci, G.B. Cassano. Department ofPsychiae, Neurobiology, Pharmacology and Biotechnology University of Piss, via Roma 67, 56100 Pisa, Italy
Several studies reported that substance abuse has a negative impact on phenomenology of psychosis. However, no studies, at our knowledge, have investigated the differential impact of substance abuse on psychotic phenomenology when it occurs alone with psychotic illness as compared to when it occurs concomitantly with other Axis I disorders. Method: The method of this study has been described in detail elsewhere’, One hundred ninety eight consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-IIIR (SCID-P). Psychopathology was assessed by the Brief Psychiatric Rating Scale (BPRS) and the Hopkins Symptoms Checklist (HSCL-90). Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders (SUMD). Results: Of the entire cohort of 198 consecutively hospitalized patients with psychotic features, 125 (63.2%) received a diagnosis of bipolar I disorder with psychotic features, 27 (13.6%) of unipolar major depression with psychotic features and 46 (23.2%) of schizophrenia spectrum disorders. The total cohort was categorized into four groups according to patterns of comorbidity. The first group was composed by 14 (7.1%) patients with substance abuse disorder without any other axis I comorbidity (S/nA); the second group was constituted by 29 (14.7%) patients with substance abuse plus at least one other Axis I comorbid disorder (A/S); the third group of 81 (40.1%) patients had at least one Axis I disorder without substance abuse (A/nS); the four group of 74 (37.4%) patients had neither substance abuse nor other Axis I comorbidities (nA/nS). The age at onset of psychotic disorder was found to be significantly earlier in A/S (21 f 4.7 years) group as compared to nA/nS group (26.5 f 8.7 years) (F = 3.192, p. < 03). As to level of patient’s awareness of current episode of illness, this was found to be significantly better in A/nS group that in nA/nS group (2.6 f 1.5 vs 3.4.1.5, F = 4.616, p < .004), while such a difference was not found for SInA or S/A as compared to nA/nS. The BPRS anxiety/depression subscale (2.9 f 1.3 vs 2.2 1.1, F = 5.287, p < ,002) and HSCL-90 total score (120.2 f 64.6
vs 92.3 & 55.7, F = 2.944, p < .05) were significantly higher in the A/nS group than in nA/nS group. Conclusions: Our findings suggest that substance abuse is associated with an earlier age at onset of psychosis as compared to patients without any comorbidity and that such a difference is significantly more pronounced when it is associated with other Axis I disorders. Conversely, Axis 1 comorbidity in the absence of substance abuse is associated with more subjective distress and higher level of anxiety/depression. References [I] Cassano GB, Pini S, Saettoni M, Rucci P, Dell’Osso L (1998) Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders. Journalof ClinicalPsychiatry59, 6&668.
-1
Application of the factor pyramidical model in diagnosing and treating schizophrenia
G. Tacchini, J. Sironi, S. Charitos, 0. Fusi, G. Penati. Institute of Psychiatry, University of Mlano, IRCCS Ospedale Maggiore Policlinico ofhlilano, Via I? Sforza 35, 20122 Milan. Italy In 1987 Kay and co-workers introduced a new scale for the assessment of the positive and negative symptoms - the Positive And Negative Syndrome Scale (PANSS) for schizophrenia. The scale includes 30 items, 18 of which from the Brief Psychiatric Rating Scale (BPRS), and 12 from the Psychopathology Rating Scale (PRS). The use of the PANSS led to the following conclusions: . the inter-rater reliability was quite satisfactory for the positive and the general psychopathology scales, however some problems remained with the inter-rater reliability of the negative scale; ?? seven factors emerged from factor analysis and the first four factors (positive, negative, excited and depressed) were retained and included in a four factor pyramidical model. Later, Kay himself introduced the Structured Clinical Interview for the PANSS (SCI-PANSS), and demonstrated a considerable increase in the inter-rater reliability of the negative scale. The multifactor pyramidical model of schizophrenia, developed by Kay and Savy, was afterwards extended by Lindstrom and Von Knorring, who described five factors: negative, positive, excited, anxious/depressive and cognitive; each of them was distributed to an angle of a hypothetical pyramid. The negative factor includes: motor retardation, lack of spontaneity, poor relationship, blunted affect, emotional withdrawal and passive social withdrawal. The positive factor includes: delusions, grandiosity, hallucinatory behaviour, and unusual thought content. The cognitive factor includes: disorientation, preoccupation, poor attention, conceptual disorganisation and difficulties in abstract thinking. The anxious/depressive factor includes: anxiety, depression, guilt feelings and somatic concerns. The excited factor includes: poor impulse control, hostility, excitement and uncooperativeness. It could be demonstrated that all these factors are sensitive to the action of the selective 5-HTz/D2 antagonists such as risperidone or zotepine that determine a direct action on the negative symptoms, but also indirect on the same symptoms through a preceding action on the positive and extrapyramidal symptoms. In our study 86 patients were selected by means of the PANSS and were followed during the hospitalisation with the SCI-PANSS. We propose to evaluate, through the use of the pyramidical model, whether: . the negative symptoms, i.e. the target of the new antipsychotic drugs, can be placed on the peak of the pyramid and therefore considered the dominant factor of schizophrenia, even if sometimes they are “hidden” compared to the others; on the contrary other factors can lie in the four angles of the base, as symbols of their essential contributions to diagnosis; . the modem therapy is effective because: a) has a direct action on the peak and on the four angles of the base, and b) has an additional effect on the “dominant” factor through the above-mentioned direct action on the four “subordinate” factors.