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Differences in the prevalence of psychosensory features among schizophrenic, schizoaffective, and manic patients
Differences in the Prevalence of Psychosensory Features Among Schizophrenic, Schizoaffective, and Manic Patients Nutan Atre-Vaidya and Michael Alan Taylor The purpose of the study was to test the sensitization m o d e l f o r m o o d disorder by comparing the prevalence of psychosensory features in bipolar, schizoaffectivemanic, and schizophrenic patients. We e v a l u a t e d 66 patients (13 schizophrenics, 13 schizoaffective bipolar types, and 40 bipolars) for the presence of psychosensory features and psychopathology. Schizoaffective
A
TEMPOROLIMBIC sensitization model was introduced by Post et al. 1,2 to explain the course of bipolar mood disorder. Sensitization of the nervous system is a phenomenon analogous to kindling. Although both phenomena involve repeated subthreshold stimulation of neurons, in kindling the stimulus is electrophysiologic, whereas in sensitization it is neurochemical. Repeated stimulation reduces the threshold, ultimately leading to autonomous seizures in kindling and permanent behavioral change in sensitization.1 Post and Weiss3 hypothesized that each mood disorder episode serves as a temporolimbic sensitizing stimulus for subsequent episodes. They proposed that (1) having an episode leaves neurobiologic residue that makes a patient more vulnerable to relapses, and (2) as sensitization occurs, the duration of wellness intervals progressively decreases while episode severity increases. The model explains the progressively severe and frequent relapses observed in the late states of bipolar mood disorder. Similarly, memory and learning deficits observed in bipolar mood disorder4-6 can also be explained by the sensitization model. Unfortunately, there are no documented specific clinical markers of sensitization of the temporolimbic system. However, some investigators7 propose that in temporal lobe epilepsy and in mood disorder, psychosensory features suggest neuronal irritability, and their presence in mood disorder indicates
manics had the highest prevalence of recent (F = 6.9(2,32), P = < . 0 0 1 ) a n d p a s t (F = 3.7(2,32), P = <.05) psychosensory features. We conclude t h a t
psychosensory features are markers of severity of affective rather than nonaffective psychosis. Copyright© 1997 by W.B. SaundersCompany
undedying temporolimbic sensitization.8These psychosensory features include sensory, emotional, and cognitive phenomena (e.g., perceptual distortions, brief intense euphoria or sadness, and forced thinking) that can be induced by electrical stimulation of the temporolimbic systems.9 These features are reported in bipolar patients,7,8,1° and several investigators studied them as predictors of treatment response in bipolar patients. 7,ram However, none investigated the potential of psychosensory features to predict the long-term prognosis of bipolar mood disorder. We 12 have demonstrated that in bipolar mood disorder, psychosensory features suggest a more severe illness because they are associated with hallucinations and cognitive deficits. However, the diagnostic specificity of this relationship has not been demonstrated. Since a sensitization hypothesis has not been proposed for other psychoses (e.g., schizophrenia), the specificity of psychosensory features in bipolar mood disorder would be important supporting evidence for the sensitization model. In this preliminary investigation, we assessed the presence of psychosensory features in schizophrenic, schizoaffectivebipolar type, and bipolar patients. We hypothesized that bipolar patients with more severe illness, i.e., hallucinations and delusions, will have the highest prevalence of psychosensory features and schizophrenic patients will not have many of these phenomena. METHOD
From the Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences'The Chicago Medical School, North Chicago; and the Veterans Affairs Medical Center, North Chicago, 1L. Address reprint requests to Nutan Atre-Vaidya, M.D., Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences~The Chicago Medical School, 3333 Green Bay Rd, North Chicago, IL 60064. Copyright © 1997 by W.B. Saunders Company 0010-440X/97/3802-0006503.00/0 88
Subjects We randomly recruited 66 patients from the mental health clinics of a Dean's Committee Veteran Affairs Medical Center. All were 18 years of age or older, spoke English, and provided informed consent. All met DSM-IV diagnostic criteria for either schizophrenia, bipolar disorder, or schizoaffective-manic disorder. Two research psychiatrists made consensus diagnoses based on information collected during a semistructured interview. One
ComprehensivePsychiatry,Vol. 38, No. 2 (March/April), 1997: pp 88-92
PSYCHOSENSORY FEATURES IN SCHIZOPHRENIC, SCHIZOAFFECTIVE, AND MANIC PATIENTS
psychiatrist assessed psychopathology using an instrument that includes screening and follow-up questions for major psychiatric disorder based on the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) 13 and the Schedule for Assessment of Positive (SAPS)]4 and Negative J5 Symptoms. The Scale for Assessment of Positive Symptoms was modified to include more items assessing affective features and specific thought disorders and additional items of symptom intensity and duration needed to make a DSM-III-R diagnosis (recent: schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], and schizophrenic
2.61 [3.25]). We initially rated each item as required by each instrument. At the time of analysis we receded all items, rating present as "2," questionable as "1," and absent as "0." We believed that this uniform receding was justified, since correlations between receded and full scores on all scales were greater than .9, except anhedonia, which was .86 (recent: schizoaffective 5.6 [5.% bipolar 2.64 [3.04], and schizophrenic 2.6] [3.25]). A second
psychiatrist assessed psychosensory features using another instrument, the Profile of Psychomotor Symptoms (POPS). 16 It assesses a wide range of epilepsy-like features, including sensory (e.g., dysmegalopsia), emotional (e.g., sudden transient euphoria), neurological (e.g., speech arrest), and interictal (e.g., viscosity) behaviors. We scored all items as present (2), questionable (1), or absent (0). For a psychosensory feature to be
present, a patient had to experience a symptom paroxysmally, with a sufficient intensity and frequency to be of concern to the patient or the family or to have affected the patient's functioning. If a patient experienced a symptom within the last 6 months, we considered it a recent symptom; otherwise, it was rated as a past symptom. We excluded features suggestive of classic psychopathology such as complete auditory hallucinations (recent-schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], and schizophrenic 2.61 [3.25]). A research assistant trained by one of the investigators (N.A.-V.) reviewed the charts to obtain information about alcohol and substance abuse. A subject was considered to have a positive history of alcohol and substance abuse if the symptoms were severe enough for the treating psychiatrist to make an additional diagnosis of alcohol and substance abuse or dependence. Details of this method are described elsewhere.E° Of 66 subjects, 13 met the criteria for schizophrenia, 13 for schizoaffective-bipolar type, and 40 for bipolar mood disorder. Table 1 lists the demographic information, including alcohol and substance abuse and treatment history, for all three diagnostic groups. Analysis of variance ([ANOVA] one-way) showed no significant group differences in demographic variables, history of psychosis, seizure, and drug and alcohol abuse, and treatment history.
RESULTS
We compared the three groups for the presence of psychosensory features and other psychopathology using ANOVA (one-way) followed by planned comparisons contrasting the individual groups (Table 2). Due to the large number of ANOVAs performed based on Bonferroni correction, we established a significance value of .004. For the planned comparisons, significance was established at .05. Instead of eliminating subjects with missing values, we chose to record missing values as
89
Table 1. Demographic Data for the Schizophrenic, Schizoaffective, and Manic Patients Variable
Schizophrenic Schizoaffective Manic (n = 13) (n = 13) (n = 40)
Age (yr) Mean SD
53.4
12.6
49.8 13.8
53.8 15.7
Gender(n) Male Female
13 0
12 1
37 3
Ethnicity (n) Euroamerican
10
11 2
32 7
African-American
3
A g e o f o n s e t (yr) Mean
25.6
5.7
27.3 6.3
31.5 14.0
Years of education Mean SD Drug and alcohol abuse (n)
11.0 3.0
13.1 1.6
13,4 2,5
SD
Present
6
Absent
7
Missing data
0
Family history of psychosis (n)
Present
Absent Missing data Treatment history In) Lithium
5 7 1 2
Anticonvulsants Multiple medications
8 3
Missing data
0
6 7 0
19 19 2
5 6 2
14 20 6
3 1 8 1
3 19 17 1
"questionable." Other investigators have demonstrated that this method of scoring is preferable to eliminating subjects with missing values.
Psychosensory Features Among the three groups, schizoaffective manics had the highest prevalence of both recent (F = 6.9(2,63), P < .001) and past (F = 3.7(2,63), P < .05) psychosensory features. We next compared individual groups using planned comparison tests. Compared with schizoaffective-bipolar type patients, bipolar patients had fewer psychosensory features (P < .05). Although bipolar patients reported fewer psychosensory features than schizophrenics, this difference was not statistically significant. Schizophrenics also had fewer psychosensory features than schizoaffectives (P < .05). In a previous study, we found a strong correlation between hallucinations and psychosensory features. We concluded that psychosensory features such as hallucinations suggest episode severity. A large number of the bipolar patients did not have
90
ATRE-VAIDYA AND TAYLOR
Table 2. Psychopathology Among the Three Diagnostic Groups Psychopathology Psychosensory features Recent Past Nonaffective positive features Hallucination Delusion Bizarre behavior Formal thought disorder Total SAPS score Negative features Affective flattening Anhedonie Avolition Alogia Total SANS score Affective features Present Past
Schizophrenic (n = 13)
Schizoaffective (n = 13)
Bipolar (n = 40)
F(2,63)
P
2.6 (3.25) 3.0 (3.8)
5.6 (5.2)* 7.3 (5.0)*
1.7 (2.3) 3.3 (4.9)
6.9 3.7
<.001 <.05
4.4 (3.3)* 4.2 (3.9)* 1.6 (2.1) 4.8 (5.5)* 1.0 (1.3)
4.4 (3.8)* 4.2 (3.3)* .46 (1.6) 1.6 (3.5) 1.6 (1.6)
1.4 (2.2) 1.9 (3.0) .15 (.48) 1.2 (2.7) 1.2 (1.5)
8.6 3.7 7.5 5.0 .42
<.001 <.05 <.001 <.01 .65
3.0 (4.1)* 5.7 (4.4) 2,3 (1.9)* 1.5 (2.5)* 3.9 (2.5)*
.57 (1.2) 3.4 (3.8) .82 (1.05) .3 (.6) 1.7 (1.9)
6.9 6.2 11.23 5.78 9.8
<.001 <.01 <.001 <.01 <.001
7,3 (7.0) 27.8 (3.2)*
6.3 (6.3) 27.5 (3.7)*
2.2 21.5
.12 <.001
2.76 7.6 2.5 .69 4.3
(3.19)* (3.5)* (1.4)* (.94) (2.4)*
2.8 (2.7) 20.2 (3.5)
*Denotes pair of groups significantly different at P < .05 level.
hallucinations. To determine whether the higher prevalence of psychosensory features in schizoaffectives was because they simply had more hallucinations than bipolars, we performed another ANOVA and included only bipolar patients who had hallucinations. This resulted in a substantial decrease in the bipolar sample size (n = 13). We found that compared with bipolar and schizophrenic patients, schizoaffectives still had the highest number of both past (schizoaffective 7.3 [5.0], bipolar 4.0 [4.8], and schizophrenic 3.8 [3.8]) and present (schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], schizophrenic 2.61 [3.25]) psychosensory features. Bipolar patients with hallucinations had more past psychosensory features than schizophrenics. However, none of these differences reached statistical significance (past, F = 3.13(2,40), P = NS; recent, F = 2.6(2,40), P = NS). Based on the distribution of psychosensory features among the groups (Fig 1B and C), it is unlikely that the failure to reach significance is due to a lack of power.
Other Psychopathology Both schizoaffective bipolars and schizophrenics had significantly more positive and negative symptoms than bipolars. Specifically, although the groups did not differ on total psychotic features (F = .4(2,63), P = NS), schizophrenics and schizoaffecrives had significantly more hallucinations than bipolars (F = 8.6(2,63), P < .001) but the two groups did not differ from each other. Bipolars had
significantly lower scores on total negative features (F = 9.8(2,63), P = < .001). Because the subjects were outpatients and mostly asymptomatic, we found that although schizophrenics had fewer current affective symptoms than the other two groups, differences among the three groups were not significant (F = 2.1(2,63), P = NS). As expected, both schizoaffectives and bipolars had significantly more past affective features than schizophrenics (F = 21.5(2,63), P < .001), but they did not differ significantly from each other. On planned comparisons, schizophrenics demonstrated more formal thought disorders and bizarre behaviors than schizoaffective manics (P < .05). Among negative features, schizophrenics had significantly more anhedonia (P < .05), but schizoaffectives had more alogia (P < .06). The two groups did not differ on measures of affective flattening, avolition, and total negative features. Compared with bipolars, schizophrenics had significantly more hallucinations, delusions, bizarre behavior, and formal thought disorder and all the negative features (P < .05) (except alogia), whereas schizoaffectives had significantly more hallucinations, delusions, and all the negative features (P < .05) (except anhedonia).
Psychosensory Features, Comorbidity, and TreatmentResponse To assess the association of medications and alcohol and substance abuse and the prevalence of
PSYCHOSENSORY FEATURES IN SCHIZOPHRENIC, SCHIZOAFFECTIVE, AND MANIC PATIENTS
91
psychosensory features, we further analyzed the data using analysis of covariance. After controlling for medications by using medication as the covariate, the results were virtually identical to those listed in Table 2, and the same was true when we used alcohol and drug abuse as a covariate. Thus, even after accounting for variance due to alcohol and substance abuse, as well as different medications, statistically significant differences among the three groups persisted.
A
12.oo
+i
10.o0
+ I
__+__
I +--+--4-
T __+_+-.-+
2.00
I +
.00
!
---
Schizophrenic
,,O~EROF CASBS."
13.00
I
+-----+
--+--
Schizoaffective
Bipolar with hallucination
13.00
17.00
18.00 +
B
DISCUSSION
We found that although some psychosensory features were reported by all three diagnostic groups, schizoaffective manics had a significantly higher prevalence of psychosensory features than schizophrenic and bipolar patients. This difference cannot be accounted for by the severity of psychosis alone. In a previous study, 8 we demonstrated that psychosensory features are associated with hallucinations and postulated that their presence suggests episode severity. However, if psychosensory features only indicate severity of psychosis, then their prevalence should be highest in the most severe psychoses. Yet in our sample, this was not the case. Schizophrenics and schizoaffectives differed only in the prevalence of psychosensory features and number of affective features, suggesting that the co-occurrence of psychosensory features has additional significance, i.e., psychosensory features are markers of severity of affective rather than nonaffective psychosis. This assumption has face validity, because in our sample we found that schizoaffectives had more psychosensory features than bipolars. Studies of schizoaffective manic patients have demonstrated that although it is a heterogenous disorder, a substantial number of these patients have a variant of bipolar mood disorder with a poorer prognosis than typical bipolar patients. 17,18 Dysfunction of the temporolimbic system could result in expression of psychosensory features in bipolar mood disorder, and sensitization would result in a higher prevalence of schizoaffective manics. Our findings are preliminary and our sample is small, nevertheless, our data support the hypothesis that psychosensory features may suggest an underlying sensitization process. It could be argued that the number of schizoaffectives we studied was too small to draw any specific conclusions. However,
12.00
+
-i +
i[
6.00
--+--
.00 !
+
+---+
+
I
Schizophrenic NUMBER OF CASES :
BipOlar with hallucination
Schizoaffective
13.00
17.00
13.00
18.00
C
12.00
--+--
6.00
+-+-+
+
+---+
Schizophrenic NUMBER OF CASTS :
13.00
--+
.
.
.
.
.
Schizoaffective
Bipolar with hallucination
13.00
17.00
Fig 1. Distribution among the 3 diagnostic groups of (A) hallucinations, (B) past p s y c h o s e n s o w features, and (C) recent psychosensory features. *Median.
92
ATRE-VAIDYA AND TAYLOR
differences b e t w e e n schizoaffectives and the other two subject groups were large despite the small sample size, and inspection of the distribution of psychosensory scores across groups (Fig 1) suggests that these relationships are unlikely to change with a larger sample. Based on our hypothesis, we also expected to see significant differences b e t w e e n schizophrenic and bipolar subjects. We previously demonstrated that subjects who experience more hallucinations also experience more psychosensory features. 8 Therefore, we thought that the failure to detect any significant differences was due to a less severely ill bipolar sample (this sample experienced a low n u m b e r of hallucinations). However, based on the distribution of the psychosensory features in schizo-
phrenics and those bipolars with hallucinations, it is unlikely that the differences b e t w e e n the two groups will be significant in a larger sample consisting of bipolars with hallucinations (Fig 1A). F u t u r e studies should compare schizoaffective manic and bipolar patients for the presence of psychosensory features and cognitive deficits and follow their course and prognosis. We w o u l d expect to see schizoaffectives with psychosensory features to also have more cognitive deficits, and a worse prognosis. Finally, it is also relevant to study psychosensory features role in predicting anticonvulsant response in schizoaffective and bipolar patients. Such studies are important steps in testing a theoretical model in clinical settings.
REFERENCES
1. Post RM, Rublnow DR, Ballenger JC. Conditioning sensitization and kindling: implications for course of affective illness. In: Post RM, Ballenger JC (eds): Neurobiology of Mood Disorders. Baltimore, MD: Williams & Wilkins, 1984:432-466. 2. Post RM. Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. Am J Psychiatry 1992;149:999-1010. 3. Post RM, Weiss SRB. Kindling and manic-depressive illness. In: Bolwig TG, Trimble MR (eds): The Clinical Relevance of Kindling. New York, NY: Wiley, 1989:209-230. 4. Landro NI, Orbeck AL, Rund BR. Memory functioning in chronic and nonchronic schizophrenics, affectively disturbed patients and normal controls. Schizophr Res 1993;10:85-92. 5. Gruzelier J, Seymour K, Wilson L, Jolley A, Hirsch S. Impairment on neuropsychologic tests of temporohippocampal and frontohippocampal functions and word fluency in remitting schizophrenia and affective disorders. Arch Gen Psychiatry 1988;45:623-629. 6. Post RM, Savard RJ, Rey AC. Halstead-Reitan Category Test in bipolar and unipolar affective disorders. J Nerv Ment Dis 1980;168:297-304. 7. Hayes SG, Goldsmith BK. Psychosensory symptomatology in anticonvulsant responsive psychiatric illness. Ann Clin Psychiatry 1991;3:27-35. 8. Atre-Vaidya N, Taylor MA, Jampala VC, Srinivasaraghavan J. Psychosensory features in mood disorder: a preliminary report. Compr Psychiatry 1994;35:286-289. 9. Halgren E, Walter RD, Cherlow DG, Crandall PH. Mental
phenomena evoked by electrical stimulation of the human hippocampal formation and anaygdala. Brain 1978;101:83-117. 10. Post RM, Silberman EK. Transient sensory cognitive and affective phenomena in affective illness. Br J Psychiatry 1985; 146:81-89. l 1. McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI, Morris D. Correlates of manic response to valproate. Psychopharmacol Bull 1991;27:127-133. 12. Atre-Vaidya N, Taylor MA, Seidenberg M, Perrine A. Cognitive deficits and psychosensory features in bipolar mood disorder. In preparation. 13. Spitzer RL, Endicott J. Schedule for Affective Disorders and Schizophrenia. Ed. 3. Lifetime Version. New York, NY: New York State Psychiatric Institute, 1979. 14. Andreasen N. Scale for Assessment of Positive Symptoms. Iowa City, IA: University of Iowa, 1984. 15. Andreasen N. Scale for Assessment of Negative Symptoms. Iowa City, IA: University of Iowa, 1984. 16. Jampala VC, Atre-Vaidya N, Taylor MA, Schrift MJ, Srinivasaraghavan J, Sierles FS. A profile of psychomotor symptoms (POPS) in psychiatric patients. Neuropsychiatry Neuropsychol Behav Neurol 1992; 5:15-19. 17. Taylor MA, Amir N. The problem of missing clinical data for research in psychopathology--some solution guidelines. J Nerv Ment Dis 1994;22-229. 18. Levinson DF, Levitt MEM. Schizoaffective mania reconsidered. Am J Psychiatry 1987;144:415-426. 19. Levitt J, Tsuang L. The heterogeneity of schizoaffective disorder: implications for treatment. Am J Psychiatry 1988;145:8.
A
TEMPOROLIMBIC sensitization model was introduced by Post et al. 1,2 to explain the course of bipolar mood disorder. Sensitization of the nervous system is a phenomenon analogous to kindling. Although both phenomena involve repeated subthreshold stimulation of neurons, in kindling the stimulus is electrophysiologic, whereas in sensitization it is neurochemical. Repeated stimulation reduces the threshold, ultimately leading to autonomous seizures in kindling and permanent behavioral change in sensitization.1 Post and Weiss3 hypothesized that each mood disorder episode serves as a temporolimbic sensitizing stimulus for subsequent episodes. They proposed that (1) having an episode leaves neurobiologic residue that makes a patient more vulnerable to relapses, and (2) as sensitization occurs, the duration of wellness intervals progressively decreases while episode severity increases. The model explains the progressively severe and frequent relapses observed in the late states of bipolar mood disorder. Similarly, memory and learning deficits observed in bipolar mood disorder4-6 can also be explained by the sensitization model. Unfortunately, there are no documented specific clinical markers of sensitization of the temporolimbic system. However, some investigators7 propose that in temporal lobe epilepsy and in mood disorder, psychosensory features suggest neuronal irritability, and their presence in mood disorder indicates
manics had the highest prevalence of recent (F = 6.9(2,32), P = < . 0 0 1 ) a n d p a s t (F = 3.7(2,32), P = <.05) psychosensory features. We conclude t h a t
psychosensory features are markers of severity of affective rather than nonaffective psychosis. Copyright© 1997 by W.B. SaundersCompany
undedying temporolimbic sensitization.8These psychosensory features include sensory, emotional, and cognitive phenomena (e.g., perceptual distortions, brief intense euphoria or sadness, and forced thinking) that can be induced by electrical stimulation of the temporolimbic systems.9 These features are reported in bipolar patients,7,8,1° and several investigators studied them as predictors of treatment response in bipolar patients. 7,ram However, none investigated the potential of psychosensory features to predict the long-term prognosis of bipolar mood disorder. We 12 have demonstrated that in bipolar mood disorder, psychosensory features suggest a more severe illness because they are associated with hallucinations and cognitive deficits. However, the diagnostic specificity of this relationship has not been demonstrated. Since a sensitization hypothesis has not been proposed for other psychoses (e.g., schizophrenia), the specificity of psychosensory features in bipolar mood disorder would be important supporting evidence for the sensitization model. In this preliminary investigation, we assessed the presence of psychosensory features in schizophrenic, schizoaffectivebipolar type, and bipolar patients. We hypothesized that bipolar patients with more severe illness, i.e., hallucinations and delusions, will have the highest prevalence of psychosensory features and schizophrenic patients will not have many of these phenomena. METHOD
From the Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences'The Chicago Medical School, North Chicago; and the Veterans Affairs Medical Center, North Chicago, 1L. Address reprint requests to Nutan Atre-Vaidya, M.D., Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences~The Chicago Medical School, 3333 Green Bay Rd, North Chicago, IL 60064. Copyright © 1997 by W.B. Saunders Company 0010-440X/97/3802-0006503.00/0 88
Subjects We randomly recruited 66 patients from the mental health clinics of a Dean's Committee Veteran Affairs Medical Center. All were 18 years of age or older, spoke English, and provided informed consent. All met DSM-IV diagnostic criteria for either schizophrenia, bipolar disorder, or schizoaffective-manic disorder. Two research psychiatrists made consensus diagnoses based on information collected during a semistructured interview. One
ComprehensivePsychiatry,Vol. 38, No. 2 (March/April), 1997: pp 88-92
PSYCHOSENSORY FEATURES IN SCHIZOPHRENIC, SCHIZOAFFECTIVE, AND MANIC PATIENTS
psychiatrist assessed psychopathology using an instrument that includes screening and follow-up questions for major psychiatric disorder based on the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) 13 and the Schedule for Assessment of Positive (SAPS)]4 and Negative J5 Symptoms. The Scale for Assessment of Positive Symptoms was modified to include more items assessing affective features and specific thought disorders and additional items of symptom intensity and duration needed to make a DSM-III-R diagnosis (recent: schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], and schizophrenic
2.61 [3.25]). We initially rated each item as required by each instrument. At the time of analysis we receded all items, rating present as "2," questionable as "1," and absent as "0." We believed that this uniform receding was justified, since correlations between receded and full scores on all scales were greater than .9, except anhedonia, which was .86 (recent: schizoaffective 5.6 [5.% bipolar 2.64 [3.04], and schizophrenic 2.6] [3.25]). A second
psychiatrist assessed psychosensory features using another instrument, the Profile of Psychomotor Symptoms (POPS). 16 It assesses a wide range of epilepsy-like features, including sensory (e.g., dysmegalopsia), emotional (e.g., sudden transient euphoria), neurological (e.g., speech arrest), and interictal (e.g., viscosity) behaviors. We scored all items as present (2), questionable (1), or absent (0). For a psychosensory feature to be
present, a patient had to experience a symptom paroxysmally, with a sufficient intensity and frequency to be of concern to the patient or the family or to have affected the patient's functioning. If a patient experienced a symptom within the last 6 months, we considered it a recent symptom; otherwise, it was rated as a past symptom. We excluded features suggestive of classic psychopathology such as complete auditory hallucinations (recent-schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], and schizophrenic 2.61 [3.25]). A research assistant trained by one of the investigators (N.A.-V.) reviewed the charts to obtain information about alcohol and substance abuse. A subject was considered to have a positive history of alcohol and substance abuse if the symptoms were severe enough for the treating psychiatrist to make an additional diagnosis of alcohol and substance abuse or dependence. Details of this method are described elsewhere.E° Of 66 subjects, 13 met the criteria for schizophrenia, 13 for schizoaffective-bipolar type, and 40 for bipolar mood disorder. Table 1 lists the demographic information, including alcohol and substance abuse and treatment history, for all three diagnostic groups. Analysis of variance ([ANOVA] one-way) showed no significant group differences in demographic variables, history of psychosis, seizure, and drug and alcohol abuse, and treatment history.
RESULTS
We compared the three groups for the presence of psychosensory features and other psychopathology using ANOVA (one-way) followed by planned comparisons contrasting the individual groups (Table 2). Due to the large number of ANOVAs performed based on Bonferroni correction, we established a significance value of .004. For the planned comparisons, significance was established at .05. Instead of eliminating subjects with missing values, we chose to record missing values as
89
Table 1. Demographic Data for the Schizophrenic, Schizoaffective, and Manic Patients Variable
Schizophrenic Schizoaffective Manic (n = 13) (n = 13) (n = 40)
Age (yr) Mean SD
53.4
12.6
49.8 13.8
53.8 15.7
Gender(n) Male Female
13 0
12 1
37 3
Ethnicity (n) Euroamerican
10
11 2
32 7
African-American
3
A g e o f o n s e t (yr) Mean
25.6
5.7
27.3 6.3
31.5 14.0
Years of education Mean SD Drug and alcohol abuse (n)
11.0 3.0
13.1 1.6
13,4 2,5
SD
Present
6
Absent
7
Missing data
0
Family history of psychosis (n)
Present
Absent Missing data Treatment history In) Lithium
5 7 1 2
Anticonvulsants Multiple medications
8 3
Missing data
0
6 7 0
19 19 2
5 6 2
14 20 6
3 1 8 1
3 19 17 1
"questionable." Other investigators have demonstrated that this method of scoring is preferable to eliminating subjects with missing values.
Psychosensory Features Among the three groups, schizoaffective manics had the highest prevalence of both recent (F = 6.9(2,63), P < .001) and past (F = 3.7(2,63), P < .05) psychosensory features. We next compared individual groups using planned comparison tests. Compared with schizoaffective-bipolar type patients, bipolar patients had fewer psychosensory features (P < .05). Although bipolar patients reported fewer psychosensory features than schizophrenics, this difference was not statistically significant. Schizophrenics also had fewer psychosensory features than schizoaffectives (P < .05). In a previous study, we found a strong correlation between hallucinations and psychosensory features. We concluded that psychosensory features such as hallucinations suggest episode severity. A large number of the bipolar patients did not have
90
ATRE-VAIDYA AND TAYLOR
Table 2. Psychopathology Among the Three Diagnostic Groups Psychopathology Psychosensory features Recent Past Nonaffective positive features Hallucination Delusion Bizarre behavior Formal thought disorder Total SAPS score Negative features Affective flattening Anhedonie Avolition Alogia Total SANS score Affective features Present Past
Schizophrenic (n = 13)
Schizoaffective (n = 13)
Bipolar (n = 40)
F(2,63)
P
2.6 (3.25) 3.0 (3.8)
5.6 (5.2)* 7.3 (5.0)*
1.7 (2.3) 3.3 (4.9)
6.9 3.7
<.001 <.05
4.4 (3.3)* 4.2 (3.9)* 1.6 (2.1) 4.8 (5.5)* 1.0 (1.3)
4.4 (3.8)* 4.2 (3.3)* .46 (1.6) 1.6 (3.5) 1.6 (1.6)
1.4 (2.2) 1.9 (3.0) .15 (.48) 1.2 (2.7) 1.2 (1.5)
8.6 3.7 7.5 5.0 .42
<.001 <.05 <.001 <.01 .65
3.0 (4.1)* 5.7 (4.4) 2,3 (1.9)* 1.5 (2.5)* 3.9 (2.5)*
.57 (1.2) 3.4 (3.8) .82 (1.05) .3 (.6) 1.7 (1.9)
6.9 6.2 11.23 5.78 9.8
<.001 <.01 <.001 <.01 <.001
7,3 (7.0) 27.8 (3.2)*
6.3 (6.3) 27.5 (3.7)*
2.2 21.5
.12 <.001
2.76 7.6 2.5 .69 4.3
(3.19)* (3.5)* (1.4)* (.94) (2.4)*
2.8 (2.7) 20.2 (3.5)
*Denotes pair of groups significantly different at P < .05 level.
hallucinations. To determine whether the higher prevalence of psychosensory features in schizoaffectives was because they simply had more hallucinations than bipolars, we performed another ANOVA and included only bipolar patients who had hallucinations. This resulted in a substantial decrease in the bipolar sample size (n = 13). We found that compared with bipolar and schizophrenic patients, schizoaffectives still had the highest number of both past (schizoaffective 7.3 [5.0], bipolar 4.0 [4.8], and schizophrenic 3.8 [3.8]) and present (schizoaffective 5.6 [5.2], bipolar 2.64 [3.04], schizophrenic 2.61 [3.25]) psychosensory features. Bipolar patients with hallucinations had more past psychosensory features than schizophrenics. However, none of these differences reached statistical significance (past, F = 3.13(2,40), P = NS; recent, F = 2.6(2,40), P = NS). Based on the distribution of psychosensory features among the groups (Fig 1B and C), it is unlikely that the failure to reach significance is due to a lack of power.
Other Psychopathology Both schizoaffective bipolars and schizophrenics had significantly more positive and negative symptoms than bipolars. Specifically, although the groups did not differ on total psychotic features (F = .4(2,63), P = NS), schizophrenics and schizoaffecrives had significantly more hallucinations than bipolars (F = 8.6(2,63), P < .001) but the two groups did not differ from each other. Bipolars had
significantly lower scores on total negative features (F = 9.8(2,63), P = < .001). Because the subjects were outpatients and mostly asymptomatic, we found that although schizophrenics had fewer current affective symptoms than the other two groups, differences among the three groups were not significant (F = 2.1(2,63), P = NS). As expected, both schizoaffectives and bipolars had significantly more past affective features than schizophrenics (F = 21.5(2,63), P < .001), but they did not differ significantly from each other. On planned comparisons, schizophrenics demonstrated more formal thought disorders and bizarre behaviors than schizoaffective manics (P < .05). Among negative features, schizophrenics had significantly more anhedonia (P < .05), but schizoaffectives had more alogia (P < .06). The two groups did not differ on measures of affective flattening, avolition, and total negative features. Compared with bipolars, schizophrenics had significantly more hallucinations, delusions, bizarre behavior, and formal thought disorder and all the negative features (P < .05) (except alogia), whereas schizoaffectives had significantly more hallucinations, delusions, and all the negative features (P < .05) (except anhedonia).
Psychosensory Features, Comorbidity, and TreatmentResponse To assess the association of medications and alcohol and substance abuse and the prevalence of
PSYCHOSENSORY FEATURES IN SCHIZOPHRENIC, SCHIZOAFFECTIVE, AND MANIC PATIENTS
91
psychosensory features, we further analyzed the data using analysis of covariance. After controlling for medications by using medication as the covariate, the results were virtually identical to those listed in Table 2, and the same was true when we used alcohol and drug abuse as a covariate. Thus, even after accounting for variance due to alcohol and substance abuse, as well as different medications, statistically significant differences among the three groups persisted.
A
12.oo
+i
10.o0
+ I
__+__
I +--+--4-
T __+_+-.-+
2.00
I +
.00
!
---
Schizophrenic
,,O~EROF CASBS."
13.00
I
+-----+
--+--
Schizoaffective
Bipolar with hallucination
13.00
17.00
18.00 +
B
DISCUSSION
We found that although some psychosensory features were reported by all three diagnostic groups, schizoaffective manics had a significantly higher prevalence of psychosensory features than schizophrenic and bipolar patients. This difference cannot be accounted for by the severity of psychosis alone. In a previous study, 8 we demonstrated that psychosensory features are associated with hallucinations and postulated that their presence suggests episode severity. However, if psychosensory features only indicate severity of psychosis, then their prevalence should be highest in the most severe psychoses. Yet in our sample, this was not the case. Schizophrenics and schizoaffectives differed only in the prevalence of psychosensory features and number of affective features, suggesting that the co-occurrence of psychosensory features has additional significance, i.e., psychosensory features are markers of severity of affective rather than nonaffective psychosis. This assumption has face validity, because in our sample we found that schizoaffectives had more psychosensory features than bipolars. Studies of schizoaffective manic patients have demonstrated that although it is a heterogenous disorder, a substantial number of these patients have a variant of bipolar mood disorder with a poorer prognosis than typical bipolar patients. 17,18 Dysfunction of the temporolimbic system could result in expression of psychosensory features in bipolar mood disorder, and sensitization would result in a higher prevalence of schizoaffective manics. Our findings are preliminary and our sample is small, nevertheless, our data support the hypothesis that psychosensory features may suggest an underlying sensitization process. It could be argued that the number of schizoaffectives we studied was too small to draw any specific conclusions. However,
12.00
+
-i +
i[
6.00
--+--
.00 !
+
+---+
+
I
Schizophrenic NUMBER OF CASES :
BipOlar with hallucination
Schizoaffective
13.00
17.00
13.00
18.00
C
12.00
--+--
6.00
+-+-+
+
+---+
Schizophrenic NUMBER OF CASTS :
13.00
--+
.
.
.
.
.
Schizoaffective
Bipolar with hallucination
13.00
17.00
Fig 1. Distribution among the 3 diagnostic groups of (A) hallucinations, (B) past p s y c h o s e n s o w features, and (C) recent psychosensory features. *Median.
92
ATRE-VAIDYA AND TAYLOR
differences b e t w e e n schizoaffectives and the other two subject groups were large despite the small sample size, and inspection of the distribution of psychosensory scores across groups (Fig 1) suggests that these relationships are unlikely to change with a larger sample. Based on our hypothesis, we also expected to see significant differences b e t w e e n schizophrenic and bipolar subjects. We previously demonstrated that subjects who experience more hallucinations also experience more psychosensory features. 8 Therefore, we thought that the failure to detect any significant differences was due to a less severely ill bipolar sample (this sample experienced a low n u m b e r of hallucinations). However, based on the distribution of the psychosensory features in schizo-
phrenics and those bipolars with hallucinations, it is unlikely that the differences b e t w e e n the two groups will be significant in a larger sample consisting of bipolars with hallucinations (Fig 1A). F u t u r e studies should compare schizoaffective manic and bipolar patients for the presence of psychosensory features and cognitive deficits and follow their course and prognosis. We w o u l d expect to see schizoaffectives with psychosensory features to also have more cognitive deficits, and a worse prognosis. Finally, it is also relevant to study psychosensory features role in predicting anticonvulsant response in schizoaffective and bipolar patients. Such studies are important steps in testing a theoretical model in clinical settings.
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