عوامل روانی در اختلالات عاطفی اپیزود اول و روانی غیرعاطفی

Background Since the onset, prevalence, and course of specific psychopathological features rarely have been analyzed simultaneously from the start of dissimilar psychotic illnesses, we compared symptom-clusters in first-episode DSM-IV affective and non-affective psychotic disorders. Methods Subjects (N = 377) from the McLean–Harvard First Episode Project hospitalized for first-lifetime primary psychotic illnesses were followed prospectively for 2 years to verify stable DSM-IV diagnoses. We ascertained initial symptoms from baseline SCID and clinical assessments, applying AMDP and Bonn psychopathology schemes systematically to describe a broad range of features. Final consensus diagnoses were based on intake and follow-up SCID assessments, family interviews, and medical records. Factor-analytic methods defined first-episode symptom-clusters (Factors), and multiple-regression modeling related identified factors to initial DSM-IV diagnoses and to later categories (affective, non-affective, or schizoaffective disorders). Results Psychopathological features were accommodated by four factors: I represented mania with psychosis; II a mixed depressive-agitated state; III an excited-hallucinatory-delusional state; IV a disorganized-catatonic-autistic state. Each factor was associated with characteristic prodromal symptoms. Factors I and III associated with DSM-IV mania, II with major depression or bipolar mixed-state, III negatively with delusional disorder, IV with major depression and negatively with mania. Factors I and II predicted later affective diagnoses; absence of Factor I features predicted non-affective diagnoses, and no Factor predicted later schizoaffective diagnoses. Conclusion The findings contribute to descriptive categorizations of psychopathology from onset of dissimilar psychotic illnesses. This approach was effective in identifying and subtyping affective psychotic disorders early in their clinical evolution, but non-affective and schizoaffective conditions appear to be more complex and unstable.

The psychopathological and nosological constructs of primary psychotic illnesses have undergone intense theoretical debate since the origins of clinical psychiatry (Baethge et al., 2003 and Trede et al., 2005). Current taxonomies (WHO, 1992 and APA, 2000) use a categorical-hierarchical scheme to diagnose and subtype psychotic disorders, conceptually based on the Kraepelinian dichotomy between schizophrenia-like psychotic versus major affective disorders with psychotic features ( Trede et al., 2005). Alternative approaches include searching for pathognomonic features ( Bleuler, 1950 and Schneider, 1959) or attending to psychopathological dimensions ( Crow, 1980 and Liddle, 1987), with less concern about diagnostic categorization. However, such a dimensional approach has focused largely on defining schizophrenia, with less effort to distinguish among disorders with psychotic features. Lack of compelling support for either categorical or dimensional models has encouraged searching for links between etiology and phenomenology ( Tsuang et al., 1990), or an emphasis on defining domains of psychopathology that might relate to particular pathophysiological or genetic disturbances ( Buchanan and Carpenter, 1994, Flaum et al., 1995, Sabri et al., 1997, Crow, 1998, Serretti et al., 2000 and Alfimova and Uvarova, 2002), as well as defining external validators, such as family history, demographic or historical features, longitudinal course, or treatment effects ( Johnstone and Frith, 1996 and Pavuluri et al., 2004). Despite efforts to develop alternative methods of defining disorders, standard psychiatric diagnostic systems (WHO, 1992 and APA, 2000) continue to conceive of primary non-affective and affective psychotic disorders as discrete syndromes based on distinct symptom structures, courses, and outcomes. For better or worse, in the continued absence of etiologic, pathophysiological, or genetic criteria, early 21st-century psychiatric nosology remains dependent on descriptive clinical criteria, despite considerable overlap of psychopathological features and common intermediate syndromal types recognized at least since Kraepelin (Pope and Lipinski, 1978 and Trede et al., 2005). We propose that psychiatric nosology has remained insufficiently sensitive to the heterogeneity among individual and groups of psychotic disorder cases. This limitation and an overwhelmingly descriptive approach, probably have limited progress in both clinical and biological studies (McGorry et al., 1990 and Cuesta and Peralta, 2001). Comparing affective vs. non-affective psychotic syndromes, and studying the evolution of their psychopathological patterns from illness-onset are key elements of research on psychosis constructs (Arndt et al., 1995, McGorry et al., 1998 and Cuesta et al., 2003). Modern multivariate statistical methods provide new approaches to identifying clinical typologies (Manton et al., 1994 and Kendler et al., 1998) and developing dimensional models within syndromal categories (Van Os et al., 1996, Van Os et al., 1999, Serretti et al., 1996, McGorry et al., 1998 and Cuesta et al., 2003). At the very least, further progress in differentiating psychotic disorders requires simultaneous consideration of broad groups of patients with psychotic features, close investigation of individuals early in the evolution of their illnesses, and a longitudinal-ontogenic perspective based on long-term follow-up, with due regard to artifacts associated with long-term illness and disability, as well as effects of treatment and institutionalization (McGorry et al., 1998, Tohen et al., 2003 and Meagher et al., 2004). In response to these requirements, we report on initial exploration of symptom structure in a large and clinically heterogeneous sample of first-episode psychotic patients, using modern factor-analytical techniques, exploring the longitudinal evolution of symptom patterns, and comparing initial symptom-clusters to secure DSM-IV diagnoses established over time.

Psychopathological symptoms observed in 377 first-episode patients with a broad range of DSM-IV psychotic disorder diagnoses were found to form four discrete clusters (Factors) defined by factor analysis. Prodromal symptoms were strongly correlated with three Factors (I–III) defined at a first-lifetime syndromal illness (pure mania with psychosis, excited-depressive mixed-state, and an excited-delusional-hallucinatory state), with a striking disparity between prodromal and syndromal symptoms with Factor IV (disorganized-catatonic state). The latter disparity might reflect the intrinsically polymorphous nature of catatonia and its tendency to follow a recurring course with alternation of inconsistent features. Potential diagnostic and prognostic value of early symptom patterns was suggested by strong associations of Factor-I with bipolar-I mania at index first hospitalization and with the group of DSM-IV affective disorders with psychotic features, diagnostically based on all information assembled during two years of follow-up assessments. Factor-II associated strongly with major depression with psychotic features and with bipolar-I mixed-state at intake and with affective disorders at follow-up. We found that relatively high individual scores on Factors I and II were associated with particularly stable diagnoses during prospective follow-up. Also, Factor-IV was associated with the diagnosis of major depression with psychotic features at baseline, whereas Factor-III was associated with bipolar-I mania. Yet, neither Factor-III nor -IV helped to distinguish between non-affective and affective psychotic disorders. Schizoaffective diagnoses emerged only during long-term follow-up and were uncorrelated with any of the four symptom-cluster Factors. Limitations of this study include moderate and unbalanced numbers of subjects with specific DSM-IV disorders, particularly among the less common non-affective psychotic disorders. In addition, the symptom characterizations, though carried out without knowledge of initial or final diagnoses, were derived retrospectively from clinical records rather than by direct examinations at various times of interest. The large number of psychopathological features considered versus limited numbers of subjects per diagnostic category presented a major challenge to statistical power. We attempted to manage this challenge by use of a stepwise factor analytic strategy, and limiting symptomatic features to those with relatively high prevalence and involving substantial numbers of cases. In addition, some secondary analyses involved multiple comparisons (e.g., see Table 2, Table 3 and Table 5) without adjustment of p-values. Overall, the present findings suggest that: (a) a dimensional approach to diagnosis of psychotic disorders, based on symptom profiles considered longitudinally, might advantageously anticipate illness course, treatment-response and outcome, and might even serve as an innovative basis for future biological studies; (b) the approach appears to help in distinguishing affective vs. non-affective disorders earlier in their evolution; (c) moreover, it clearly distinguished future pure manic and mixed manic-depressive disorders in prodromal phases prior to their first lifetime syndromal expression; (d) considering co-morbidities as well as symptomatic features may further support early diagnosis; (e) in general, psychopathology may be more valuable diagnostically with affective than with non-affective and schizoaffective psychotic disorders, which appear to be much more heterogeneous and pathoplastic early in their clinical evolution.