Tara Haelle

Psychoticlike symptoms were not positively associated with violent recidivism in a population of male adolescents, even when these symptoms were comorbid with substance abuse disorders, a study has shown.

In addition, having paranoid delusions and threat/control override delusions was actually linked to a lower risk of reoffending with violence, reported Olivier F. Colins, Ph.D., of Leiden (the Netherlands) University Medical Center and his associates in the June issue of the Journal of Nervous and Mental Disease.

"By identifying detained youths with [paranoid delusions] or [threat/control override delusions], clinicians are likely to identify youths with a low risk for future violent crimes," Dr. Colins and his associates wrote (J. Nerv. Ment. Dis. 2013;201:478-83).

The researchers assessed 224 male adolescents, aged 12-17, with the Diagnostic Interview Schedule for Children (DISC-IV), specifically analyzing the results of the schizophrenia module and the substance use disorder module. The boys had all been recently detained at youth detention centers in Flanders, Belgium, and were recruited between January 2005 and February 2007.

All boys were of Belgian origin except 22.3% who were of Moroccan origin. All of them had been placed in detention for at least 1 month. A quarter (25%) of the boys had a criminal history of violence. Violent recidivism included arrests, after the initial clinical interviews, for murder, manslaughter, assault, sexual offenses, and theft with violence.

The schizophrenia module of the DISC-IV investigates 22 psychoticlike symptoms within the past year that are grouped into four subsets: paranoid delusions, nonparanoid delusions, hallucinations, and threat/control override delusions. The substance use disorder module measured the existence of alcohol use disorder, marijuana use disorder, and other substance abuse disorders, including cocaine and amphetamines.

A total of 79% of the boys had at least one psychoticlike symptom, including 43% with at least one hallucination, 67% with at least one paranoid delusion, 26% with at least one nonparanoid delusion, and 53% with at least one threat/control override delusion. Substance abuse disorders were evenly distributed: 26% of the boys had no substance abuse disorder, 23% had one, 24% had two, and 27% had three. Just over half the boys (54%) had substance use disorder, 64% had marijuana use disorder, and a third (33%) had other substance use disorders.

After a mean follow-up of 1,219 days, two-thirds (66%) of the boys were rearrested for violent crimes during their time at risk, defined as the number of days between the DISC-IV and Feb. 1, 2009, minus the participants’ days in detention.

In both the univariate and multivariate analyses, odds ratios for all psychoticlike symptoms and total substance use disorders were not significant for predicting violent recidivism or violent rearrest frequency – except total delusions, paranoid delusions, and threat/control override delusions, which showed several significant negative associations. In the univariate analysis for violent rearrest frequency, total delusions had an odds ratio of 0.84 (CI, 0.73-0.98; P = .03), paranoid delusions had an OR of 0.78 (CI, 0.63-0.96; P = .02), and threat/control override delusions had an OR of 0.76 (CI, 0.61-0.95; P = .01).

In the multivariate analysis, the number of threat/control override delusions was negatively associated with violent recidivism even after the investigators controlled for hallucinations and the number of substance use disorders. The negative association for total delusions and threat/control override delusions for violent rearrest frequency also remained in the multivariate analysis even after hallucinations and the number of substance use disorders were controlled for.

Aside from the different psychoticlike symptoms and substance use disorders, the confounders in the multivariate analysis included age, origin, and parental/caretaker’s occupation.

"The absence of a positive relation between [psychoticlike symptoms] and violent recidivism may simply suggest that detained male adolescents with psychoticlike symptoms do not have a higher risk for future violent crimes than detained male adolescents without psychoticlike symptoms and, consequently, that findings from community samples are not generalizable to juvenile justice settings," the authors wrote. They suggested that the negative association between violent recidivism and delusions might result from fewer opportunities for interpersonal violence if delusional individuals are less inclined to engage in interpersonal interactions in the first place.

The authors noted that larger populations would be needed to assess alcohol, marijuana, and other substance use disorders as independent predictors. They also noted the study’s limitation of not accounting for the clinical significance, frequency, or intensity of any psychoticlike symptoms. The study also did not assess actual schizophrenia diagnoses; other symptoms of schizophrenia might independently increase the risk of violence.

The authors reported no relevant financial disclosures.

Psychoticlike symptoms were not positively associated with violent recidivism in a population of male adolescents, even when these symptoms were comorbid with substance abuse disorders, a study has shown.

In addition, having paranoid delusions and threat/control override delusions was actually linked to a lower risk of reoffending with violence, reported Olivier F. Colins, Ph.D., of Leiden (the Netherlands) University Medical Center and his associates in the June issue of the Journal of Nervous and Mental Disease.

"By identifying detained youths with [paranoid delusions] or [threat/control override delusions], clinicians are likely to identify youths with a low risk for future violent crimes," Dr. Colins and his associates wrote (J. Nerv. Ment. Dis. 2013;201:478-83).

The researchers assessed 224 male adolescents, aged 12-17, with the Diagnostic Interview Schedule for Children (DISC-IV), specifically analyzing the results of the schizophrenia module and the substance use disorder module. The boys had all been recently detained at youth detention centers in Flanders, Belgium, and were recruited between January 2005 and February 2007.

All boys were of Belgian origin except 22.3% who were of Moroccan origin. All of them had been placed in detention for at least 1 month. A quarter (25%) of the boys had a criminal history of violence. Violent recidivism included arrests, after the initial clinical interviews, for murder, manslaughter, assault, sexual offenses, and theft with violence.

The schizophrenia module of the DISC-IV investigates 22 psychoticlike symptoms within the past year that are grouped into four subsets: paranoid delusions, nonparanoid delusions, hallucinations, and threat/control override delusions. The substance use disorder module measured the existence of alcohol use disorder, marijuana use disorder, and other substance abuse disorders, including cocaine and amphetamines.

A total of 79% of the boys had at least one psychoticlike symptom, including 43% with at least one hallucination, 67% with at least one paranoid delusion, 26% with at least one nonparanoid delusion, and 53% with at least one threat/control override delusion. Substance abuse disorders were evenly distributed: 26% of the boys had no substance abuse disorder, 23% had one, 24% had two, and 27% had three. Just over half the boys (54%) had substance use disorder, 64% had marijuana use disorder, and a third (33%) had other substance use disorders.

After a mean follow-up of 1,219 days, two-thirds (66%) of the boys were rearrested for violent crimes during their time at risk, defined as the number of days between the DISC-IV and Feb. 1, 2009, minus the participants’ days in detention.

In both the univariate and multivariate analyses, odds ratios for all psychoticlike symptoms and total substance use disorders were not significant for predicting violent recidivism or violent rearrest frequency – except total delusions, paranoid delusions, and threat/control override delusions, which showed several significant negative associations. In the univariate analysis for violent rearrest frequency, total delusions had an odds ratio of 0.84 (CI, 0.73-0.98; P = .03), paranoid delusions had an OR of 0.78 (CI, 0.63-0.96; P = .02), and threat/control override delusions had an OR of 0.76 (CI, 0.61-0.95; P = .01).

In the multivariate analysis, the number of threat/control override delusions was negatively associated with violent recidivism even after the investigators controlled for hallucinations and the number of substance use disorders. The negative association for total delusions and threat/control override delusions for violent rearrest frequency also remained in the multivariate analysis even after hallucinations and the number of substance use disorders were controlled for.

Aside from the different psychoticlike symptoms and substance use disorders, the confounders in the multivariate analysis included age, origin, and parental/caretaker’s occupation.

"The absence of a positive relation between [psychoticlike symptoms] and violent recidivism may simply suggest that detained male adolescents with psychoticlike symptoms do not have a higher risk for future violent crimes than detained male adolescents without psychoticlike symptoms and, consequently, that findings from community samples are not generalizable to juvenile justice settings," the authors wrote. They suggested that the negative association between violent recidivism and delusions might result from fewer opportunities for interpersonal violence if delusional individuals are less inclined to engage in interpersonal interactions in the first place.

The authors noted that larger populations would be needed to assess alcohol, marijuana, and other substance use disorders as independent predictors. They also noted the study’s limitation of not accounting for the clinical significance, frequency, or intensity of any psychoticlike symptoms. The study also did not assess actual schizophrenia diagnoses; other symptoms of schizophrenia might independently increase the risk of violence.

The authors reported no relevant financial disclosures.

Psychoticlike symptoms were not positively associated with violent recidivism in a population of male adolescents, even when these symptoms were comorbid with substance abuse disorders, a study has shown.

In addition, having paranoid delusions and threat/control override delusions was actually linked to a lower risk of reoffending with violence, reported Olivier F. Colins, Ph.D., of Leiden (the Netherlands) University Medical Center and his associates in the June issue of the Journal of Nervous and Mental Disease.

"By identifying detained youths with [paranoid delusions] or [threat/control override delusions], clinicians are likely to identify youths with a low risk for future violent crimes," Dr. Colins and his associates wrote (J. Nerv. Ment. Dis. 2013;201:478-83).

The researchers assessed 224 male adolescents, aged 12-17, with the Diagnostic Interview Schedule for Children (DISC-IV), specifically analyzing the results of the schizophrenia module and the substance use disorder module. The boys had all been recently detained at youth detention centers in Flanders, Belgium, and were recruited between January 2005 and February 2007.

All boys were of Belgian origin except 22.3% who were of Moroccan origin. All of them had been placed in detention for at least 1 month. A quarter (25%) of the boys had a criminal history of violence. Violent recidivism included arrests, after the initial clinical interviews, for murder, manslaughter, assault, sexual offenses, and theft with violence.

The schizophrenia module of the DISC-IV investigates 22 psychoticlike symptoms within the past year that are grouped into four subsets: paranoid delusions, nonparanoid delusions, hallucinations, and threat/control override delusions. The substance use disorder module measured the existence of alcohol use disorder, marijuana use disorder, and other substance abuse disorders, including cocaine and amphetamines.

A total of 79% of the boys had at least one psychoticlike symptom, including 43% with at least one hallucination, 67% with at least one paranoid delusion, 26% with at least one nonparanoid delusion, and 53% with at least one threat/control override delusion. Substance abuse disorders were evenly distributed: 26% of the boys had no substance abuse disorder, 23% had one, 24% had two, and 27% had three. Just over half the boys (54%) had substance use disorder, 64% had marijuana use disorder, and a third (33%) had other substance use disorders.

After a mean follow-up of 1,219 days, two-thirds (66%) of the boys were rearrested for violent crimes during their time at risk, defined as the number of days between the DISC-IV and Feb. 1, 2009, minus the participants’ days in detention.

In both the univariate and multivariate analyses, odds ratios for all psychoticlike symptoms and total substance use disorders were not significant for predicting violent recidivism or violent rearrest frequency – except total delusions, paranoid delusions, and threat/control override delusions, which showed several significant negative associations. In the univariate analysis for violent rearrest frequency, total delusions had an odds ratio of 0.84 (CI, 0.73-0.98; P = .03), paranoid delusions had an OR of 0.78 (CI, 0.63-0.96; P = .02), and threat/control override delusions had an OR of 0.76 (CI, 0.61-0.95; P = .01).

In the multivariate analysis, the number of threat/control override delusions was negatively associated with violent recidivism even after the investigators controlled for hallucinations and the number of substance use disorders. The negative association for total delusions and threat/control override delusions for violent rearrest frequency also remained in the multivariate analysis even after hallucinations and the number of substance use disorders were controlled for.

Aside from the different psychoticlike symptoms and substance use disorders, the confounders in the multivariate analysis included age, origin, and parental/caretaker’s occupation.

"The absence of a positive relation between [psychoticlike symptoms] and violent recidivism may simply suggest that detained male adolescents with psychoticlike symptoms do not have a higher risk for future violent crimes than detained male adolescents without psychoticlike symptoms and, consequently, that findings from community samples are not generalizable to juvenile justice settings," the authors wrote. They suggested that the negative association between violent recidivism and delusions might result from fewer opportunities for interpersonal violence if delusional individuals are less inclined to engage in interpersonal interactions in the first place.

The authors noted that larger populations would be needed to assess alcohol, marijuana, and other substance use disorders as independent predictors. They also noted the study’s limitation of not accounting for the clinical significance, frequency, or intensity of any psychoticlike symptoms. The study also did not assess actual schizophrenia diagnoses; other symptoms of schizophrenia might independently increase the risk of violence.

The authors reported no relevant financial disclosures.

Clinical insight appears comparable across both schizophrenia and bipolar I patients in a small sample, but its relationship to symptoms and social cognition differs in the two disorders, a recent study showed.

"Social cognition was found to be associated with clinical insight in schizophrenia but not bipolar I disorder," reported Anja Vaskinn, Ph.D., of Oslo University Hospital and her associates in the June issue of the Journal of Nervous and Mental Disease. In bipolar I disorder, symptoms appear more meaningful in clinical insight than emotion recognition, the aspect of social cognition explored in this study.

Because both clinical insight and emotion perception require observation from an outside perspective, Dr. Vaskinn and her colleagues hypothesized that the constructs would be related to one another. The investigators used the Face/Voice Emotion Identification and Discrimination Test to measure emotion perception (visual and auditory with photographs and recordings). They used Birchwood’s Insight Scale to assess clinical insight, including subscales for awareness of illness, relabeling of symptoms as attributable to the illness, and recognizing the need for treatment (J. Nerv. Ment. Dis. 2013;201:445-51).

Among the 48 participants in the study, 29 had schizophrenia, and 19 had bipolar I disorder – including 13 bipolar patients who had experienced psychotic symptoms. Only schizophrenia patients with a score below 6 on the Positive and Negative Symptom Scale (PANSS) were included. Functioning of the participants was assessed with the Global Assessment Functioning Scale-split version, and depressive and mania symptoms also were assessed. All of the participants were white.

As the researchers had found in a previous study using controls, the participants with schizophrenia performed more poorly on the auditory emotion perception, compared with the participants with bipolar. Clinical insight, however, was about the same among patients in both groups. Not surprisingly, the patients with schizophrenia experienced greater positive and negative symptoms and poorer functioning than did the patients with bipolar disorder.

Across the whole group, no association appeared to exist between clinical insight and emotion recognition with the assessment tools used, but a subsample analysis showed some significant associations. Among the participants with bipolar, no link was found between overall social cognition (based on emotion recognition) and clinical insight, but those with greater PANSS positive symptoms or with greater depressive symptoms had poorer clinical insight (r = –0.54 with P less than .05 and r = –0.61 with P less than .01, respectively), Dr. Vaskinn and her associates said.

Those with greater mania symptoms had poorer scores on the subscale related to need for treatment (r = 0.37) while greater PANSS negative symptoms were moderately associated with both the relabeling of symptoms (–0.36) and the need for treatment (r = 0.30). Greater symptoms in general among the patients with bipolar were linked to lower clinical insight, they reported.

Among the patients with schizophrenia, overall clinical insight as well as relabeling of symptoms had a moderate to large association (r = 0.44) with the auditory emotion recognition test. Relabeling of symptoms also was moderately, positively associated with visual emotional recognition (r = 0.36). Clinical insight among schizophrenia participants was poorer in those with greater PANSS negative symptoms (r = –0.33).

The authors noted that it appears reasonable for the relabeling of symptoms subscale of the clinical insight tool to be most strongly associated with social cognition. "This subscale specifically addresses the degree to which someone can detach oneself from one’s own symptoms, observing them from an outside perspective," they wrote. "This observer’s eye on emotionally salient information is also at play in emotion perception."

One implication of the study’s findings is that "social cognition may be a potential treatment target in efforts to reduce the negative consequences of limited clinical insight in schizophrenia, whereas interventions aimed at reducing symptoms will be more appropriate for bipolar disorder," Dr. Vaskinn and her associates wrote.

The investigators reported no disclosures.

Clinical insight appears comparable across both schizophrenia and bipolar I patients in a small sample, but its relationship to symptoms and social cognition differs in the two disorders, a recent study showed.

"Social cognition was found to be associated with clinical insight in schizophrenia but not bipolar I disorder," reported Anja Vaskinn, Ph.D., of Oslo University Hospital and her associates in the June issue of the Journal of Nervous and Mental Disease. In bipolar I disorder, symptoms appear more meaningful in clinical insight than emotion recognition, the aspect of social cognition explored in this study.

Because both clinical insight and emotion perception require observation from an outside perspective, Dr. Vaskinn and her colleagues hypothesized that the constructs would be related to one another. The investigators used the Face/Voice Emotion Identification and Discrimination Test to measure emotion perception (visual and auditory with photographs and recordings). They used Birchwood’s Insight Scale to assess clinical insight, including subscales for awareness of illness, relabeling of symptoms as attributable to the illness, and recognizing the need for treatment (J. Nerv. Ment. Dis. 2013;201:445-51).

Among the 48 participants in the study, 29 had schizophrenia, and 19 had bipolar I disorder – including 13 bipolar patients who had experienced psychotic symptoms. Only schizophrenia patients with a score below 6 on the Positive and Negative Symptom Scale (PANSS) were included. Functioning of the participants was assessed with the Global Assessment Functioning Scale-split version, and depressive and mania symptoms also were assessed. All of the participants were white.

As the researchers had found in a previous study using controls, the participants with schizophrenia performed more poorly on the auditory emotion perception, compared with the participants with bipolar. Clinical insight, however, was about the same among patients in both groups. Not surprisingly, the patients with schizophrenia experienced greater positive and negative symptoms and poorer functioning than did the patients with bipolar disorder.

Across the whole group, no association appeared to exist between clinical insight and emotion recognition with the assessment tools used, but a subsample analysis showed some significant associations. Among the participants with bipolar, no link was found between overall social cognition (based on emotion recognition) and clinical insight, but those with greater PANSS positive symptoms or with greater depressive symptoms had poorer clinical insight (r = –0.54 with P less than .05 and r = –0.61 with P less than .01, respectively), Dr. Vaskinn and her associates said.

Those with greater mania symptoms had poorer scores on the subscale related to need for treatment (r = 0.37) while greater PANSS negative symptoms were moderately associated with both the relabeling of symptoms (–0.36) and the need for treatment (r = 0.30). Greater symptoms in general among the patients with bipolar were linked to lower clinical insight, they reported.

Among the patients with schizophrenia, overall clinical insight as well as relabeling of symptoms had a moderate to large association (r = 0.44) with the auditory emotion recognition test. Relabeling of symptoms also was moderately, positively associated with visual emotional recognition (r = 0.36). Clinical insight among schizophrenia participants was poorer in those with greater PANSS negative symptoms (r = –0.33).

The authors noted that it appears reasonable for the relabeling of symptoms subscale of the clinical insight tool to be most strongly associated with social cognition. "This subscale specifically addresses the degree to which someone can detach oneself from one’s own symptoms, observing them from an outside perspective," they wrote. "This observer’s eye on emotionally salient information is also at play in emotion perception."

One implication of the study’s findings is that "social cognition may be a potential treatment target in efforts to reduce the negative consequences of limited clinical insight in schizophrenia, whereas interventions aimed at reducing symptoms will be more appropriate for bipolar disorder," Dr. Vaskinn and her associates wrote.

The investigators reported no disclosures.

Clinical insight appears comparable across both schizophrenia and bipolar I patients in a small sample, but its relationship to symptoms and social cognition differs in the two disorders, a recent study showed.

"Social cognition was found to be associated with clinical insight in schizophrenia but not bipolar I disorder," reported Anja Vaskinn, Ph.D., of Oslo University Hospital and her associates in the June issue of the Journal of Nervous and Mental Disease. In bipolar I disorder, symptoms appear more meaningful in clinical insight than emotion recognition, the aspect of social cognition explored in this study.

Because both clinical insight and emotion perception require observation from an outside perspective, Dr. Vaskinn and her colleagues hypothesized that the constructs would be related to one another. The investigators used the Face/Voice Emotion Identification and Discrimination Test to measure emotion perception (visual and auditory with photographs and recordings). They used Birchwood’s Insight Scale to assess clinical insight, including subscales for awareness of illness, relabeling of symptoms as attributable to the illness, and recognizing the need for treatment (J. Nerv. Ment. Dis. 2013;201:445-51).

Among the 48 participants in the study, 29 had schizophrenia, and 19 had bipolar I disorder – including 13 bipolar patients who had experienced psychotic symptoms. Only schizophrenia patients with a score below 6 on the Positive and Negative Symptom Scale (PANSS) were included. Functioning of the participants was assessed with the Global Assessment Functioning Scale-split version, and depressive and mania symptoms also were assessed. All of the participants were white.

As the researchers had found in a previous study using controls, the participants with schizophrenia performed more poorly on the auditory emotion perception, compared with the participants with bipolar. Clinical insight, however, was about the same among patients in both groups. Not surprisingly, the patients with schizophrenia experienced greater positive and negative symptoms and poorer functioning than did the patients with bipolar disorder.

Across the whole group, no association appeared to exist between clinical insight and emotion recognition with the assessment tools used, but a subsample analysis showed some significant associations. Among the participants with bipolar, no link was found between overall social cognition (based on emotion recognition) and clinical insight, but those with greater PANSS positive symptoms or with greater depressive symptoms had poorer clinical insight (r = –0.54 with P less than .05 and r = –0.61 with P less than .01, respectively), Dr. Vaskinn and her associates said.

Those with greater mania symptoms had poorer scores on the subscale related to need for treatment (r = 0.37) while greater PANSS negative symptoms were moderately associated with both the relabeling of symptoms (–0.36) and the need for treatment (r = 0.30). Greater symptoms in general among the patients with bipolar were linked to lower clinical insight, they reported.

Among the patients with schizophrenia, overall clinical insight as well as relabeling of symptoms had a moderate to large association (r = 0.44) with the auditory emotion recognition test. Relabeling of symptoms also was moderately, positively associated with visual emotional recognition (r = 0.36). Clinical insight among schizophrenia participants was poorer in those with greater PANSS negative symptoms (r = –0.33).

The authors noted that it appears reasonable for the relabeling of symptoms subscale of the clinical insight tool to be most strongly associated with social cognition. "This subscale specifically addresses the degree to which someone can detach oneself from one’s own symptoms, observing them from an outside perspective," they wrote. "This observer’s eye on emotionally salient information is also at play in emotion perception."

One implication of the study’s findings is that "social cognition may be a potential treatment target in efforts to reduce the negative consequences of limited clinical insight in schizophrenia, whereas interventions aimed at reducing symptoms will be more appropriate for bipolar disorder," Dr. Vaskinn and her associates wrote.

The investigators reported no disclosures.

Using a formal, validated caregiver screening tool in addition to an adolescent’s screening results appears to provide more accurate identification of adolescents who are at clinical high risk for psychosis, a new study in Schizophrenia Research suggested.

Because the Structured Interview for Psychosis Risk Syndromes is resource-intensive to screen youth for attenuated psychosis syndrome, several shorter screening tools often are used with adolescents, including the 12-item Prime Screen-Revised (PS-R) that tests for attenuated or psychotic-like symptoms. Yet clinicians also might seek parent or guardian input, in light of the median age of psychosis of 22 years.

Noting that "parent input appears to be a valued but unstandardized component of (clinical high risk for psychosis) assessment," Emily Kline and her associates at the University of Maryland, Baltimore, sought to test a modified version of the PS-R for caregivers (CGPS-R).

Although they found that the PS-R and the CGPS-R were not correlated with each other, "both measures demonstrated moderate to large correlations with clinician ratings on the [Scale of Prodromal Symptoms]" and improved the overall accuracy of positive cases based on the Structured Interview for Psychosis Risk Syndromes, reported Ms. Kline, a doctoral candidate at the university, and her associates (Schizophr. Res. 2013;147:147-52).

They recruited 52 youths (54% female) who were a mean age of 15 years (SD, 2.09), all within the ages of 12-22 and currently receiving mental health services, and their caregivers to test the caregiver-modified screening tool. About 50% of the youth participants were African American, 37% were white, and 13% were categorized as more than one race or "other."

Among the caregivers, 63% of those filling out the screens were mothers, 13% were fathers, 10% were mothers and fathers, 10% were grandparents, and 4% were another caregiver. The modification of the PS-R for caregivers involved only replacing "I," "me," and "my" with "he/she," "him/her," and "his/her."

After all participants and their caregivers had completed the PS-R and CGPS-R screens, respectively, the youth and caregivers were evaluated by staff with the Kiddie Schedule for Affective Disorders and Schizophrenia, present and lifetime version (K-SADS-PL). Then the youths only were evaluated using the Structured Interview for Psychosis Risk Syndromes. Finally, Ms. Kline’s team compared the results of the Structured Interview for Psychosis Risk Syndromes with the PS-R only, the PS-R with the CGPS-R, and the CGPS-R only.

The researchers specifically used the sum of positive symptoms ratings within the Scale of Prodromal Symptoms part of the Structured Interview for Psychosis Risk Syndromes since the five positive symptoms "are most central to the risk syndrome diagnoses," they wrote.

Because the PS-R authors recommend a threshold of at least two responses of five or six on a Likert-type agreement scale of zero to six, the investigators used a threshold of at least four responses of five or six when the PS-R and CGPS-R results were "summed" in a combined screen to identify "positive" cases. Based on Structured Interview for Psychosis Risk Syndromes classification, 27 of the 52 participants (52%) were identified as positive cases for psychosis risk syndrome or current psychosis (six participants).

Comparing the youth screening (PS-R) results with those of the caregivers (CGPS-R), agreement was poor (r = 0.09), though the caregiver screen did correlate with the clinician Scale of Prodromal Symptoms ratings (r = 0.41, P < .01). When the researchers compared the accuracy of the PS-R to that of the PS-R and CGPS-R together in identifying youth as positive cases according to Structured Interview for Psychosis Risk Syndromes, the accuracy and specificity improved at cost to sensitivity.

The PS-R had an overall accuracy of 71%, with a specificity of 0.60 and a positive predictive value of 0.69. These numbers improved when the CGPS-R was added to the PS-R, for 75% accuracy, 0.76 specificity, and 0.77 positive predictive value, albeit dropping sensitivity from 0.81 with the PS-R to 0.74 with both tools and "resulting in a potentially greater number of [clinically high risk] youth ‘missed’ by the screener," they wrote.

Screening items with the most agreement among adolescents, caregivers, and clinicians were those related to auditory hallucinations, while items related to being controlled by an outside force showed poor agreement between caregivers and youth "but were highly predictive of Scale of Prodromal Symptoms ratings and/or [Structured Interview for Psychosis Risk Syndromes] diagnosis."

The authors discussed several possible reasons for the disparities between the youth and caregivers, including differing interpretations of the items, concern about stigma for revealing some information, caregivers’ misinterpretation of youths’ behavior, youths’ mental illness–induced distorted perceptions, caregivers’ own psychopathology, and the inability of caregivers to observe certain items in youths.

The authors noted that using the PS-R and CGPS-R as a first-step assessment tool, with a combined threshold of four items rated at five or six, could have reduced clinician workload in conducting the Structured Interview for Psychosis Risk Syndromes by half (fully evaluating 26 instead of 52 youths) while retaining 74% (20 of 27) of the positive cases.

Ms. Kline and her colleagues cited several study limitations, including the relatively small sample size. Still, the findings suggest that "soliciting caregiver information through a brief screening questionnaire can yield incremental value" toward predicting patients’ clinical high-risk status, they wrote.

The study was funded by several sources, including the Maryland Department of Health and Mental Hygiene and Baltimore Mental Health Systems. The authors declared no potential conflicts of interest.

Using a formal, validated caregiver screening tool in addition to an adolescent’s screening results appears to provide more accurate identification of adolescents who are at clinical high risk for psychosis, a new study in Schizophrenia Research suggested.

Because the Structured Interview for Psychosis Risk Syndromes is resource-intensive to screen youth for attenuated psychosis syndrome, several shorter screening tools often are used with adolescents, including the 12-item Prime Screen-Revised (PS-R) that tests for attenuated or psychotic-like symptoms. Yet clinicians also might seek parent or guardian input, in light of the median age of psychosis of 22 years.

Noting that "parent input appears to be a valued but unstandardized component of (clinical high risk for psychosis) assessment," Emily Kline and her associates at the University of Maryland, Baltimore, sought to test a modified version of the PS-R for caregivers (CGPS-R).

Although they found that the PS-R and the CGPS-R were not correlated with each other, "both measures demonstrated moderate to large correlations with clinician ratings on the [Scale of Prodromal Symptoms]" and improved the overall accuracy of positive cases based on the Structured Interview for Psychosis Risk Syndromes, reported Ms. Kline, a doctoral candidate at the university, and her associates (Schizophr. Res. 2013;147:147-52).

They recruited 52 youths (54% female) who were a mean age of 15 years (SD, 2.09), all within the ages of 12-22 and currently receiving mental health services, and their caregivers to test the caregiver-modified screening tool. About 50% of the youth participants were African American, 37% were white, and 13% were categorized as more than one race or "other."

Among the caregivers, 63% of those filling out the screens were mothers, 13% were fathers, 10% were mothers and fathers, 10% were grandparents, and 4% were another caregiver. The modification of the PS-R for caregivers involved only replacing "I," "me," and "my" with "he/she," "him/her," and "his/her."

After all participants and their caregivers had completed the PS-R and CGPS-R screens, respectively, the youth and caregivers were evaluated by staff with the Kiddie Schedule for Affective Disorders and Schizophrenia, present and lifetime version (K-SADS-PL). Then the youths only were evaluated using the Structured Interview for Psychosis Risk Syndromes. Finally, Ms. Kline’s team compared the results of the Structured Interview for Psychosis Risk Syndromes with the PS-R only, the PS-R with the CGPS-R, and the CGPS-R only.

The researchers specifically used the sum of positive symptoms ratings within the Scale of Prodromal Symptoms part of the Structured Interview for Psychosis Risk Syndromes since the five positive symptoms "are most central to the risk syndrome diagnoses," they wrote.

Because the PS-R authors recommend a threshold of at least two responses of five or six on a Likert-type agreement scale of zero to six, the investigators used a threshold of at least four responses of five or six when the PS-R and CGPS-R results were "summed" in a combined screen to identify "positive" cases. Based on Structured Interview for Psychosis Risk Syndromes classification, 27 of the 52 participants (52%) were identified as positive cases for psychosis risk syndrome or current psychosis (six participants).

Comparing the youth screening (PS-R) results with those of the caregivers (CGPS-R), agreement was poor (r = 0.09), though the caregiver screen did correlate with the clinician Scale of Prodromal Symptoms ratings (r = 0.41, P < .01). When the researchers compared the accuracy of the PS-R to that of the PS-R and CGPS-R together in identifying youth as positive cases according to Structured Interview for Psychosis Risk Syndromes, the accuracy and specificity improved at cost to sensitivity.

The PS-R had an overall accuracy of 71%, with a specificity of 0.60 and a positive predictive value of 0.69. These numbers improved when the CGPS-R was added to the PS-R, for 75% accuracy, 0.76 specificity, and 0.77 positive predictive value, albeit dropping sensitivity from 0.81 with the PS-R to 0.74 with both tools and "resulting in a potentially greater number of [clinically high risk] youth ‘missed’ by the screener," they wrote.

Screening items with the most agreement among adolescents, caregivers, and clinicians were those related to auditory hallucinations, while items related to being controlled by an outside force showed poor agreement between caregivers and youth "but were highly predictive of Scale of Prodromal Symptoms ratings and/or [Structured Interview for Psychosis Risk Syndromes] diagnosis."

The authors discussed several possible reasons for the disparities between the youth and caregivers, including differing interpretations of the items, concern about stigma for revealing some information, caregivers’ misinterpretation of youths’ behavior, youths’ mental illness–induced distorted perceptions, caregivers’ own psychopathology, and the inability of caregivers to observe certain items in youths.

The authors noted that using the PS-R and CGPS-R as a first-step assessment tool, with a combined threshold of four items rated at five or six, could have reduced clinician workload in conducting the Structured Interview for Psychosis Risk Syndromes by half (fully evaluating 26 instead of 52 youths) while retaining 74% (20 of 27) of the positive cases.

Ms. Kline and her colleagues cited several study limitations, including the relatively small sample size. Still, the findings suggest that "soliciting caregiver information through a brief screening questionnaire can yield incremental value" toward predicting patients’ clinical high-risk status, they wrote.

The study was funded by several sources, including the Maryland Department of Health and Mental Hygiene and Baltimore Mental Health Systems. The authors declared no potential conflicts of interest.

Using a formal, validated caregiver screening tool in addition to an adolescent’s screening results appears to provide more accurate identification of adolescents who are at clinical high risk for psychosis, a new study in Schizophrenia Research suggested.

Because the Structured Interview for Psychosis Risk Syndromes is resource-intensive to screen youth for attenuated psychosis syndrome, several shorter screening tools often are used with adolescents, including the 12-item Prime Screen-Revised (PS-R) that tests for attenuated or psychotic-like symptoms. Yet clinicians also might seek parent or guardian input, in light of the median age of psychosis of 22 years.

Noting that "parent input appears to be a valued but unstandardized component of (clinical high risk for psychosis) assessment," Emily Kline and her associates at the University of Maryland, Baltimore, sought to test a modified version of the PS-R for caregivers (CGPS-R).

Although they found that the PS-R and the CGPS-R were not correlated with each other, "both measures demonstrated moderate to large correlations with clinician ratings on the [Scale of Prodromal Symptoms]" and improved the overall accuracy of positive cases based on the Structured Interview for Psychosis Risk Syndromes, reported Ms. Kline, a doctoral candidate at the university, and her associates (Schizophr. Res. 2013;147:147-52).

They recruited 52 youths (54% female) who were a mean age of 15 years (SD, 2.09), all within the ages of 12-22 and currently receiving mental health services, and their caregivers to test the caregiver-modified screening tool. About 50% of the youth participants were African American, 37% were white, and 13% were categorized as more than one race or "other."

Among the caregivers, 63% of those filling out the screens were mothers, 13% were fathers, 10% were mothers and fathers, 10% were grandparents, and 4% were another caregiver. The modification of the PS-R for caregivers involved only replacing "I," "me," and "my" with "he/she," "him/her," and "his/her."

After all participants and their caregivers had completed the PS-R and CGPS-R screens, respectively, the youth and caregivers were evaluated by staff with the Kiddie Schedule for Affective Disorders and Schizophrenia, present and lifetime version (K-SADS-PL). Then the youths only were evaluated using the Structured Interview for Psychosis Risk Syndromes. Finally, Ms. Kline’s team compared the results of the Structured Interview for Psychosis Risk Syndromes with the PS-R only, the PS-R with the CGPS-R, and the CGPS-R only.

The researchers specifically used the sum of positive symptoms ratings within the Scale of Prodromal Symptoms part of the Structured Interview for Psychosis Risk Syndromes since the five positive symptoms "are most central to the risk syndrome diagnoses," they wrote.

Because the PS-R authors recommend a threshold of at least two responses of five or six on a Likert-type agreement scale of zero to six, the investigators used a threshold of at least four responses of five or six when the PS-R and CGPS-R results were "summed" in a combined screen to identify "positive" cases. Based on Structured Interview for Psychosis Risk Syndromes classification, 27 of the 52 participants (52%) were identified as positive cases for psychosis risk syndrome or current psychosis (six participants).

Comparing the youth screening (PS-R) results with those of the caregivers (CGPS-R), agreement was poor (r = 0.09), though the caregiver screen did correlate with the clinician Scale of Prodromal Symptoms ratings (r = 0.41, P < .01). When the researchers compared the accuracy of the PS-R to that of the PS-R and CGPS-R together in identifying youth as positive cases according to Structured Interview for Psychosis Risk Syndromes, the accuracy and specificity improved at cost to sensitivity.

The PS-R had an overall accuracy of 71%, with a specificity of 0.60 and a positive predictive value of 0.69. These numbers improved when the CGPS-R was added to the PS-R, for 75% accuracy, 0.76 specificity, and 0.77 positive predictive value, albeit dropping sensitivity from 0.81 with the PS-R to 0.74 with both tools and "resulting in a potentially greater number of [clinically high risk] youth ‘missed’ by the screener," they wrote.

Screening items with the most agreement among adolescents, caregivers, and clinicians were those related to auditory hallucinations, while items related to being controlled by an outside force showed poor agreement between caregivers and youth "but were highly predictive of Scale of Prodromal Symptoms ratings and/or [Structured Interview for Psychosis Risk Syndromes] diagnosis."

The authors discussed several possible reasons for the disparities between the youth and caregivers, including differing interpretations of the items, concern about stigma for revealing some information, caregivers’ misinterpretation of youths’ behavior, youths’ mental illness–induced distorted perceptions, caregivers’ own psychopathology, and the inability of caregivers to observe certain items in youths.

The authors noted that using the PS-R and CGPS-R as a first-step assessment tool, with a combined threshold of four items rated at five or six, could have reduced clinician workload in conducting the Structured Interview for Psychosis Risk Syndromes by half (fully evaluating 26 instead of 52 youths) while retaining 74% (20 of 27) of the positive cases.

Ms. Kline and her colleagues cited several study limitations, including the relatively small sample size. Still, the findings suggest that "soliciting caregiver information through a brief screening questionnaire can yield incremental value" toward predicting patients’ clinical high-risk status, they wrote.

The study was funded by several sources, including the Maryland Department of Health and Mental Hygiene and Baltimore Mental Health Systems. The authors declared no potential conflicts of interest.

Screening first-episode psychotic patients with a 6-minute assessment tool provides a more reliable indication of a patient’s risk of readmission than urinalysis, according to a new study in Schizophrenia Research.

Patients scoring in the "at-risk" range of the cannabis/cocaine subscale of the Dartmouth Assessment of Lifestyle Inventory (DALI) were at 4.5 times greater risk of readmission, with a better sensitivity rate than urinalysis after adjusting for confounders. "The optimum cutoff point for DALI cannabis/cocaine subscale to predict readmission was above minus one," Dr. Albert Batalla of the University of Barcelona and his associates reported (Schizophr. Res. 2013;146:125-31).

The DALI is an 18-item screening tool in which the 15 scored items are divided into the alcohol subscale and the cannabis/cocaine subscale. It takes an average of 6 minutes to administer.

The team’s analysis of 58 patients’ readmissions found no association between readmission risk and self-reported alcohol use or the alcohol subscale of the DALI. Although a positive urinalysis for cannabis was associated with readmission in the bivariate analysis, only the DALI cannabis/cocaine subscale remained significantly associated with readmission after controlling for sex, age, duration of psychosis, and the positive subscale of the Positive and Negative Syndrome Scale (PANSS).

The 58 nonaffective first-episode psychotic patients were consecutively recruited from the Hospital Clinic in Barcelona from Jan. 1, 2004 to Oct. 31, 2010, with a study end date of April 30, 2011. Using DSM-IV diagnoses, 40 patients (69%) had schizophrenia, 5 (8.6%) had brief psychotic disorder, 4 (6.9%) had schizophreniform disorder, and 9 (15.5%) had psychosis not otherwise specified.

The patients underwent blood and urine sampling (at least one of which was within 48 hours of admission) and were interviewed with the PANSS and the DALI. Patients were drug naive, with no history of diabetes or any other condition associated with glucose intolerance or insulin resistance, and were taking no medications related to insulin resistance.

Urine was screened for benzodiazepines, cannabis, cocaine, amphetamines, opiates, methadone, and LSD. Blood samples were analyzed for alcohol. Among the 25 patients (43.1%; 95% confidence interval, 31.2%-55.9%) whose blood/urine screened positive for psychoactive substances, four patients (6.9%) screened positive for alcohol and 22 (37.9%) for cannabis.

During interviews, patients also were asked whether they had used alcohol, tobacco, cannabis, cocaine, amphetamines, LSD, or ecstasy within the previous 3 months. A total of 38 patients (65.5%) reported using at least one substance of abuse, excluding tobacco, including 31 (53.4%) reporting using cannabis (29 patients, 50%) and/or cocaine (14 patients, 24.1%). Meanwhile, the DALI cannabis/cocaine subscale identified 20 patients (50%) as high risk for cannabis and/or cocaine-use disorders, 80% of whom had reported recent cannabis and/or cocaine use during interviews.

Over a median follow-up of 888 days (348-1,556), 16 patients (27.6%) were readmitted, three of whom (18.8%) were false negatives on the DALI cannabis/cocaine subscale. With the cutoff of above minus one on the DALI subscale, sensitivity was 0.81 (95% CI, 0.57-0.93) and specificity was 0.62 (0.47-0.75), compared with a sensitivity of 0.56 (95% CI, 0.33-0.77) and a specificity of 0.69 (95% CI, 0.54-0.81) for the urine test.

The baseline DALI cannabis/cocaine subscale score yielded a hazard ratio of 4.5 (95% CI, 1.1-18.7; P = .036) in the multivariate analysis, while the urinalysis’ hazard ratio of 2.0 was not statistically significant (P = .2) when confounders were factored in. Factors significantly associated with readmission in the bivariate analysis included younger age, male gender, and high PANSS positive subscale scores. Neither a positive alcohol blood test (P = .773) nor the alcohol subscale of the DALI (P = .330) was associated with readmission.

The study was limited by the population’s sample size and exclusivity of nonaffective psychosis, as well as the fact that the DALI does not quantify amount or severity of drug use. The researchers only assessed substance use at baseline and did not assess medication adherence.

The study was funded by several sources, including the government of Catalonia and the Esther Koplowitz Center. The authors declared no conflicts of interest.

Screening first-episode psychotic patients with a 6-minute assessment tool provides a more reliable indication of a patient’s risk of readmission than urinalysis, according to a new study in Schizophrenia Research.

Patients scoring in the "at-risk" range of the cannabis/cocaine subscale of the Dartmouth Assessment of Lifestyle Inventory (DALI) were at 4.5 times greater risk of readmission, with a better sensitivity rate than urinalysis after adjusting for confounders. "The optimum cutoff point for DALI cannabis/cocaine subscale to predict readmission was above minus one," Dr. Albert Batalla of the University of Barcelona and his associates reported (Schizophr. Res. 2013;146:125-31).

The DALI is an 18-item screening tool in which the 15 scored items are divided into the alcohol subscale and the cannabis/cocaine subscale. It takes an average of 6 minutes to administer.

The team’s analysis of 58 patients’ readmissions found no association between readmission risk and self-reported alcohol use or the alcohol subscale of the DALI. Although a positive urinalysis for cannabis was associated with readmission in the bivariate analysis, only the DALI cannabis/cocaine subscale remained significantly associated with readmission after controlling for sex, age, duration of psychosis, and the positive subscale of the Positive and Negative Syndrome Scale (PANSS).

The 58 nonaffective first-episode psychotic patients were consecutively recruited from the Hospital Clinic in Barcelona from Jan. 1, 2004 to Oct. 31, 2010, with a study end date of April 30, 2011. Using DSM-IV diagnoses, 40 patients (69%) had schizophrenia, 5 (8.6%) had brief psychotic disorder, 4 (6.9%) had schizophreniform disorder, and 9 (15.5%) had psychosis not otherwise specified.

The patients underwent blood and urine sampling (at least one of which was within 48 hours of admission) and were interviewed with the PANSS and the DALI. Patients were drug naive, with no history of diabetes or any other condition associated with glucose intolerance or insulin resistance, and were taking no medications related to insulin resistance.

Urine was screened for benzodiazepines, cannabis, cocaine, amphetamines, opiates, methadone, and LSD. Blood samples were analyzed for alcohol. Among the 25 patients (43.1%; 95% confidence interval, 31.2%-55.9%) whose blood/urine screened positive for psychoactive substances, four patients (6.9%) screened positive for alcohol and 22 (37.9%) for cannabis.

During interviews, patients also were asked whether they had used alcohol, tobacco, cannabis, cocaine, amphetamines, LSD, or ecstasy within the previous 3 months. A total of 38 patients (65.5%) reported using at least one substance of abuse, excluding tobacco, including 31 (53.4%) reporting using cannabis (29 patients, 50%) and/or cocaine (14 patients, 24.1%). Meanwhile, the DALI cannabis/cocaine subscale identified 20 patients (50%) as high risk for cannabis and/or cocaine-use disorders, 80% of whom had reported recent cannabis and/or cocaine use during interviews.

Over a median follow-up of 888 days (348-1,556), 16 patients (27.6%) were readmitted, three of whom (18.8%) were false negatives on the DALI cannabis/cocaine subscale. With the cutoff of above minus one on the DALI subscale, sensitivity was 0.81 (95% CI, 0.57-0.93) and specificity was 0.62 (0.47-0.75), compared with a sensitivity of 0.56 (95% CI, 0.33-0.77) and a specificity of 0.69 (95% CI, 0.54-0.81) for the urine test.

The baseline DALI cannabis/cocaine subscale score yielded a hazard ratio of 4.5 (95% CI, 1.1-18.7; P = .036) in the multivariate analysis, while the urinalysis’ hazard ratio of 2.0 was not statistically significant (P = .2) when confounders were factored in. Factors significantly associated with readmission in the bivariate analysis included younger age, male gender, and high PANSS positive subscale scores. Neither a positive alcohol blood test (P = .773) nor the alcohol subscale of the DALI (P = .330) was associated with readmission.

The study was limited by the population’s sample size and exclusivity of nonaffective psychosis, as well as the fact that the DALI does not quantify amount or severity of drug use. The researchers only assessed substance use at baseline and did not assess medication adherence.

The study was funded by several sources, including the government of Catalonia and the Esther Koplowitz Center. The authors declared no conflicts of interest.

Screening first-episode psychotic patients with a 6-minute assessment tool provides a more reliable indication of a patient’s risk of readmission than urinalysis, according to a new study in Schizophrenia Research.

Patients scoring in the "at-risk" range of the cannabis/cocaine subscale of the Dartmouth Assessment of Lifestyle Inventory (DALI) were at 4.5 times greater risk of readmission, with a better sensitivity rate than urinalysis after adjusting for confounders. "The optimum cutoff point for DALI cannabis/cocaine subscale to predict readmission was above minus one," Dr. Albert Batalla of the University of Barcelona and his associates reported (Schizophr. Res. 2013;146:125-31).

The DALI is an 18-item screening tool in which the 15 scored items are divided into the alcohol subscale and the cannabis/cocaine subscale. It takes an average of 6 minutes to administer.

The team’s analysis of 58 patients’ readmissions found no association between readmission risk and self-reported alcohol use or the alcohol subscale of the DALI. Although a positive urinalysis for cannabis was associated with readmission in the bivariate analysis, only the DALI cannabis/cocaine subscale remained significantly associated with readmission after controlling for sex, age, duration of psychosis, and the positive subscale of the Positive and Negative Syndrome Scale (PANSS).

The 58 nonaffective first-episode psychotic patients were consecutively recruited from the Hospital Clinic in Barcelona from Jan. 1, 2004 to Oct. 31, 2010, with a study end date of April 30, 2011. Using DSM-IV diagnoses, 40 patients (69%) had schizophrenia, 5 (8.6%) had brief psychotic disorder, 4 (6.9%) had schizophreniform disorder, and 9 (15.5%) had psychosis not otherwise specified.

The patients underwent blood and urine sampling (at least one of which was within 48 hours of admission) and were interviewed with the PANSS and the DALI. Patients were drug naive, with no history of diabetes or any other condition associated with glucose intolerance or insulin resistance, and were taking no medications related to insulin resistance.

Urine was screened for benzodiazepines, cannabis, cocaine, amphetamines, opiates, methadone, and LSD. Blood samples were analyzed for alcohol. Among the 25 patients (43.1%; 95% confidence interval, 31.2%-55.9%) whose blood/urine screened positive for psychoactive substances, four patients (6.9%) screened positive for alcohol and 22 (37.9%) for cannabis.

During interviews, patients also were asked whether they had used alcohol, tobacco, cannabis, cocaine, amphetamines, LSD, or ecstasy within the previous 3 months. A total of 38 patients (65.5%) reported using at least one substance of abuse, excluding tobacco, including 31 (53.4%) reporting using cannabis (29 patients, 50%) and/or cocaine (14 patients, 24.1%). Meanwhile, the DALI cannabis/cocaine subscale identified 20 patients (50%) as high risk for cannabis and/or cocaine-use disorders, 80% of whom had reported recent cannabis and/or cocaine use during interviews.

Over a median follow-up of 888 days (348-1,556), 16 patients (27.6%) were readmitted, three of whom (18.8%) were false negatives on the DALI cannabis/cocaine subscale. With the cutoff of above minus one on the DALI subscale, sensitivity was 0.81 (95% CI, 0.57-0.93) and specificity was 0.62 (0.47-0.75), compared with a sensitivity of 0.56 (95% CI, 0.33-0.77) and a specificity of 0.69 (95% CI, 0.54-0.81) for the urine test.

The baseline DALI cannabis/cocaine subscale score yielded a hazard ratio of 4.5 (95% CI, 1.1-18.7; P = .036) in the multivariate analysis, while the urinalysis’ hazard ratio of 2.0 was not statistically significant (P = .2) when confounders were factored in. Factors significantly associated with readmission in the bivariate analysis included younger age, male gender, and high PANSS positive subscale scores. Neither a positive alcohol blood test (P = .773) nor the alcohol subscale of the DALI (P = .330) was associated with readmission.

The study was limited by the population’s sample size and exclusivity of nonaffective psychosis, as well as the fact that the DALI does not quantify amount or severity of drug use. The researchers only assessed substance use at baseline and did not assess medication adherence.

The study was funded by several sources, including the government of Catalonia and the Esther Koplowitz Center. The authors declared no conflicts of interest.

The theoretical bipartite model for dissociation was clinically confirmed in a sample of schizophrenia patients and might represent a dissociation subtype of schizophrenia, a recent study shows.

The bipartite model proposes that dissociative detachment and dissociative compartmentalization are two different types of dissociation rather than variations found on a dissociation continuum. Dr. Matthias Vogel of the Clinic for Psychosomatic Medicine and Psychotherapy at the Medical University of Rostock, Germany, and his associates reported that "around 25% of the variance in clinical symptoms of schizophrenia are explained by detachment equivalents and compartmentalization equivalent" (J. Trauma Dissociation 2013;14:1-15).

Previous estimates of the prevalence of a theoretical dissociative subtype of schizophrenia have been between 25% and 40% of patients diagnosed with schizophrenia. The researchers had set out to test the bipartite model of dissociation in a clinical sample while seeking potential overlap of dissociation among schizophrenia patients.

The clinical sample included 74 patients who were diagnosed with schizophrenia spectrum disorders based on the DSM-IV and were receiving treatment at a northern Germany psychiatric university clinic. Among the patients were 60 with paranoid schizophrenia, 5 with residual schizophrenia, and 9 with schizoaffective disorder; 25 (33.8%) patients were female, and the patients’ mean age was 39.

The Positive and Negative Syndrome Scale (PANSS), and the Association for Methodology and Documentation in Psychiatry (AMDP) scale for dissociation were used to interview the patients. Then, the researchers conducted a factor analysis for the 15 items on the AMDP-dis, seeking detachment and compartmentalization equivalents scores among the patients.

Compartmentalization dissociation refers to the temporary loss of control of specific systems of the brain related to memory, senses, and motor functions, which clinically presents as "dissociative amnesia or medically unexplained neurological symptoms." Meanwhile, detachment dissociation refers to a patient’s "unreal" or dreamlike feeling of being separated from his or her body, self, or the environment. The former specifically relates to disrupted memory function, and the latter is an altered state of consciousness.

The mean scores of the patients on the PANSS included 23.48 (SD 6.33) on the positive subscale, 24.22 (SD 7.33) on the negative subscale, and 47.12 (SD 10.74) on the general symptom subscale. The mean dissociation total score was 9.81 (SD 7.81). In the factor analysis with the AMDP-dis, a mean of 4.75 (SD 4.84) was identified for the detachment equivalents, and a mean 4.99 (SD 4.08) was identified for the compartmentalization equivalents.

The analysis confirmed discrete types of detachment and compartmentalization dissociative states, thereby confirming the bipartite dissociation model. "Consistent with the study hypothesis, dissociation as measured using the AMDP module was not on a continuum in the present sample but was discontinuous with detachment equivalents distinct from compartmentalization equivalents," the authors wrote.

Further, the authors found correlations between the detachment equivalents, and both positive symptoms and general schizophrenia symptoms. The compartmentalization equivalents were correlated with all three PANSS subscales.

Multiple regression analyses, however, found "intense interactions between detachment equivalents and positive symptoms of schizophrenia and between compartmentalization equivalents and negative symptoms of schizophrenia," thereby confirming the potential for both kinds of dissociation to comprise a dissociative subtype of schizophrenia. "This pattern of specific association linking schizophrenia and dissociation by subtype is also confirmed by the finding of a nonspecific association with the general symptoms subscale of the PANSS," Dr. Vogel and his associates wrote.

The researchers noted that the overlapping subtypes of dissociation and schizophrenia symptoms suggest a "link between detachment equivalents and psychotic symptoms." They suggest that this pattern is not indicative of a comorbidity but rather possibly a common disease process that potentially involves neurobiological mechanisms, or a bidirectional interaction between dissociation and psychosis.

The clinical implications of their findings are that additional treatment might be appropriate for schizophrenia patients experiencing dissociation. "Dissociation is an important part of the schizophrenic patient’s suffering, at the same time offering the advantage of an additional therapeutic access," they wrote. "The current results add to the findings that indicate the need of patients diagnosed with schizophrenia for such specific antidissociative treatment in addition to the standard of care for schizophrenia.

The study was limited by the high percentage of paranoid schizophrenia patients in the nonrepresentative sample.

Dr. Vogel reported no disclosures.

The theoretical bipartite model for dissociation was clinically confirmed in a sample of schizophrenia patients and might represent a dissociation subtype of schizophrenia, a recent study shows.

The bipartite model proposes that dissociative detachment and dissociative compartmentalization are two different types of dissociation rather than variations found on a dissociation continuum. Dr. Matthias Vogel of the Clinic for Psychosomatic Medicine and Psychotherapy at the Medical University of Rostock, Germany, and his associates reported that "around 25% of the variance in clinical symptoms of schizophrenia are explained by detachment equivalents and compartmentalization equivalent" (J. Trauma Dissociation 2013;14:1-15).

Previous estimates of the prevalence of a theoretical dissociative subtype of schizophrenia have been between 25% and 40% of patients diagnosed with schizophrenia. The researchers had set out to test the bipartite model of dissociation in a clinical sample while seeking potential overlap of dissociation among schizophrenia patients.

The clinical sample included 74 patients who were diagnosed with schizophrenia spectrum disorders based on the DSM-IV and were receiving treatment at a northern Germany psychiatric university clinic. Among the patients were 60 with paranoid schizophrenia, 5 with residual schizophrenia, and 9 with schizoaffective disorder; 25 (33.8%) patients were female, and the patients’ mean age was 39.

The Positive and Negative Syndrome Scale (PANSS), and the Association for Methodology and Documentation in Psychiatry (AMDP) scale for dissociation were used to interview the patients. Then, the researchers conducted a factor analysis for the 15 items on the AMDP-dis, seeking detachment and compartmentalization equivalents scores among the patients.

Compartmentalization dissociation refers to the temporary loss of control of specific systems of the brain related to memory, senses, and motor functions, which clinically presents as "dissociative amnesia or medically unexplained neurological symptoms." Meanwhile, detachment dissociation refers to a patient’s "unreal" or dreamlike feeling of being separated from his or her body, self, or the environment. The former specifically relates to disrupted memory function, and the latter is an altered state of consciousness.

The mean scores of the patients on the PANSS included 23.48 (SD 6.33) on the positive subscale, 24.22 (SD 7.33) on the negative subscale, and 47.12 (SD 10.74) on the general symptom subscale. The mean dissociation total score was 9.81 (SD 7.81). In the factor analysis with the AMDP-dis, a mean of 4.75 (SD 4.84) was identified for the detachment equivalents, and a mean 4.99 (SD 4.08) was identified for the compartmentalization equivalents.

The analysis confirmed discrete types of detachment and compartmentalization dissociative states, thereby confirming the bipartite dissociation model. "Consistent with the study hypothesis, dissociation as measured using the AMDP module was not on a continuum in the present sample but was discontinuous with detachment equivalents distinct from compartmentalization equivalents," the authors wrote.

Further, the authors found correlations between the detachment equivalents, and both positive symptoms and general schizophrenia symptoms. The compartmentalization equivalents were correlated with all three PANSS subscales.

Multiple regression analyses, however, found "intense interactions between detachment equivalents and positive symptoms of schizophrenia and between compartmentalization equivalents and negative symptoms of schizophrenia," thereby confirming the potential for both kinds of dissociation to comprise a dissociative subtype of schizophrenia. "This pattern of specific association linking schizophrenia and dissociation by subtype is also confirmed by the finding of a nonspecific association with the general symptoms subscale of the PANSS," Dr. Vogel and his associates wrote.

The researchers noted that the overlapping subtypes of dissociation and schizophrenia symptoms suggest a "link between detachment equivalents and psychotic symptoms." They suggest that this pattern is not indicative of a comorbidity but rather possibly a common disease process that potentially involves neurobiological mechanisms, or a bidirectional interaction between dissociation and psychosis.

The clinical implications of their findings are that additional treatment might be appropriate for schizophrenia patients experiencing dissociation. "Dissociation is an important part of the schizophrenic patient’s suffering, at the same time offering the advantage of an additional therapeutic access," they wrote. "The current results add to the findings that indicate the need of patients diagnosed with schizophrenia for such specific antidissociative treatment in addition to the standard of care for schizophrenia.

The study was limited by the high percentage of paranoid schizophrenia patients in the nonrepresentative sample.

Dr. Vogel reported no disclosures.

The theoretical bipartite model for dissociation was clinically confirmed in a sample of schizophrenia patients and might represent a dissociation subtype of schizophrenia, a recent study shows.

The bipartite model proposes that dissociative detachment and dissociative compartmentalization are two different types of dissociation rather than variations found on a dissociation continuum. Dr. Matthias Vogel of the Clinic for Psychosomatic Medicine and Psychotherapy at the Medical University of Rostock, Germany, and his associates reported that "around 25% of the variance in clinical symptoms of schizophrenia are explained by detachment equivalents and compartmentalization equivalent" (J. Trauma Dissociation 2013;14:1-15).

Previous estimates of the prevalence of a theoretical dissociative subtype of schizophrenia have been between 25% and 40% of patients diagnosed with schizophrenia. The researchers had set out to test the bipartite model of dissociation in a clinical sample while seeking potential overlap of dissociation among schizophrenia patients.

The clinical sample included 74 patients who were diagnosed with schizophrenia spectrum disorders based on the DSM-IV and were receiving treatment at a northern Germany psychiatric university clinic. Among the patients were 60 with paranoid schizophrenia, 5 with residual schizophrenia, and 9 with schizoaffective disorder; 25 (33.8%) patients were female, and the patients’ mean age was 39.

The Positive and Negative Syndrome Scale (PANSS), and the Association for Methodology and Documentation in Psychiatry (AMDP) scale for dissociation were used to interview the patients. Then, the researchers conducted a factor analysis for the 15 items on the AMDP-dis, seeking detachment and compartmentalization equivalents scores among the patients.

Compartmentalization dissociation refers to the temporary loss of control of specific systems of the brain related to memory, senses, and motor functions, which clinically presents as "dissociative amnesia or medically unexplained neurological symptoms." Meanwhile, detachment dissociation refers to a patient’s "unreal" or dreamlike feeling of being separated from his or her body, self, or the environment. The former specifically relates to disrupted memory function, and the latter is an altered state of consciousness.

The mean scores of the patients on the PANSS included 23.48 (SD 6.33) on the positive subscale, 24.22 (SD 7.33) on the negative subscale, and 47.12 (SD 10.74) on the general symptom subscale. The mean dissociation total score was 9.81 (SD 7.81). In the factor analysis with the AMDP-dis, a mean of 4.75 (SD 4.84) was identified for the detachment equivalents, and a mean 4.99 (SD 4.08) was identified for the compartmentalization equivalents.

The analysis confirmed discrete types of detachment and compartmentalization dissociative states, thereby confirming the bipartite dissociation model. "Consistent with the study hypothesis, dissociation as measured using the AMDP module was not on a continuum in the present sample but was discontinuous with detachment equivalents distinct from compartmentalization equivalents," the authors wrote.

Further, the authors found correlations between the detachment equivalents, and both positive symptoms and general schizophrenia symptoms. The compartmentalization equivalents were correlated with all three PANSS subscales.

Multiple regression analyses, however, found "intense interactions between detachment equivalents and positive symptoms of schizophrenia and between compartmentalization equivalents and negative symptoms of schizophrenia," thereby confirming the potential for both kinds of dissociation to comprise a dissociative subtype of schizophrenia. "This pattern of specific association linking schizophrenia and dissociation by subtype is also confirmed by the finding of a nonspecific association with the general symptoms subscale of the PANSS," Dr. Vogel and his associates wrote.

The researchers noted that the overlapping subtypes of dissociation and schizophrenia symptoms suggest a "link between detachment equivalents and psychotic symptoms." They suggest that this pattern is not indicative of a comorbidity but rather possibly a common disease process that potentially involves neurobiological mechanisms, or a bidirectional interaction between dissociation and psychosis.

The clinical implications of their findings are that additional treatment might be appropriate for schizophrenia patients experiencing dissociation. "Dissociation is an important part of the schizophrenic patient’s suffering, at the same time offering the advantage of an additional therapeutic access," they wrote. "The current results add to the findings that indicate the need of patients diagnosed with schizophrenia for such specific antidissociative treatment in addition to the standard of care for schizophrenia.

The study was limited by the high percentage of paranoid schizophrenia patients in the nonrepresentative sample.

Dr. Vogel reported no disclosures.

The severity of schizophrenia patients’ negative symptoms might predict their service engagement after their first episode of psychosis, according to a study published in The Journal of Nervous and Mental Disease.

Researchers also found poorer engagement, as rated by clinicians, linked to greater positive and negative symptoms, greater general psychopathology, and poorer premorbid adolescent social adjustment (early and late) before regression analysis, reported Angus MacBeth, Ph.D., D.Clin.Psy., of the University of Glasgow, and his associates (J. Nerv. Ment. Dis. 2013;201:359-64 [doi: 10.1097/NMD.0b013e31828e0e19]).

Yet no correlation between duration of psychosis and engagement was found, and "only negative symptoms emerged as a significant independent predictor of engagement" following multiple regression analysis.

The researchers used a cross-sectional cohort design that included 64 people presenting with first-episode psychosis to early intervention psychosis services in two cities in Scotland. The sample comprised 43 men and 21 women, predominantly white and British. A plurality of patients was diagnosed with schizophrenia (28 patients). Among the others, 14 had bipolar disorder, 10 had schizoaffective disorder, 6 had persistent delusional disorder, 4 had schizophreniform disorder, and 2 had mania with psychotic symptoms.

Patients were included if they were in their first 12 months of treatment for first-episode psychosis and they did not have substance abuse, head injury, or an organic disorder determined to be the main cause of their psychotic symptoms.

In addition to the use of the Positive and Negative Syndrome Scale (PANSS) to assess schizophrenia symptoms, the researchers used the Premorbid Adjustment Scale (PAS), the Service Engagement Scale (SES), and an unstructured interview with the individual (when no longer floridly psychotic), and/or a caretaker or loved one to establish duration of psychosis.

The PAS measured prepsychosis academic and social functioning during the first three of four life stages: childhood, early adolescence, late adolescence, and adulthood. The four subscales of the Service Engagement Scale completed by clinicians were availability, collaboration, help-seeking, and treatment adherence.

Men and women scored similarly on the total clinician-rated SES score and the help-seeking and availability subscales. However, women scored more poorly (higher score) on the subscales of collaboration and treatment adherence (mean 3.63 for females, 1.87 for males, t = –2.42, df = 45, P = .02). Women also reported "significantly greater impairment in [adolescent] social functioning than male participants did" (t = –2.233, df = 40, P = .031).

The authors found the post–regression-analysis association with negative symptoms "puzzling," given that previous studies on predictors of disengagement have not found such a correlation with negative symptoms. They suggested a possible conflation of negative symptoms with social functioning as a potential underlying mechanism for the association.

"Perhaps negative symptoms are more likely to predict engagement, because they reflect a more contemporaneous measure of social functioning than the PAS does," the authors wrote. "This does not negate the role of premorbid adjustment but suggests that engagement difficulties may reflect both immediate and more longstanding issues."

They wrote that social and interpersonal malfunctioning might have preceded the frank psychotic symptoms and then become more conspicuous after positive symptoms fade, especially given the correlation found between negative symptoms and poor premorbid social adjustment.

It’s unclear what the implications of poorer engagement portend. The authors noted that patients might be at risk of disengagement if they present poorer levels of engagement, or "engagement difficulties may be a marker for difficulties in adapting to the diagnosis of psychosis and its associated impact."

The study was limited by its exploratory cross-sectional design and the small sample size. Further, the patients’ participation during nonacute illness (though not asymptomatic) and their responsiveness to early intervention may mean the participants "represent a higher functioning group of individuals, with a corresponding reduction of variance in the duration of psychosis and lower levels of positive and negative symptoms," than do other cohorts.

The authors said their findings underscore "the importance of clear and comprehensive measurement of premorbid and onset variables in first-episode psychosis."

Dr. MacBeth was supported by a PhD scholarship from the University of Glasgow Medical School. The authors reported no disclosures.

The severity of schizophrenia patients’ negative symptoms might predict their service engagement after their first episode of psychosis, according to a study published in The Journal of Nervous and Mental Disease.

Researchers also found poorer engagement, as rated by clinicians, linked to greater positive and negative symptoms, greater general psychopathology, and poorer premorbid adolescent social adjustment (early and late) before regression analysis, reported Angus MacBeth, Ph.D., D.Clin.Psy., of the University of Glasgow, and his associates (J. Nerv. Ment. Dis. 2013;201:359-64 [doi: 10.1097/NMD.0b013e31828e0e19]).

Yet no correlation between duration of psychosis and engagement was found, and "only negative symptoms emerged as a significant independent predictor of engagement" following multiple regression analysis.

The researchers used a cross-sectional cohort design that included 64 people presenting with first-episode psychosis to early intervention psychosis services in two cities in Scotland. The sample comprised 43 men and 21 women, predominantly white and British. A plurality of patients was diagnosed with schizophrenia (28 patients). Among the others, 14 had bipolar disorder, 10 had schizoaffective disorder, 6 had persistent delusional disorder, 4 had schizophreniform disorder, and 2 had mania with psychotic symptoms.

Patients were included if they were in their first 12 months of treatment for first-episode psychosis and they did not have substance abuse, head injury, or an organic disorder determined to be the main cause of their psychotic symptoms.

In addition to the use of the Positive and Negative Syndrome Scale (PANSS) to assess schizophrenia symptoms, the researchers used the Premorbid Adjustment Scale (PAS), the Service Engagement Scale (SES), and an unstructured interview with the individual (when no longer floridly psychotic), and/or a caretaker or loved one to establish duration of psychosis.

The PAS measured prepsychosis academic and social functioning during the first three of four life stages: childhood, early adolescence, late adolescence, and adulthood. The four subscales of the Service Engagement Scale completed by clinicians were availability, collaboration, help-seeking, and treatment adherence.

Men and women scored similarly on the total clinician-rated SES score and the help-seeking and availability subscales. However, women scored more poorly (higher score) on the subscales of collaboration and treatment adherence (mean 3.63 for females, 1.87 for males, t = –2.42, df = 45, P = .02). Women also reported "significantly greater impairment in [adolescent] social functioning than male participants did" (t = –2.233, df = 40, P = .031).

The authors found the post–regression-analysis association with negative symptoms "puzzling," given that previous studies on predictors of disengagement have not found such a correlation with negative symptoms. They suggested a possible conflation of negative symptoms with social functioning as a potential underlying mechanism for the association.

"Perhaps negative symptoms are more likely to predict engagement, because they reflect a more contemporaneous measure of social functioning than the PAS does," the authors wrote. "This does not negate the role of premorbid adjustment but suggests that engagement difficulties may reflect both immediate and more longstanding issues."

They wrote that social and interpersonal malfunctioning might have preceded the frank psychotic symptoms and then become more conspicuous after positive symptoms fade, especially given the correlation found between negative symptoms and poor premorbid social adjustment.

It’s unclear what the implications of poorer engagement portend. The authors noted that patients might be at risk of disengagement if they present poorer levels of engagement, or "engagement difficulties may be a marker for difficulties in adapting to the diagnosis of psychosis and its associated impact."

The study was limited by its exploratory cross-sectional design and the small sample size. Further, the patients’ participation during nonacute illness (though not asymptomatic) and their responsiveness to early intervention may mean the participants "represent a higher functioning group of individuals, with a corresponding reduction of variance in the duration of psychosis and lower levels of positive and negative symptoms," than do other cohorts.

The authors said their findings underscore "the importance of clear and comprehensive measurement of premorbid and onset variables in first-episode psychosis."

Dr. MacBeth was supported by a PhD scholarship from the University of Glasgow Medical School. The authors reported no disclosures.

The severity of schizophrenia patients’ negative symptoms might predict their service engagement after their first episode of psychosis, according to a study published in The Journal of Nervous and Mental Disease.

Researchers also found poorer engagement, as rated by clinicians, linked to greater positive and negative symptoms, greater general psychopathology, and poorer premorbid adolescent social adjustment (early and late) before regression analysis, reported Angus MacBeth, Ph.D., D.Clin.Psy., of the University of Glasgow, and his associates (J. Nerv. Ment. Dis. 2013;201:359-64 [doi: 10.1097/NMD.0b013e31828e0e19]).

Yet no correlation between duration of psychosis and engagement was found, and "only negative symptoms emerged as a significant independent predictor of engagement" following multiple regression analysis.

The researchers used a cross-sectional cohort design that included 64 people presenting with first-episode psychosis to early intervention psychosis services in two cities in Scotland. The sample comprised 43 men and 21 women, predominantly white and British. A plurality of patients was diagnosed with schizophrenia (28 patients). Among the others, 14 had bipolar disorder, 10 had schizoaffective disorder, 6 had persistent delusional disorder, 4 had schizophreniform disorder, and 2 had mania with psychotic symptoms.

Patients were included if they were in their first 12 months of treatment for first-episode psychosis and they did not have substance abuse, head injury, or an organic disorder determined to be the main cause of their psychotic symptoms.

In addition to the use of the Positive and Negative Syndrome Scale (PANSS) to assess schizophrenia symptoms, the researchers used the Premorbid Adjustment Scale (PAS), the Service Engagement Scale (SES), and an unstructured interview with the individual (when no longer floridly psychotic), and/or a caretaker or loved one to establish duration of psychosis.

The PAS measured prepsychosis academic and social functioning during the first three of four life stages: childhood, early adolescence, late adolescence, and adulthood. The four subscales of the Service Engagement Scale completed by clinicians were availability, collaboration, help-seeking, and treatment adherence.

Men and women scored similarly on the total clinician-rated SES score and the help-seeking and availability subscales. However, women scored more poorly (higher score) on the subscales of collaboration and treatment adherence (mean 3.63 for females, 1.87 for males, t = –2.42, df = 45, P = .02). Women also reported "significantly greater impairment in [adolescent] social functioning than male participants did" (t = –2.233, df = 40, P = .031).

The authors found the post–regression-analysis association with negative symptoms "puzzling," given that previous studies on predictors of disengagement have not found such a correlation with negative symptoms. They suggested a possible conflation of negative symptoms with social functioning as a potential underlying mechanism for the association.

"Perhaps negative symptoms are more likely to predict engagement, because they reflect a more contemporaneous measure of social functioning than the PAS does," the authors wrote. "This does not negate the role of premorbid adjustment but suggests that engagement difficulties may reflect both immediate and more longstanding issues."

They wrote that social and interpersonal malfunctioning might have preceded the frank psychotic symptoms and then become more conspicuous after positive symptoms fade, especially given the correlation found between negative symptoms and poor premorbid social adjustment.

It’s unclear what the implications of poorer engagement portend. The authors noted that patients might be at risk of disengagement if they present poorer levels of engagement, or "engagement difficulties may be a marker for difficulties in adapting to the diagnosis of psychosis and its associated impact."

The study was limited by its exploratory cross-sectional design and the small sample size. Further, the patients’ participation during nonacute illness (though not asymptomatic) and their responsiveness to early intervention may mean the participants "represent a higher functioning group of individuals, with a corresponding reduction of variance in the duration of psychosis and lower levels of positive and negative symptoms," than do other cohorts.

The authors said their findings underscore "the importance of clear and comprehensive measurement of premorbid and onset variables in first-episode psychosis."

Dr. MacBeth was supported by a PhD scholarship from the University of Glasgow Medical School. The authors reported no disclosures.

Children with autism spectrum disorders spent significantly more time than their typically developing siblings playing video games, and playing certain types of video games was associated with behavioral issues, according to two studies published in Research in Autism Spectrum Disorders and in the Journal of Autism and Development Disorders.

But children with autism spectrum disorders (ASD) spent significantly less time than their typically developing (TD) siblings on social media and socially interactive games, as well as on all nonscreen activities in general, such as homework, socializing, or sports.

©adamfilip/iStockphoto.com

Meanwhile, boys with ASD who played video games showed addictive behaviors in their gaming if they played them for more hours or if they played shooter or role-playing games, and problem behaviors were positively associated with inattention and oppositional defiant symptoms, the researchers found.

The findings on video game behaviors among boys with ASD were reported on Feb. 13 by Micah O. Mazurek, Ph.D., and Christopher R. Engelhardt of the University of Missouri, Columbia (Res. Autism Spectr. Disord. 2013;7:316-24). Dr. Mazurek and her colleague Colleen Wenstrup reported the screen behavior findings in ASD children and their siblings in 2012 (J. Autism Dev. Disord. 2012 Sept. 22 [doi: 10.1007/s10803-012-1659-9]).

The researchers recruited the parents of 202 children and teens with ASD and their 179 TD siblings through the Interactive Autism Network Project at the Kennedy Krieger Institute in Baltimore. The project is sponsored by the Autism Speaks Foundation. The predominantly white children were aged 8-18 years; the mean age of the children in the ASD group was 12.1 years, and the mean age for the sibling group was 12.5 years.

Among the 202 ASD children, 53.5% had autistic disorder, 27.2% had Asperger’s disorder, and 17.3% had pervasive developmental disorder, not otherwise specified (PDD NOS). A subgroup of the ASD children, comprised of 169 boys who played video games, was evaluated for the study on video game playing and problem behaviors.

Parents were surveyed via the Web for information on their children’s video game usage. In addition to information on age, race, parent marital status, household income, number of siblings, the autistic child’s estimated IQ (if known), and diagnostic information, the parents estimated how much time their children spent in hours each weekday and each weekend day on the following activities:

• Reading for pleasure.

• Doing homework/studying.

• Spending time with friends.

• Playing sports/other physical activity.

• Watching TV.

• Playing video or computer games.

• Using e-mail, Facebook, or texting.

Parents whose children played video games also were asked whether the children played the games with other children in the same place and whether they play multiplayer networked games. Parents also answered questions for the Problem Video Game Playing Test (PVGT) to assess problematic aspects of the children’s video gaming.

ASD children spent 62% more time on screen-based activities (mean, 4.5 hours daily) than on all nonscreen activities combined (mean, 2.8 hours daily), and a substantial portion of this additional screen time included video games, where ASD children outplayed their TD siblings. ASD children spent an average of 2 hours each weekday and 3.1 hours a day on weekends playing video games, compared with 1.2 daily weekday hours and 1.7 weekend daily hours spent by the TD children.

Dr. Mazurek, a clinical child psychologist at the Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, said there are several possibilities she and colleagues are exploring related to why ASD children play more video games. "One theory is that children with autism have really strong visual spatial skill and are really drawn to visual stimuli," she said in an interview. "These games also are designed to provide really frequent reinforcement: They’re engaging, but they have a lot of structure, and that can be reinforcing for kids with ASD." She added that video games don’t require a lot of face-to-face interaction like other social games might require.

ASD boys spent an average of only 0.2 hours daily on social media, compared with 0.8 hours daily among TD boys, and ASD girls spent 0.3 hours daily on social media, compared with 1.2 hours daily among TD girls. Time spent with friends showed similar patterns: ASD boys spent 0.4 hours daily and ASD girls spent 0.2 hours daily socializing with friends, while TD boys spent 1.8 hours daily and TD girls spent 1.7 hours daily.

The ASD children were not getting additional social interaction from their video game play: 48% of the ASD boys and 61% of the ASD girls had never played video games with other people, and 76% of boys and 90% of girls had never played online multiplayer games. Only 15% of boys and 6.5% of girls played video games once a week with others.

"Anecdotally, I’ve heard people hypothesize that video game play or technology use may be a social outlet for ASD children, but we found that kids with autism are using a lot less of those social media and social video games than their typically developing siblings," Dr. Mazurek said. "It does seem to be more of an isolated experience for them."

Among the 169 boys who were assessed for problem behaviors associated with video game play, 52.7% had autistic disorder, 28.4% had Asperger’s disorder, and 18.9% had PDD NOS. The parents of these boys filled out additional questionnaires about the video game genres their children most often played and the boys’ symptoms of inattention, hyperactivity/impulsivity, and oppositional defiant behaviors as assessed through the Vanderbilt Attention-Deficit/Hyperactivity Disorder Patient Rating Scale (VADPRS).

The three most popular game genres were action (this genre was ranked by 16% of parents as their child’s first preference, and by 31% of parents as one of their child’s top three preferences), platform (14% ranked it first and 25% ranked it in the top three), and shooter (13% ranked it first and 21% ranked it in the top three). The researchers found statistically significant associations only between the children’s VADPRS scores and the role-playing and shooter games. Role playing was ranked first by 9% of the parents as their child’s primary game and was ranked in the top three by 20% of parents.

Hours per day spent playing games was not associated with any of the problem behaviors (inattention, hyperactivity, or oppositional defiant behavior). "Rather, the most reliable predictors of problem behaviors were shown to be video game genre and problematic, or addictive, qualities of play," the investigators wrote. The number of daily hours spent playing video games was positively and significantly associated with PVGT scores, especially among boys playing shooter or role-playing games.

PVGT scores were positively associated with inattention and oppositional defiant behavior, but not hyperactivity/impulsivity – a surprising finding, Dr. Mazurek said, because other studies have found correlations with impulsivity. No association was found for predicting inattention based on age, video game hours, or video game genre. Oppositional defiant behavior was predicted for role-playing genres, but not age, video game hours, or shooter games.

"Given their tendency to engage in restricted and repetitive patterns of activity, children with ASD may be at particular risk for developing problematic, or addictive, game play patterns," the researchers wrote.

However, the attraction of video games could serve therapeutic purposes as well. "I would encourage parents not to let their kids have free rein to play games as much as they want," Dr. Mazurek said. "If we’re going to capitalize on this interest in technology in therapeutic ways, we need to do that alongside face-to-face interactions."

The authors noted that the cross-sectional design of the video game behaviors study precludes conclusions about causality. "It is possible that children with pre-existing behavior problems are more inclined to play video games for longer periods of time and in a more intense manner," they wrote, or video game play patterns could influence problem behavior, or the problems could be bidirectional.

Both studies were internally funded, and the authors had no disclosures.

Children with autism spectrum disorders spent significantly more time than their typically developing siblings playing video games, and playing certain types of video games was associated with behavioral issues, according to two studies published in Research in Autism Spectrum Disorders and in the Journal of Autism and Development Disorders.

But children with autism spectrum disorders (ASD) spent significantly less time than their typically developing (TD) siblings on social media and socially interactive games, as well as on all nonscreen activities in general, such as homework, socializing, or sports.

©adamfilip/iStockphoto.com

Meanwhile, boys with ASD who played video games showed addictive behaviors in their gaming if they played them for more hours or if they played shooter or role-playing games, and problem behaviors were positively associated with inattention and oppositional defiant symptoms, the researchers found.

The findings on video game behaviors among boys with ASD were reported on Feb. 13 by Micah O. Mazurek, Ph.D., and Christopher R. Engelhardt of the University of Missouri, Columbia (Res. Autism Spectr. Disord. 2013;7:316-24). Dr. Mazurek and her colleague Colleen Wenstrup reported the screen behavior findings in ASD children and their siblings in 2012 (J. Autism Dev. Disord. 2012 Sept. 22 [doi: 10.1007/s10803-012-1659-9]).

The researchers recruited the parents of 202 children and teens with ASD and their 179 TD siblings through the Interactive Autism Network Project at the Kennedy Krieger Institute in Baltimore. The project is sponsored by the Autism Speaks Foundation. The predominantly white children were aged 8-18 years; the mean age of the children in the ASD group was 12.1 years, and the mean age for the sibling group was 12.5 years.

Among the 202 ASD children, 53.5% had autistic disorder, 27.2% had Asperger’s disorder, and 17.3% had pervasive developmental disorder, not otherwise specified (PDD NOS). A subgroup of the ASD children, comprised of 169 boys who played video games, was evaluated for the study on video game playing and problem behaviors.

Parents were surveyed via the Web for information on their children’s video game usage. In addition to information on age, race, parent marital status, household income, number of siblings, the autistic child’s estimated IQ (if known), and diagnostic information, the parents estimated how much time their children spent in hours each weekday and each weekend day on the following activities:

• Reading for pleasure.

• Doing homework/studying.

• Spending time with friends.

• Playing sports/other physical activity.

• Watching TV.

• Playing video or computer games.

• Using e-mail, Facebook, or texting.

Parents whose children played video games also were asked whether the children played the games with other children in the same place and whether they play multiplayer networked games. Parents also answered questions for the Problem Video Game Playing Test (PVGT) to assess problematic aspects of the children’s video gaming.

ASD children spent 62% more time on screen-based activities (mean, 4.5 hours daily) than on all nonscreen activities combined (mean, 2.8 hours daily), and a substantial portion of this additional screen time included video games, where ASD children outplayed their TD siblings. ASD children spent an average of 2 hours each weekday and 3.1 hours a day on weekends playing video games, compared with 1.2 daily weekday hours and 1.7 weekend daily hours spent by the TD children.

Dr. Mazurek, a clinical child psychologist at the Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, said there are several possibilities she and colleagues are exploring related to why ASD children play more video games. "One theory is that children with autism have really strong visual spatial skill and are really drawn to visual stimuli," she said in an interview. "These games also are designed to provide really frequent reinforcement: They’re engaging, but they have a lot of structure, and that can be reinforcing for kids with ASD." She added that video games don’t require a lot of face-to-face interaction like other social games might require.

ASD boys spent an average of only 0.2 hours daily on social media, compared with 0.8 hours daily among TD boys, and ASD girls spent 0.3 hours daily on social media, compared with 1.2 hours daily among TD girls. Time spent with friends showed similar patterns: ASD boys spent 0.4 hours daily and ASD girls spent 0.2 hours daily socializing with friends, while TD boys spent 1.8 hours daily and TD girls spent 1.7 hours daily.

The ASD children were not getting additional social interaction from their video game play: 48% of the ASD boys and 61% of the ASD girls had never played video games with other people, and 76% of boys and 90% of girls had never played online multiplayer games. Only 15% of boys and 6.5% of girls played video games once a week with others.

"Anecdotally, I’ve heard people hypothesize that video game play or technology use may be a social outlet for ASD children, but we found that kids with autism are using a lot less of those social media and social video games than their typically developing siblings," Dr. Mazurek said. "It does seem to be more of an isolated experience for them."

Among the 169 boys who were assessed for problem behaviors associated with video game play, 52.7% had autistic disorder, 28.4% had Asperger’s disorder, and 18.9% had PDD NOS. The parents of these boys filled out additional questionnaires about the video game genres their children most often played and the boys’ symptoms of inattention, hyperactivity/impulsivity, and oppositional defiant behaviors as assessed through the Vanderbilt Attention-Deficit/Hyperactivity Disorder Patient Rating Scale (VADPRS).

The three most popular game genres were action (this genre was ranked by 16% of parents as their child’s first preference, and by 31% of parents as one of their child’s top three preferences), platform (14% ranked it first and 25% ranked it in the top three), and shooter (13% ranked it first and 21% ranked it in the top three). The researchers found statistically significant associations only between the children’s VADPRS scores and the role-playing and shooter games. Role playing was ranked first by 9% of the parents as their child’s primary game and was ranked in the top three by 20% of parents.

Hours per day spent playing games was not associated with any of the problem behaviors (inattention, hyperactivity, or oppositional defiant behavior). "Rather, the most reliable predictors of problem behaviors were shown to be video game genre and problematic, or addictive, qualities of play," the investigators wrote. The number of daily hours spent playing video games was positively and significantly associated with PVGT scores, especially among boys playing shooter or role-playing games.

PVGT scores were positively associated with inattention and oppositional defiant behavior, but not hyperactivity/impulsivity – a surprising finding, Dr. Mazurek said, because other studies have found correlations with impulsivity. No association was found for predicting inattention based on age, video game hours, or video game genre. Oppositional defiant behavior was predicted for role-playing genres, but not age, video game hours, or shooter games.

"Given their tendency to engage in restricted and repetitive patterns of activity, children with ASD may be at particular risk for developing problematic, or addictive, game play patterns," the researchers wrote.

However, the attraction of video games could serve therapeutic purposes as well. "I would encourage parents not to let their kids have free rein to play games as much as they want," Dr. Mazurek said. "If we’re going to capitalize on this interest in technology in therapeutic ways, we need to do that alongside face-to-face interactions."

The authors noted that the cross-sectional design of the video game behaviors study precludes conclusions about causality. "It is possible that children with pre-existing behavior problems are more inclined to play video games for longer periods of time and in a more intense manner," they wrote, or video game play patterns could influence problem behavior, or the problems could be bidirectional.

Both studies were internally funded, and the authors had no disclosures.

Children with autism spectrum disorders spent significantly more time than their typically developing siblings playing video games, and playing certain types of video games was associated with behavioral issues, according to two studies published in Research in Autism Spectrum Disorders and in the Journal of Autism and Development Disorders.

But children with autism spectrum disorders (ASD) spent significantly less time than their typically developing (TD) siblings on social media and socially interactive games, as well as on all nonscreen activities in general, such as homework, socializing, or sports.

©adamfilip/iStockphoto.com

Meanwhile, boys with ASD who played video games showed addictive behaviors in their gaming if they played them for more hours or if they played shooter or role-playing games, and problem behaviors were positively associated with inattention and oppositional defiant symptoms, the researchers found.

The findings on video game behaviors among boys with ASD were reported on Feb. 13 by Micah O. Mazurek, Ph.D., and Christopher R. Engelhardt of the University of Missouri, Columbia (Res. Autism Spectr. Disord. 2013;7:316-24). Dr. Mazurek and her colleague Colleen Wenstrup reported the screen behavior findings in ASD children and their siblings in 2012 (J. Autism Dev. Disord. 2012 Sept. 22 [doi: 10.1007/s10803-012-1659-9]).

The researchers recruited the parents of 202 children and teens with ASD and their 179 TD siblings through the Interactive Autism Network Project at the Kennedy Krieger Institute in Baltimore. The project is sponsored by the Autism Speaks Foundation. The predominantly white children were aged 8-18 years; the mean age of the children in the ASD group was 12.1 years, and the mean age for the sibling group was 12.5 years.

Among the 202 ASD children, 53.5% had autistic disorder, 27.2% had Asperger’s disorder, and 17.3% had pervasive developmental disorder, not otherwise specified (PDD NOS). A subgroup of the ASD children, comprised of 169 boys who played video games, was evaluated for the study on video game playing and problem behaviors.

Parents were surveyed via the Web for information on their children’s video game usage. In addition to information on age, race, parent marital status, household income, number of siblings, the autistic child’s estimated IQ (if known), and diagnostic information, the parents estimated how much time their children spent in hours each weekday and each weekend day on the following activities:

• Reading for pleasure.

• Doing homework/studying.

• Spending time with friends.

• Playing sports/other physical activity.

• Watching TV.

• Playing video or computer games.

• Using e-mail, Facebook, or texting.

Parents whose children played video games also were asked whether the children played the games with other children in the same place and whether they play multiplayer networked games. Parents also answered questions for the Problem Video Game Playing Test (PVGT) to assess problematic aspects of the children’s video gaming.

ASD children spent 62% more time on screen-based activities (mean, 4.5 hours daily) than on all nonscreen activities combined (mean, 2.8 hours daily), and a substantial portion of this additional screen time included video games, where ASD children outplayed their TD siblings. ASD children spent an average of 2 hours each weekday and 3.1 hours a day on weekends playing video games, compared with 1.2 daily weekday hours and 1.7 weekend daily hours spent by the TD children.

Dr. Mazurek, a clinical child psychologist at the Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, said there are several possibilities she and colleagues are exploring related to why ASD children play more video games. "One theory is that children with autism have really strong visual spatial skill and are really drawn to visual stimuli," she said in an interview. "These games also are designed to provide really frequent reinforcement: They’re engaging, but they have a lot of structure, and that can be reinforcing for kids with ASD." She added that video games don’t require a lot of face-to-face interaction like other social games might require.

ASD boys spent an average of only 0.2 hours daily on social media, compared with 0.8 hours daily among TD boys, and ASD girls spent 0.3 hours daily on social media, compared with 1.2 hours daily among TD girls. Time spent with friends showed similar patterns: ASD boys spent 0.4 hours daily and ASD girls spent 0.2 hours daily socializing with friends, while TD boys spent 1.8 hours daily and TD girls spent 1.7 hours daily.

The ASD children were not getting additional social interaction from their video game play: 48% of the ASD boys and 61% of the ASD girls had never played video games with other people, and 76% of boys and 90% of girls had never played online multiplayer games. Only 15% of boys and 6.5% of girls played video games once a week with others.

"Anecdotally, I’ve heard people hypothesize that video game play or technology use may be a social outlet for ASD children, but we found that kids with autism are using a lot less of those social media and social video games than their typically developing siblings," Dr. Mazurek said. "It does seem to be more of an isolated experience for them."

Among the 169 boys who were assessed for problem behaviors associated with video game play, 52.7% had autistic disorder, 28.4% had Asperger’s disorder, and 18.9% had PDD NOS. The parents of these boys filled out additional questionnaires about the video game genres their children most often played and the boys’ symptoms of inattention, hyperactivity/impulsivity, and oppositional defiant behaviors as assessed through the Vanderbilt Attention-Deficit/Hyperactivity Disorder Patient Rating Scale (VADPRS).

The three most popular game genres were action (this genre was ranked by 16% of parents as their child’s first preference, and by 31% of parents as one of their child’s top three preferences), platform (14% ranked it first and 25% ranked it in the top three), and shooter (13% ranked it first and 21% ranked it in the top three). The researchers found statistically significant associations only between the children’s VADPRS scores and the role-playing and shooter games. Role playing was ranked first by 9% of the parents as their child’s primary game and was ranked in the top three by 20% of parents.

Hours per day spent playing games was not associated with any of the problem behaviors (inattention, hyperactivity, or oppositional defiant behavior). "Rather, the most reliable predictors of problem behaviors were shown to be video game genre and problematic, or addictive, qualities of play," the investigators wrote. The number of daily hours spent playing video games was positively and significantly associated with PVGT scores, especially among boys playing shooter or role-playing games.

PVGT scores were positively associated with inattention and oppositional defiant behavior, but not hyperactivity/impulsivity – a surprising finding, Dr. Mazurek said, because other studies have found correlations with impulsivity. No association was found for predicting inattention based on age, video game hours, or video game genre. Oppositional defiant behavior was predicted for role-playing genres, but not age, video game hours, or shooter games.

"Given their tendency to engage in restricted and repetitive patterns of activity, children with ASD may be at particular risk for developing problematic, or addictive, game play patterns," the researchers wrote.

However, the attraction of video games could serve therapeutic purposes as well. "I would encourage parents not to let their kids have free rein to play games as much as they want," Dr. Mazurek said. "If we’re going to capitalize on this interest in technology in therapeutic ways, we need to do that alongside face-to-face interactions."

The authors noted that the cross-sectional design of the video game behaviors study precludes conclusions about causality. "It is possible that children with pre-existing behavior problems are more inclined to play video games for longer periods of time and in a more intense manner," they wrote, or video game play patterns could influence problem behavior, or the problems could be bidirectional.

Both studies were internally funded, and the authors had no disclosures.

Prophylactic administration of penicillin reduces the number of leg cellulitis recurrences without an increase in adverse events in patients who have a history of recurrences, according to a study published in the May 2 issue of the New England Journal of Medicine.

"Low-dose prophylactic penicillin given for a period of 12 months almost halved the risk of recurrence during the intervention period, and patients who received prophylaxis had significantly fewer recurrent episodes over the 3-year period than those who received placebo," reported Dr. Kim S. Thomas of the University of Nottingham, England, and her associates (N. Engl. J. Med. 2013 [doi: 10.1056/NEJMoa1206300]).

A total of 274 patients with recurrent cellulitis of the leg (two episodes within the past 3 years) who had experienced an episode within the previous 24 weeks, confirmed by a dermatologist or by medical records, were enrolled in the study between July 2006 and January 2010 from 28 hospitals in the United Kingdom and Ireland.

Patients were only included if they had "local warmth, tenderness or acute pain," unilateral or bilateral erythema, and unilateral edema. They were excluded if they had taken antibiotics for cellulitis within the previous 6 months, were allergic to penicillin, or had a "previous leg ulceration, surgery or penetrating trauma," the investigators wrote.

In the double-blind, randomized controlled trial, the placebo group included 138 subjects and the intervention group included 136 participants who received 250 mg of penicillin twice daily for a year, beginning after the index episode of cellulitis had been treated. At least 90% of the participants underwent a minimum of 18 months’ follow-up – 5% withdrew or were lost to follow-up and 4% died.

During the 12 months of prophylaxis, 76 recurrences of cellulitis occurred in the penicillin group and 122 occurred in the placebo group (P = .03). The 45% risk reduction for a recurrence of cellulitis among the patients taking the penicillin, however, did not persist after the year of prophylaxis, with 43 recurrences in the penicillin group and 42 in the placebo group (P = .88) during postprophylaxis follow-up, Dr. Thomas and her associates reported.

During all of the follow-up (median, 25 months), 119 repeat episodes occurred in the penicillin group, with a median 626 days to first recurrence, and 164 occurred among the placebo patients, with a median 532 days to first recurrence (P = .02 for repeat episodes). Overall, 129 participants experienced 281 recurrences, including 50 patients (39%) who had one repeat episode, 38 patients (29%) who had two, 20 patients (16%) who had three, and 21 patients (16%) who had at least four. A total of 58 repeat episodes (30 in the penicillin group and 28 in the placebo group) resulted in admission to the hospital.

None of the 11 deaths (8 penicillin, 3 placebo) that occurred were attributed to the study drugs, and adverse event rates were similar in both groups, with 37 among the penicillin patients and 48 in the placebo group (P = .05).

Participants who responded poorly to penicillin treatment were more likely to have a body mass index of 33 or higher (P = .01), to have a history of at least three previous cellulitis episodes (P < .001), or to have an edema (P = .06, or borderline statistical significance). "The poor treatment response in participants with a high BMI may mean that a higher dose of penicillin is required in these patients," Dr. Thomas and her associates suggested.

Because the effect of the prophylaxis was gone by the third year of follow-up, the authors noted that it is unclear how long the penicillin should be given and may depend "on whether any predisposing factors, such as broken skin or lymphedema, can be adequately treated."

The study was funded by a grant from Action Medical Research. Dr. James Mason reported non–cellulitis-related consultancy for Reckitt Beckiser and receiving non–cellulitis-related grant funding from the U.K.’s National Institute for Health Research (NIHR). Dr. Kim Thomas reported that NIHR Comprehensive Local Research Network has provided funding to her institution for her work on this study. No other disclosures were reported beyond travel funds from the Action Medical Research study grant.

Prophylactic administration of penicillin reduces the number of leg cellulitis recurrences without an increase in adverse events in patients who have a history of recurrences, according to a study published in the May 2 issue of the New England Journal of Medicine.

"Low-dose prophylactic penicillin given for a period of 12 months almost halved the risk of recurrence during the intervention period, and patients who received prophylaxis had significantly fewer recurrent episodes over the 3-year period than those who received placebo," reported Dr. Kim S. Thomas of the University of Nottingham, England, and her associates (N. Engl. J. Med. 2013 [doi: 10.1056/NEJMoa1206300]).

A total of 274 patients with recurrent cellulitis of the leg (two episodes within the past 3 years) who had experienced an episode within the previous 24 weeks, confirmed by a dermatologist or by medical records, were enrolled in the study between July 2006 and January 2010 from 28 hospitals in the United Kingdom and Ireland.

Patients were only included if they had "local warmth, tenderness or acute pain," unilateral or bilateral erythema, and unilateral edema. They were excluded if they had taken antibiotics for cellulitis within the previous 6 months, were allergic to penicillin, or had a "previous leg ulceration, surgery or penetrating trauma," the investigators wrote.

In the double-blind, randomized controlled trial, the placebo group included 138 subjects and the intervention group included 136 participants who received 250 mg of penicillin twice daily for a year, beginning after the index episode of cellulitis had been treated. At least 90% of the participants underwent a minimum of 18 months’ follow-up – 5% withdrew or were lost to follow-up and 4% died.

During the 12 months of prophylaxis, 76 recurrences of cellulitis occurred in the penicillin group and 122 occurred in the placebo group (P = .03). The 45% risk reduction for a recurrence of cellulitis among the patients taking the penicillin, however, did not persist after the year of prophylaxis, with 43 recurrences in the penicillin group and 42 in the placebo group (P = .88) during postprophylaxis follow-up, Dr. Thomas and her associates reported.

During all of the follow-up (median, 25 months), 119 repeat episodes occurred in the penicillin group, with a median 626 days to first recurrence, and 164 occurred among the placebo patients, with a median 532 days to first recurrence (P = .02 for repeat episodes). Overall, 129 participants experienced 281 recurrences, including 50 patients (39%) who had one repeat episode, 38 patients (29%) who had two, 20 patients (16%) who had three, and 21 patients (16%) who had at least four. A total of 58 repeat episodes (30 in the penicillin group and 28 in the placebo group) resulted in admission to the hospital.

None of the 11 deaths (8 penicillin, 3 placebo) that occurred were attributed to the study drugs, and adverse event rates were similar in both groups, with 37 among the penicillin patients and 48 in the placebo group (P = .05).

Participants who responded poorly to penicillin treatment were more likely to have a body mass index of 33 or higher (P = .01), to have a history of at least three previous cellulitis episodes (P < .001), or to have an edema (P = .06, or borderline statistical significance). "The poor treatment response in participants with a high BMI may mean that a higher dose of penicillin is required in these patients," Dr. Thomas and her associates suggested.

Because the effect of the prophylaxis was gone by the third year of follow-up, the authors noted that it is unclear how long the penicillin should be given and may depend "on whether any predisposing factors, such as broken skin or lymphedema, can be adequately treated."

The study was funded by a grant from Action Medical Research. Dr. James Mason reported non–cellulitis-related consultancy for Reckitt Beckiser and receiving non–cellulitis-related grant funding from the U.K.’s National Institute for Health Research (NIHR). Dr. Kim Thomas reported that NIHR Comprehensive Local Research Network has provided funding to her institution for her work on this study. No other disclosures were reported beyond travel funds from the Action Medical Research study grant.

Prophylactic administration of penicillin reduces the number of leg cellulitis recurrences without an increase in adverse events in patients who have a history of recurrences, according to a study published in the May 2 issue of the New England Journal of Medicine.

"Low-dose prophylactic penicillin given for a period of 12 months almost halved the risk of recurrence during the intervention period, and patients who received prophylaxis had significantly fewer recurrent episodes over the 3-year period than those who received placebo," reported Dr. Kim S. Thomas of the University of Nottingham, England, and her associates (N. Engl. J. Med. 2013 [doi: 10.1056/NEJMoa1206300]).

A total of 274 patients with recurrent cellulitis of the leg (two episodes within the past 3 years) who had experienced an episode within the previous 24 weeks, confirmed by a dermatologist or by medical records, were enrolled in the study between July 2006 and January 2010 from 28 hospitals in the United Kingdom and Ireland.

Patients were only included if they had "local warmth, tenderness or acute pain," unilateral or bilateral erythema, and unilateral edema. They were excluded if they had taken antibiotics for cellulitis within the previous 6 months, were allergic to penicillin, or had a "previous leg ulceration, surgery or penetrating trauma," the investigators wrote.

In the double-blind, randomized controlled trial, the placebo group included 138 subjects and the intervention group included 136 participants who received 250 mg of penicillin twice daily for a year, beginning after the index episode of cellulitis had been treated. At least 90% of the participants underwent a minimum of 18 months’ follow-up – 5% withdrew or were lost to follow-up and 4% died.

During the 12 months of prophylaxis, 76 recurrences of cellulitis occurred in the penicillin group and 122 occurred in the placebo group (P = .03). The 45% risk reduction for a recurrence of cellulitis among the patients taking the penicillin, however, did not persist after the year of prophylaxis, with 43 recurrences in the penicillin group and 42 in the placebo group (P = .88) during postprophylaxis follow-up, Dr. Thomas and her associates reported.

During all of the follow-up (median, 25 months), 119 repeat episodes occurred in the penicillin group, with a median 626 days to first recurrence, and 164 occurred among the placebo patients, with a median 532 days to first recurrence (P = .02 for repeat episodes). Overall, 129 participants experienced 281 recurrences, including 50 patients (39%) who had one repeat episode, 38 patients (29%) who had two, 20 patients (16%) who had three, and 21 patients (16%) who had at least four. A total of 58 repeat episodes (30 in the penicillin group and 28 in the placebo group) resulted in admission to the hospital.

None of the 11 deaths (8 penicillin, 3 placebo) that occurred were attributed to the study drugs, and adverse event rates were similar in both groups, with 37 among the penicillin patients and 48 in the placebo group (P = .05).

Participants who responded poorly to penicillin treatment were more likely to have a body mass index of 33 or higher (P = .01), to have a history of at least three previous cellulitis episodes (P < .001), or to have an edema (P = .06, or borderline statistical significance). "The poor treatment response in participants with a high BMI may mean that a higher dose of penicillin is required in these patients," Dr. Thomas and her associates suggested.

Because the effect of the prophylaxis was gone by the third year of follow-up, the authors noted that it is unclear how long the penicillin should be given and may depend "on whether any predisposing factors, such as broken skin or lymphedema, can be adequately treated."

The study was funded by a grant from Action Medical Research. Dr. James Mason reported non–cellulitis-related consultancy for Reckitt Beckiser and receiving non–cellulitis-related grant funding from the U.K.’s National Institute for Health Research (NIHR). Dr. Kim Thomas reported that NIHR Comprehensive Local Research Network has provided funding to her institution for her work on this study. No other disclosures were reported beyond travel funds from the Action Medical Research study grant.

Children and adolescents with systemic lupus erythematosus and cognitive dysfunction with or without psychosis in a recent small study generally responded well to immunosuppressive treatment lasting at least a year, with little long-term impairment.

Although about half of the patients developed new damage, the new damage did not interfere with their functional abilities, and only 15% of the 53 children in the study had persistent cognitive dysfunction after remission, reported Dr. Lily Siok Hoon Lim and her associates at the Hospital for Sick Children in Toronto.

The study included all children under age 18 years who had SLE (meeting a minimum of 4 of the 11 SLE classification criteria from the American College of Rheumatology) and an SLE-induced psychiatric illness or cognitive dysfunction while being treated at the hospital’s lupus clinic from 1985 to July 2009. Among the cohort of 40 SLE patients with psychiatric disorders and cognitive dysfunction and the 13 with only cognitive dysfunction, the median age at SLE diagnosis was 15 years, and the median age at psychiatric illness diagnosis was 16 years. Most (87%) of the patients were female (J. Rheumatol. 2013 March 1 [doi:10.3899/jrheum.121096]).

The children who were found to suffer cognitive dysfunction as a result of SLE had memory or concentration difficulties and/or academic performance impairments that improved after receiving treatment for the disease. The researchers did not include children whose psychiatric illness was preexisting, was caused by steroids, or was otherwise unrelated to SLE. In addition, none of the patients had comorbidities that may have otherwise accounted for their psychiatric condition or cognitive dysfunction.

All the patients received high-dose steroids and second-line immunosuppressants (except two patients from the earliest time period of the study), primarily azathioprine (60%), intravenous cyclophosphamide (34%), and mycophenolate mofetil (MMF, 2%). During the course of treatment, two patients were switched from azathioprine to MMF, and 10 patients receiving azathioprine were switched to intravenous cyclophosphamide after symptoms worsened. In addition, 16 of the psychiatric patients (42%) received antipsychotic medications for a median of 4.7 months; only 1 patient was still taking this medication a year later.

The patients were evaluated every 2-6 weeks until recovery, but only 49 patients could be assessed for long-term response. Of these, 9 patients (18%) did not respond to the treatment and 40 (82%) did, with a median response time of 39 weeks and no significant difference between the cognitive dysfunction and psychosis groups. The researchers defined response as an absence of all psychiatric and cognitive symptoms after the patient stopped taking antipsychotic medications and was taking less than 50% of the maximum dose of prednisone for at least 3 months.

Another 25 of the responders (63%) went into remission after a median of 71 weeks (72 weeks for the psychiatric group and 70 for the cognitive dysfunction group). Remission was defined as no psychiatric or cognitive symptoms, no antipsychotic medication, and less than 10 mg of prednisone a day or 0.2 mg/kg per day for at least 3 months. Among the 40 responders, 8 patients (20% of the total group) relapsed after a median of 17 weeks, which included 7 of the patients with psychiatric illness and 1 with only cognitive dysfunction.

Of the 51 patients who could be assessed for damage according to the SLE International Collaborative Clinics/American College of Rheumatology Damage Index (SDI), 26 of the patients (52%) had new damage since diagnosis, occurring a median of 0.9 years after diagnosis during a median follow-up time of 1.9 years (range, 0.4-6.5 years). The same proportion of patients with psychosis and cognitive dysfunction, and those with only cognitive dysfunction, had new cognitive impairment (15%) despite treatment during follow-up. There was no significant difference between the two groups in terms of the proportion of patients who had new damage. The most common damage was non–sight-threatening cataract, followed by diabetes, premature ovarian failure, and avascular necrosis. No patients developed chronic psychosis.

Though the researchers noted that the "optimal immunosuppressive treatment for psychiatric SLE is unclear," all the patients who started on cyclophosphamide responded and just over half of the patients started on azathioprine required a switch to cyclophosphamide due to a poor response. "We suggest that pediatric SLE patients with clinically important psychiatric SLE should receive induction therapy with intravenous cyclophosphamide and high-dose prednisone," the authors wrote.

Overall, Dr. Lim’s team found no significant differences between the children with psychosis and those with only cognitive dysfunction in terms of response or remission rates, time to response, relapse rates, or damage accrual.

The study was funded by the Peterborough K.M. Hunter Graduate Studentship, the Joseph M. West Family Memorial Scholarship, the Eddie Steinberg Scholarship Fund, and the Chrisholm Memorial Fellowship, all awarded to Dr. Lim.

Children and adolescents with systemic lupus erythematosus and cognitive dysfunction with or without psychosis in a recent small study generally responded well to immunosuppressive treatment lasting at least a year, with little long-term impairment.

Although about half of the patients developed new damage, the new damage did not interfere with their functional abilities, and only 15% of the 53 children in the study had persistent cognitive dysfunction after remission, reported Dr. Lily Siok Hoon Lim and her associates at the Hospital for Sick Children in Toronto.

The study included all children under age 18 years who had SLE (meeting a minimum of 4 of the 11 SLE classification criteria from the American College of Rheumatology) and an SLE-induced psychiatric illness or cognitive dysfunction while being treated at the hospital’s lupus clinic from 1985 to July 2009. Among the cohort of 40 SLE patients with psychiatric disorders and cognitive dysfunction and the 13 with only cognitive dysfunction, the median age at SLE diagnosis was 15 years, and the median age at psychiatric illness diagnosis was 16 years. Most (87%) of the patients were female (J. Rheumatol. 2013 March 1 [doi:10.3899/jrheum.121096]).

The children who were found to suffer cognitive dysfunction as a result of SLE had memory or concentration difficulties and/or academic performance impairments that improved after receiving treatment for the disease. The researchers did not include children whose psychiatric illness was preexisting, was caused by steroids, or was otherwise unrelated to SLE. In addition, none of the patients had comorbidities that may have otherwise accounted for their psychiatric condition or cognitive dysfunction.

All the patients received high-dose steroids and second-line immunosuppressants (except two patients from the earliest time period of the study), primarily azathioprine (60%), intravenous cyclophosphamide (34%), and mycophenolate mofetil (MMF, 2%). During the course of treatment, two patients were switched from azathioprine to MMF, and 10 patients receiving azathioprine were switched to intravenous cyclophosphamide after symptoms worsened. In addition, 16 of the psychiatric patients (42%) received antipsychotic medications for a median of 4.7 months; only 1 patient was still taking this medication a year later.

The patients were evaluated every 2-6 weeks until recovery, but only 49 patients could be assessed for long-term response. Of these, 9 patients (18%) did not respond to the treatment and 40 (82%) did, with a median response time of 39 weeks and no significant difference between the cognitive dysfunction and psychosis groups. The researchers defined response as an absence of all psychiatric and cognitive symptoms after the patient stopped taking antipsychotic medications and was taking less than 50% of the maximum dose of prednisone for at least 3 months.

Another 25 of the responders (63%) went into remission after a median of 71 weeks (72 weeks for the psychiatric group and 70 for the cognitive dysfunction group). Remission was defined as no psychiatric or cognitive symptoms, no antipsychotic medication, and less than 10 mg of prednisone a day or 0.2 mg/kg per day for at least 3 months. Among the 40 responders, 8 patients (20% of the total group) relapsed after a median of 17 weeks, which included 7 of the patients with psychiatric illness and 1 with only cognitive dysfunction.

Of the 51 patients who could be assessed for damage according to the SLE International Collaborative Clinics/American College of Rheumatology Damage Index (SDI), 26 of the patients (52%) had new damage since diagnosis, occurring a median of 0.9 years after diagnosis during a median follow-up time of 1.9 years (range, 0.4-6.5 years). The same proportion of patients with psychosis and cognitive dysfunction, and those with only cognitive dysfunction, had new cognitive impairment (15%) despite treatment during follow-up. There was no significant difference between the two groups in terms of the proportion of patients who had new damage. The most common damage was non–sight-threatening cataract, followed by diabetes, premature ovarian failure, and avascular necrosis. No patients developed chronic psychosis.

Though the researchers noted that the "optimal immunosuppressive treatment for psychiatric SLE is unclear," all the patients who started on cyclophosphamide responded and just over half of the patients started on azathioprine required a switch to cyclophosphamide due to a poor response. "We suggest that pediatric SLE patients with clinically important psychiatric SLE should receive induction therapy with intravenous cyclophosphamide and high-dose prednisone," the authors wrote.

Overall, Dr. Lim’s team found no significant differences between the children with psychosis and those with only cognitive dysfunction in terms of response or remission rates, time to response, relapse rates, or damage accrual.

The study was funded by the Peterborough K.M. Hunter Graduate Studentship, the Joseph M. West Family Memorial Scholarship, the Eddie Steinberg Scholarship Fund, and the Chrisholm Memorial Fellowship, all awarded to Dr. Lim.

Children and adolescents with systemic lupus erythematosus and cognitive dysfunction with or without psychosis in a recent small study generally responded well to immunosuppressive treatment lasting at least a year, with little long-term impairment.

Although about half of the patients developed new damage, the new damage did not interfere with their functional abilities, and only 15% of the 53 children in the study had persistent cognitive dysfunction after remission, reported Dr. Lily Siok Hoon Lim and her associates at the Hospital for Sick Children in Toronto.

The study included all children under age 18 years who had SLE (meeting a minimum of 4 of the 11 SLE classification criteria from the American College of Rheumatology) and an SLE-induced psychiatric illness or cognitive dysfunction while being treated at the hospital’s lupus clinic from 1985 to July 2009. Among the cohort of 40 SLE patients with psychiatric disorders and cognitive dysfunction and the 13 with only cognitive dysfunction, the median age at SLE diagnosis was 15 years, and the median age at psychiatric illness diagnosis was 16 years. Most (87%) of the patients were female (J. Rheumatol. 2013 March 1 [doi:10.3899/jrheum.121096]).

The children who were found to suffer cognitive dysfunction as a result of SLE had memory or concentration difficulties and/or academic performance impairments that improved after receiving treatment for the disease. The researchers did not include children whose psychiatric illness was preexisting, was caused by steroids, or was otherwise unrelated to SLE. In addition, none of the patients had comorbidities that may have otherwise accounted for their psychiatric condition or cognitive dysfunction.

All the patients received high-dose steroids and second-line immunosuppressants (except two patients from the earliest time period of the study), primarily azathioprine (60%), intravenous cyclophosphamide (34%), and mycophenolate mofetil (MMF, 2%). During the course of treatment, two patients were switched from azathioprine to MMF, and 10 patients receiving azathioprine were switched to intravenous cyclophosphamide after symptoms worsened. In addition, 16 of the psychiatric patients (42%) received antipsychotic medications for a median of 4.7 months; only 1 patient was still taking this medication a year later.

The patients were evaluated every 2-6 weeks until recovery, but only 49 patients could be assessed for long-term response. Of these, 9 patients (18%) did not respond to the treatment and 40 (82%) did, with a median response time of 39 weeks and no significant difference between the cognitive dysfunction and psychosis groups. The researchers defined response as an absence of all psychiatric and cognitive symptoms after the patient stopped taking antipsychotic medications and was taking less than 50% of the maximum dose of prednisone for at least 3 months.

Another 25 of the responders (63%) went into remission after a median of 71 weeks (72 weeks for the psychiatric group and 70 for the cognitive dysfunction group). Remission was defined as no psychiatric or cognitive symptoms, no antipsychotic medication, and less than 10 mg of prednisone a day or 0.2 mg/kg per day for at least 3 months. Among the 40 responders, 8 patients (20% of the total group) relapsed after a median of 17 weeks, which included 7 of the patients with psychiatric illness and 1 with only cognitive dysfunction.

Of the 51 patients who could be assessed for damage according to the SLE International Collaborative Clinics/American College of Rheumatology Damage Index (SDI), 26 of the patients (52%) had new damage since diagnosis, occurring a median of 0.9 years after diagnosis during a median follow-up time of 1.9 years (range, 0.4-6.5 years). The same proportion of patients with psychosis and cognitive dysfunction, and those with only cognitive dysfunction, had new cognitive impairment (15%) despite treatment during follow-up. There was no significant difference between the two groups in terms of the proportion of patients who had new damage. The most common damage was non–sight-threatening cataract, followed by diabetes, premature ovarian failure, and avascular necrosis. No patients developed chronic psychosis.

Though the researchers noted that the "optimal immunosuppressive treatment for psychiatric SLE is unclear," all the patients who started on cyclophosphamide responded and just over half of the patients started on azathioprine required a switch to cyclophosphamide due to a poor response. "We suggest that pediatric SLE patients with clinically important psychiatric SLE should receive induction therapy with intravenous cyclophosphamide and high-dose prednisone," the authors wrote.

Overall, Dr. Lim’s team found no significant differences between the children with psychosis and those with only cognitive dysfunction in terms of response or remission rates, time to response, relapse rates, or damage accrual.

The study was funded by the Peterborough K.M. Hunter Graduate Studentship, the Joseph M. West Family Memorial Scholarship, the Eddie Steinberg Scholarship Fund, and the Chrisholm Memorial Fellowship, all awarded to Dr. Lim.

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

rhnews@frontlinemedcom.com

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

rhnews@frontlinemedcom.com

Platelet-rich plasma therapy improved both the pain scores and elbow tenderness for almost three-quarters of patients suffering from tennis elbow during a 6-month randomized, double-blind controlled trial.

This study is the third to show a treatment response with no significant complications in patients with lateral epicondylar tendinopathy, commonly known as tennis elbow, from platelet-rich plasma (PRP) injections.

Dr. Allan Mishra, of Stanford (Calif.) University Medical Center,* and his coinvestigators from eight other institutions presented their findings from the trial at the annual meeting of the American Academy of Orthopaedic Surgeons in Chicago.

The 230 study participants had symptoms for at least 3 months and reported tenderness at the lateral epicondyle and pain scored at a minimum of 50 out of 100 on a visual analog scale during a resisted wrist extension. All participants failed to respond to conventional therapy, including a combination of physical therapy, nonsteroidal anti-inflammatory medications, and/or steroid injections, the investigators reported.

Dr. Mishra and his colleagues used a Biomet GPS centrifuge and canister system to prepare a formulation of 2-3 mL of PRP for 116 patients who received the intervention. The PRP contained concentrated platelets and concentrated white blood cells at a concentration five to six times greater than in plasma at baseline.

Both the patients who received PRP and the 114 active controls were given a local anesthesia block of 0.25% bupivacaine with epinephrine before investigators needled the origin of their extensor tendons, delivering the PRP only to the intervention group.

At 12 weeks’ follow-up, patients receiving the PRP injections reported 55.1% improvement in their pain scores, compared with their baseline pain before the procedure, whereas controls reported 47.4% improvement in pain compared with baseline. The findings were not statistically significant (P = .094). The 12-week secondary outcome measurement was statistically significant, with 37.4% of the intervention group reporting significant elbow tenderness, compared with 48.4% of controls reporting significant tenderness (P = .036).

At 24 weeks, the difference in pain scores between the two groups was statistically significant: PRP patients reported 71.5% improvement, whereas controls reported 56.1% improvement (P = .027). Similarly, significant elbow tenderness remained in 29.1% of PRP patients and 54% of the controls (P less than .001).

The two previous trials, one led by Dr. Mishra with a mean 25.6-month follow-up, and another 2-year study, used the same methodology and PRP system as this one and showed similar improvements, said Dr. Mishra. "Together these studies have treated 350 patients in a prospective, controlled fashion with all of the studies showing superiority when patients are treated with PRP," he said.

However, PRP treatment should not be used as a first-line therapy, he said. "Most patients will respond to conservative treatment such as exercise and rest," Dr. Mishra said. "PRP should, however, be used instead of cortisone for patients who have failed initial treatment."

The investigators noted that there are several potential mechanisms by which the PRP helps improve the pain in tennis elbow. Preclinical studies have shown that PRP can improve cell proliferation and others have shown it improves local blood flow, Dr. Mishra said. "Finally, it may be possible that PRP modifies neurogenic pain receptors and thereby improves clinical outcomes," he said. "More research is clearly needed in this area."

As with the other two studies, no significant complications were reported among the participants in this study, the investigators found. "Importantly, these studies were conducted over the course of a decade with an excellent safety profile for PRP," Dr. Mishra said. "Clinicians and patients can now be confident when using this specific form of PRP to treat chronic tennis elbow."

The study was funded by Biomet Biologics. All authors have received funding from a range of industry sources, including Biomet.

* Correction, 3/28/13: Dr. Mishra's affiliation has been corrected and not all of the investigators were from the same institution.

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