Alexandre Loch

Current diagnostic criteria delineate schizophrenia as a discrete entity essentially defined by positive symptoms. However, the role of positive symptoms in psychiatry is being questioned. There is compelling evidence that psychotic manifestations are expressed in the population in a continuum of varying degrees of severity, ranging from normality to full-blown psychosis. In most cases, these phenomena do not persist, but they constitute risk factors for psychiatric disorders in general. Psychotic symptoms are also present in most non-psychotic psychiatric diagnoses, being a marker of severity. Research revealed that hallucinations and delusions appear to have distinct, independent biological underpinnings-in the general population, in psychotic, and in non-psychotic disorders as well. On the other hand, negative symptoms were seen to be far more restricted to schizophrenia, have other underlying pathophysiology than positive symptoms, predict outcome and treatment response in schizophrenia, and start before the first psychotic outbreak. The current work discusses the concept of schizophrenia, suggesting that a greater emphasis should be put on cases where psychotic symptoms emerge in a premorbid subtly increasing negative/cognitive symptoms background. In those cases, psychosis would have a different course and outcome while psychosis occurring in the absence of such background deterioration would be more benign-probably having no, or a milder, underlying degenerative process. This reformulation should better drive psychopathological classification, face positive symptoms as epiphenomenon of the schizophrenia process, and dishevel stigma from schizophrenia and from delusions and hallucinations.

In the last decades, biological and environmental factors related to psychosis were investigated in individuals at ultra-risk for psychosis (UHR) to predict conversion. Although religion relates to psychosis in a variety of ways, it is understudied in subclinical samples. Therefore, we assessed the interplay between religion and prodromal symptoms in 79 UHR and 110 control individuals. They were interviewed with the Duke University Religion Index and the Structured Interview for Prodromal Syndromes (SIPS). Organizational religious activity, a measure of how often someone attends churches/temples, was positively related to perceptual abnormalities/hallucina-tions (Spearman's rho = 0.262, p = 0.02). This relationship was replicated in a path analysis model (β = 0.342, SE = 0.108, p = 0.002), as well as a link between organizational religious activity and lower ideational richness (β = 0.401, SE = 0.105, p = 0.000) with no influence of sex, age, religious denomination, or socioeconomic class. Intrinsic religious activity was negatively correlated with suspiciousness (SIPS P2) (β = −0.028, SE = 0.009, p = 0.002), and non-organizational religious activity was correlated with higher ideational richness (N5) (β = −0.220, SE = 0.097, p = 0.023). We hypothesize that subjects with subclinical psychosis may possibly use churches and other religious organizations to cope with hallucinations. Indeed, Brazil is characterized by a religious syncretism and a strong influence of Spiritism in the popular culture. The mediumistic idea that some might be able to hear and/or see spirits is probably employed to explain subclinical hallucinations in the lay knowledge. Our results emphasize the importance of assessing religion and other region-specific aspects of various cultures when studying UHR individuals. This sort of assessment would enhance understanding of differences in conversion rates, and would help to transpose prevention programs from high-income countries to other settings.

Background: Schizophrenia is one of the most stigmatized psychiatric disorders, and disclosing it is often a source of stress to individuals with the disorder. The Coming Out Proud (COP) group intervention is designed to reduce the stigma’s negative impact and help participants decide if they want to disclose their disorder.
Aims: To assess the effect of the COP intervention in individuals with the diagnosis of schizophrenia.
Methods: A pilot study of 3 2-hour group lessons (6–12 participants) per week. Individuals were selected from three specialized outpatient services in São Paulo, Brazil; 46 people were willing to participate, 11 dropped out during the intervention and 4 were excluded due to low intelligence quotient (IQ), resulting in a final sample of 31 participants. Outcomes were assessed before (T0/baseline) and after (T1/directly) after the COP intervention, and at 3-week follow- up (T2/3weeks after T1). We applied eight scales, of which four scales are analyzed in this article (Coming Out with Mental Illness Scale (COMIS), Cognitive Appraisal of Stigma as a Stressor (CogApp), Self-Stigma of Mental Illness Scale- Short Form (SSMIS) and Perceived Devaluation-Discrimination Questionnaire (PDDQ)).
Results: People who completed the COP intervention showed a significant increase in the decision to disclose their diagnosis (22.5% in T0 vs 67.7% in T2). As to the perception of stigma as a stressor, mean values significantly increased after the intervention (T0 = 3.83, standard deviation (SD) = .92 vs T2 = 4.44, SD = 1.05; p = .006). Two results had marginal significance: self-stigma was reduced (T0 = 3.10, SD = 1.70 vs T2 = 2.73, SD = 1.87; p = .063), while perceived discrimination increased (T0=2.68, SD=.55 vs T2=2.93, SD=.75; p=.063).
Conclusion: This study suggests that the COP group intervention facilitated participants’ disclosure decisions, and the increasing awareness of stigma as a stressor in life may have facilitated their decision to eventually disclose their disorder. The results raise questions that require further analysis, taking sociocultural factors into account, as stigma is experienced differently across cultures.

The aim of this study was to analyze factors associated with the legal status at psychiatric admission of individuals with psychosis or bipolar disorder in a Latin-American cultural setting. Prospective observational study was conducted in São Paulo, Brazil. We analyzed 169 individuals with bipolar or psychotic disorder in need of hospitalization. Sociodemographic data, data on the psychiatric disorder, information about the hospital stay, and data at time of discharge were collected. Their families were also contacted by telephone and interviews were conducted at 1, 2, 6, and 12 months post-discharge as a follow-up. Eighty-eight patients (52%) had a voluntary admission and 81 (48%) had an involuntary admission (IA). The average length of admission was similar in both groups (17.4 vs. 17.3 days, p = 0.22). It was significantly more common for IA patients to be admitted because of other-directed aggressiveness (47.7 vs. 65.4%, p = 0.02). The percentage of individuals that needed phys...

Background: Literature on how the general population stigmatizes individuals with mental disorders has increased considerably over the last decades. But the question remains if psychiatrists also stigmatize their patients. Objective: The present study aimed to assess Brazilian psychiatrists’ attitude towards individuals with schizophrenia. Methods: Out of the approximately 6,000 participants of the 2009 National Psychiatry Congress in Brazil, 1,414 psychiatrists agreed to undergo the survey. Face-to-face interviews were conducted using a questionnaire that assessed stigma in three dimensions: stereotypes, social distance and prejudice towards a person with schizophrenia. Their opinion on psychotropic drugs and tolerance of side-effects were also assessed. Socio-demographic and professional data were collected. Results: Brazilian psychiatrists tend to negatively stereotype individuals with schizophrenia. More negative stereotypes correlated with a positive opinion on psychotropic dru...

Objective: To assess the relationship between cognitive function, a proposed schizophrenia
endophenotype, and two genetic polymorphisms related to dopamine function, catechol-O-methyl
transferase (COMT) Val158Met and dopamine receptor 3 (DRD3) Ser9Gly.
Methods: Fifty-eight outpatients with schizophrenia/schizoaffective disorder and 88 healthy controls
underwent neurocognitive testing and genotyping. Analyses of covariance (ANCOVAs) using age, sex,
and years of education as covariates compared cognitive performance for the proposed genotypes in
patients and controls. ANCOVAs also tested for the epistatic effect of COMT and DRD3 genotype
combinations on cognitive performance.
Results: For executive functioning, COMT Val/Val patients performed in a similar range as controls
(30.70-33.26 vs. 35.53-35.67), but as COMT Met allele frequency increased, executive functioning
worsened. COMT Met/Met patients carrying the DRD3 Ser/Ser genotype performed poorest (16.184
vs. 27.388-31.824). Scores of carriers of this COMT/DRD3 combination significantly differed from all
DRD3 Gly/Gly combinations (p o 0.05), from COMT Val/Met DRD3 Ser/Gly (p = 0.02), and from
COMT Val/Val DRD3 Ser/Ser (p = 0.01) in patients. It also differed significantly from all control scores
(p o 0.001).
Conclusion: Combined genetic polymorphisms related to dopamine neurotransmission might
influence executive function in schizophrenia. Looking at the effects of multiple genes on a single
disease trait (epistasis) provides a comprehensive and more reliable way to determine genetic effects
on endophenotypes.

Before psychiatry emerged as a medical discipline, hospitalizing individuals with mental disorders was more of a social stigmatizing act than a therapeutic act. After the birth of the mental health disciplines, psychiatric hospitalization was legitimized and has proven to be indispensable, preventing suicides and helping individuals in need. However, despite more than a century passing since this legitimization occurred, psychiatric hospitalization remains a controversial issue. There is the question of possible negative outcomes after a psychiatric admis- sion ceases to take its protective effect, and even of whether the psychiatric admission itself is related to a negative setback after discharge. This review aims to summarize some of the most important negative outcomes after discharge from a psychiatric institution. These experiences were organized into two groups: those after a brief psychiatric hospitalization, and those after a long-stay admission. The author further suggests possible ways to minimize these adversities, emphasizing the need of awareness related to this important issue.