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Risk Factors for Spontaneous Dyskinesia in Schizophrenia

Risk Factors for Spontaneous Dyskinesia in Schizophrenia Abstract Objective: We describe the prevalence, clinical correlates, and prognostic significance of spontaneous dyskinesias among 100 patients with schizophrenia from the Chestnut Lodge Follow-up Study who had never received treatment with neuroleptic agents up to and including the baseline assessment. Design: Extensive case records were screened and descriptions of abnormal movements were recorded verbatim for blind rating. Neuroleptic-naive patients with and without abnormal oral-facial movements were compared across sign and symptom, schizophrenia subtype, and illness natural history variables. Results: Excluding three patients with motor symptoms who had a history of neurologic illness or injury and three who had received prochlorperazine maleate therapy (Compazine), 23% of patient records documented some form of movement disorder; 15% documented oral-facial dyskinesias with sufficient detail so that their presence was considered nearly certain. Compared with patients with schizophrenia without oral-facial movements, patients with oral-facial dyskinesias were more likely to demonstrate a lower IQ score, had more negative symptoms at index admission, and were more symptomatic at follow-up an average of 23 years later. Both the classic hebephrenic schizophrenia subtype and Carpenter's Criteria for the Deficit Syndrome defined high-risk groups for spontaneous oralfacial dyskinesia. Conclusions: In previous studies, intellectual impairment and negative symptoms have been described as risk factors for neuroleptic-induced tardive dyskinesia. The present data, however, suggest that in many cases oralfacial dyskinesias in patients with intellectual impairment and negative symptoms may actually represent spontaneous movement disorders associated with hebephrenic or deficit forms of schizophrenia. References 1. Kraepelin EL. Textbook of Psychiatry: Dementia Praecox . London, England: McMillan Publishers Ltd; 1919;3. 2. Turner T. Rich and mad in Victorian England . Psychol Med . 1989;19:29-44.Crossref 3. Casey DE, Hansen TE. Spontaneous dyskinesias . In: Jeste DV, Wyatt RJ, eds. Neuropsychiatric Movement Disorders . Washington, DC: American Psychiatric Press Inc; 1984:67-96. 4. Waddington JL, Crow TJ. Abnormal involuntary movements and psychosis in the preneuroleptic era and in unmedicated patients: implications for the concept of tardive dyskinesia . In: Wolf ME, Mosniam AD, eds. Tardive Dyskinesia: Biological Mechanisms and Clinical Aspects . Washington, DC: American Psychiatric Press Inc; 1988:51-66. 5. Rogers D. The motor disorders of severe psychiatric illness: a conflict of paradigms . Br J Psychiatry . 1985;147:221-232.Crossref 6. Khot V, Wyatt RJ. Not all that moves is tardive dyskinesia . Am J Psychiatry . 1991;148:661-666. 7. Morganstern H, Glazer WM, Niedzwiecki D, Nourjah P. The impact of neuroleptic medication on tardive dyskinesia: a meta-analysis of published studies . Am J Public Health . 1987;77:717-724.Crossref 8. Casey DE. Spontaneous and tardive dyskinesias: clinical and laboratory studies . J Clin Psychiatry . 1985;46:42-47. 9. Crow TJ, Cross AJ, Johnstone EC, Owen F, Owens DGC, Waddington JL. Abnormal involuntary movements in schizophrenia: are they related to the disease process or its treatment? are they associated with changes in dopamine receptors? J Clin Psychopharmacol . 1982;2:336-340.Crossref 10. Kane JM, Smith JM. Tardive dyskinesia: Prevalence and risk factors, 1959 to 1979 . Arch General Psychiatry . 1982;39:473-481.Crossref 11. Kane JM, Woerner M, Lieberman J, Kinon B. Tardive dyskinesia . In: Neuropsychiatric Movement Disorders . Washington, DC: American Psychiatric Press Inc; 1984:97-118. 12. Waddington JL, Youssef HA, Dolphin C, Kinsella A. Cognitive dysfunction, negative symptoms, and tardive dyskinesia in schizophrenia . Arch Gen Psychiatry . 1987;44:907-912.Crossref 13. Waddington JL, Youssef HA. Late onset involuntary movements in chronic schizophrenia: relationship of tardive dyskinesia to intellectual impairment and negative symptoms . Br J Psychiatry . 1986;149:616-620.Crossref 14. Waddington JL, Youssef HA. The lifetime outcome and involuntary movements of schizophrenia never treated with neuroleptic drugs . Br J Psychiatry . 1990;156:106-108.Crossref 15. Owens DGC, Johnstone EC. The disabilities of chronic schizophrenia: their nature and factors contributing to their development . Br J Psychiatry . 1980;136:384-395.Crossref 16. Manschreck TC, Keuthen NJ, Schneyer ML, Celada MT, Laughery J, Collins P. Abnormal involuntary movements and chronic schizophrenic disorders . Biol Psychiatry . 1990;7:150-158.Crossref 17. McGlashan TH, Fenton WS. The positive-negative distinction in schizophrenia: review of natural history validators . Arch Gen Psychiatry . 1992;49:63-73.Crossref 18. Owens DGC. Involuntary disorders of movement in chronic schizophrenia: the role of illness and its treatment . In: Casey DE, Chase TN, Christensen AV, Gerlach J, eds. Dyskinesia: Research and Treatment . Berlin, Germany: Springer Verlag; 1985:79-87. 19. Turek IS. Drug-induced dyskinesia: reality or myth? Dis Nerv Syst . 1975:36;397-399. 20. McKenna PJ, Lund CE, Mortimer AM, Biggins CA. Motor, volitional and behavioral disorders in schizophrenia, II: the 'conflict of paradigms' hypothesis . Br J Psychiatry . 1991;158:328-336.Crossref 21. Waddington JL. Tardive dyskinesia in schizophrenia and other disorders: associations with ageing, cognitive dysfunction and structural brain pathology in relation to neuroleptic exposure . Hum Psychopharmacol . 1987;2:11-22.Crossref 22. Waddington JL. Schizophrenia, affective psychosis, and other disorders treated with neuroleptic drugs: the enigma of tardive dyskinesia, its neurobiological determinants, and the conflict of paradigms . Int Rev Neurobiol . 1989;31:297-353. 23. McGlashan TH. The Chestnut Lodge Follow-up Study, I: follow-up methodology and study sample . Arch Gen Psychiatry . 1984;41:573-585.Crossref 24. McGlashan TH. The Chestnut Lodge Follow-up Study, II: long-term outcome of schizophrenia and affective disorders . Arch Gen Psychiatry . 1984;41:586-601.Crossref 25. Fenton WS, McGlashan TH. Natural history of schizophrenia subtypes, I: longitudinal study of paranoid, hebephrenic, and undifferentiated schizophrenia . Arch Gen Psychiatry . 1991;48:969-977.Crossref 26. Fenton WS, McGlashan TH. Natural history of schizophrenia subtypes, II: positive and negative symptoms and long-term course . Arch Gen Psychiatry . 1991;48:978-986.Crossref 27. Carpenter WT, Heinrichs DW, Wagman AMI. Deficit and non-deficit forms of schizophrenia: the concept . Am J Psychiatry . 1988;145:578-583. 28. Wagman AMI, Heinrichs DW, Carpenter WT. Deficit and non-deficit forms of schizophrenia: neuropsychological evaluation . Psychiatry Res . 1987;22:319-330.Crossref 29. Grove WM, Andreasen NC. Simultaneous tests of multiple hypotheses in exploratory research . J Nerv Ment Dis . 1982;170:3-8.Crossref 30. Kay SR, Opler LA, Fishbein A. Positive And Negative Syndrome Scale (PANSS) Rating Manual . Toronto, Ontario: Multihealth Systems Inc; 1992. 31. Fenton WS, McGlashan TH, Heinssen RK. DSM-III versus DSM-III-R criteria for schizophrenia . Am J Psychiatry . 1989;146:686. 32. Klawans HL, Goetz CG, Perlick S. Tardive dyskinesia: review and update . Am J Psychiatry . 1980;137:900-908. 33. Granacher RP. Differential diagnosis of tardive dyskinesia: an overview . Am J Psychiatry . 1981;138:1288-1297. 34. Guy W, ed. Abnormal Involuntary Movement Scale (AIMS). In: ECDEU Assessment Manual for Psychopharmacology, Revised, 1976. Rockville, Md: Alcohol, Drug Abuse, and Mental Health Administration; 1976:534-537. US Dept of Health, Education, and Welfare publication ADM 76-338. 35. Owen DGC, Johnstone EC, Frith CD. Spontaneous involuntary disorders of movement: their prevalence, severity, and distribution in chronic schizophrenics with and without treatment with neuroleptics . Arch Gen Psychiatry . 1982;39:452-461.Crossref 36. Feighner JP, Robins E, Guze SB, Woodruff RA. Diagnostic criteria for use in psychiatric research . Arch Gen Psychiatry . 1972:26:57-63.Crossref 37. Chorfi M, Moussaoui D. Lack of dyskinesias in unmedicated schizophrenics . Psychopharmacology . 1989;97:423.Crossref 38. Spitzer RL, Endicott J, Robins E. Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders . 3rd ed. New York, NY: New York State Psychiatric Institute; 1975. 39. McGlashan TH, Fenton WS. Subtype progression and pathophysiologic deterioration in early schizophrenia . Schizophr Bull . 1993;19:71-84.Crossref 40. Waddington JL. Spontaneous orofacial movements induced in rodents by very long-term neuroleptic drug administration: phenomenology, pathophysiology and putative relationship to tardive dyskinesia . Psychopharmacology . 1990;101:431-447.Crossref 41. Waddington JL. Tardive dyskinesia in schizophrenia and other disorders: association with aging, cognitive dysfunction and structural brain pathology in relation to neuroleptic exposure . Human Psychopharmacol . 1987;2:11-22.Crossref 42. Buchanan RW, Kirkpatrick B, Heinrichs DW, Carpenter WT. Clinical correlates of the deficit syndrome in schizophrenia . Am J Psychiatry . 1990;147:290-294. 43. Kirkpatrick B, Buchanan RW. Anhedonia and the deficit syndrome of schizophrenia . Psychiatr Res . 1989;31:25-30.Crossref 44. Thaker GK, Kirkpatrick B, Buchanan RW, Ellsberry R. Oculomotor abnormalities and their clinical cocorrelates in schizophrenia . Psychopharmacol Bull . 1989;25:491-497. 45. Buchanan RW, Kirkpatrick B, Tamminga CA. Differential patterns of glucose metabolism in deficit and non-deficit schizophrenia . Biol Psychiatry . 1989;25:99A.Crossref 46. Tamminga CA, Thaker GK, Buchanan RW, Kirkpatrick B. Limbic system abnormalities identified in schizophrenia using positron emission tomography with fluorodeoxyglucose and neocortical alterations with the deficit syndrome . Arch Gen Psychiatry . 1992;49:522-530.Crossref 47. Buchanan RW, Breier A, Kirkpatrick B, Elkashef A, Munson RC, Gellad F, Carpenter WT. Structural abnormalities in deficit and non-deficit schizophrenia . Am J Psychiatry . 1993;150:59-65. 48. Caligiuri MP, Lohr JB, Jeste DV. Parkinsonism in neuroleptic-naive schizophrenic patients . Am J Psychiatry . 1993;150:1343-1348. 49. Davis KL, Kahn RS, Ko G, Davidson M. Dopamine in schizophrenia: a review and reconceptualization . Am J Psychiatry . 1991;148:1474-1486. 50. Volkow ND, Wolf AP, Van Gelder P, Brodie JD, Overall JE, Cancro R, Gomez Mont F. Phenomenological correlates of metabolic activity in 18 patients with chronic schizophrenia . Am J Psychiatry . 1987;114:151-158. 51. Liddle PF, Friston KJ, Frith CD, Hirsch SR, Jones T, Frackowiack RSJ. Patterns of cerebral blood flow in schizophrenia . Br J Psychiatry . 1992:160;179-186.Crossref 52. Andreasen NC, Rezai K, Alliger R, Swayze VS, Flaum M, Kirchner P, Cohen G, O'Leary DS. Hypofrontality in neuroleptic-naive patients and in patients with chronic schizophrenia . Arch Gen Psychiatry . 1992:49:943-958.Crossref 53. Wolkin A, Sanfilipo M, Wolf AP, Angrist B, Brokie JD, Rotrosen J. Negative symptoms and hypofrontality in chronic schizophrenia . Arch Gen Psychiatry . 1992;49:959-965.Crossref 54. Simon RI. Ethical and legal issues in neuropsychiatry . In: Yudofsky SC, Hales RE, eds. Textbook of Neuropsychiatry . Washington, DC: American Psychiatric Press Inc; 1992:773-805. 55. Simon RI. Clinical Psychiatry and the Law . 2nd ed. Washington, DC: American Psychiatric Press Inc; 1992. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of General Psychiatry American Medical Association

Risk Factors for Spontaneous Dyskinesia in Schizophrenia

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American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-990X
eISSN
1598-3636
DOI
10.1001/archpsyc.1994.03950080055008
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Abstract

Abstract Objective: We describe the prevalence, clinical correlates, and prognostic significance of spontaneous dyskinesias among 100 patients with schizophrenia from the Chestnut Lodge Follow-up Study who had never received treatment with neuroleptic agents up to and including the baseline assessment. Design: Extensive case records were screened and descriptions of abnormal movements were recorded verbatim for blind rating. Neuroleptic-naive patients with and without abnormal oral-facial movements were compared across sign and symptom, schizophrenia subtype, and illness natural history variables. Results: Excluding three patients with motor symptoms who had a history of neurologic illness or injury and three who had received prochlorperazine maleate therapy (Compazine), 23% of patient records documented some form of movement disorder; 15% documented oral-facial dyskinesias with sufficient detail so that their presence was considered nearly certain. Compared with patients with schizophrenia without oral-facial movements, patients with oral-facial dyskinesias were more likely to demonstrate a lower IQ score, had more negative symptoms at index admission, and were more symptomatic at follow-up an average of 23 years later. Both the classic hebephrenic schizophrenia subtype and Carpenter's Criteria for the Deficit Syndrome defined high-risk groups for spontaneous oralfacial dyskinesia. Conclusions: In previous studies, intellectual impairment and negative symptoms have been described as risk factors for neuroleptic-induced tardive dyskinesia. The present data, however, suggest that in many cases oralfacial dyskinesias in patients with intellectual impairment and negative symptoms may actually represent spontaneous movement disorders associated with hebephrenic or deficit forms of schizophrenia. References 1. Kraepelin EL. Textbook of Psychiatry: Dementia Praecox . London, England: McMillan Publishers Ltd; 1919;3. 2. Turner T. Rich and mad in Victorian England . Psychol Med . 1989;19:29-44.Crossref 3. Casey DE, Hansen TE. Spontaneous dyskinesias . In: Jeste DV, Wyatt RJ, eds. Neuropsychiatric Movement Disorders . Washington, DC: American Psychiatric Press Inc; 1984:67-96. 4. Waddington JL, Crow TJ. Abnormal involuntary movements and psychosis in the preneuroleptic era and in unmedicated patients: implications for the concept of tardive dyskinesia . In: Wolf ME, Mosniam AD, eds. Tardive Dyskinesia: Biological Mechanisms and Clinical Aspects . Washington, DC: American Psychiatric Press Inc; 1988:51-66. 5. Rogers D. The motor disorders of severe psychiatric illness: a conflict of paradigms . Br J Psychiatry . 1985;147:221-232.Crossref 6. Khot V, Wyatt RJ. Not all that moves is tardive dyskinesia . Am J Psychiatry . 1991;148:661-666. 7. Morganstern H, Glazer WM, Niedzwiecki D, Nourjah P. The impact of neuroleptic medication on tardive dyskinesia: a meta-analysis of published studies . Am J Public Health . 1987;77:717-724.Crossref 8. Casey DE. Spontaneous and tardive dyskinesias: clinical and laboratory studies . J Clin Psychiatry . 1985;46:42-47. 9. Crow TJ, Cross AJ, Johnstone EC, Owen F, Owens DGC, Waddington JL. Abnormal involuntary movements in schizophrenia: are they related to the disease process or its treatment? are they associated with changes in dopamine receptors? J Clin Psychopharmacol . 1982;2:336-340.Crossref 10. Kane JM, Smith JM. Tardive dyskinesia: Prevalence and risk factors, 1959 to 1979 . Arch General Psychiatry . 1982;39:473-481.Crossref 11. Kane JM, Woerner M, Lieberman J, Kinon B. Tardive dyskinesia . In: Neuropsychiatric Movement Disorders . Washington, DC: American Psychiatric Press Inc; 1984:97-118. 12. Waddington JL, Youssef HA, Dolphin C, Kinsella A. Cognitive dysfunction, negative symptoms, and tardive dyskinesia in schizophrenia . Arch Gen Psychiatry . 1987;44:907-912.Crossref 13. Waddington JL, Youssef HA. Late onset involuntary movements in chronic schizophrenia: relationship of tardive dyskinesia to intellectual impairment and negative symptoms . Br J Psychiatry . 1986;149:616-620.Crossref 14. Waddington JL, Youssef HA. The lifetime outcome and involuntary movements of schizophrenia never treated with neuroleptic drugs . Br J Psychiatry . 1990;156:106-108.Crossref 15. Owens DGC, Johnstone EC. The disabilities of chronic schizophrenia: their nature and factors contributing to their development . Br J Psychiatry . 1980;136:384-395.Crossref 16. Manschreck TC, Keuthen NJ, Schneyer ML, Celada MT, Laughery J, Collins P. Abnormal involuntary movements and chronic schizophrenic disorders . Biol Psychiatry . 1990;7:150-158.Crossref 17. McGlashan TH, Fenton WS. The positive-negative distinction in schizophrenia: review of natural history validators . Arch Gen Psychiatry . 1992;49:63-73.Crossref 18. Owens DGC. Involuntary disorders of movement in chronic schizophrenia: the role of illness and its treatment . In: Casey DE, Chase TN, Christensen AV, Gerlach J, eds. Dyskinesia: Research and Treatment . Berlin, Germany: Springer Verlag; 1985:79-87. 19. Turek IS. Drug-induced dyskinesia: reality or myth? Dis Nerv Syst . 1975:36;397-399. 20. McKenna PJ, Lund CE, Mortimer AM, Biggins CA. Motor, volitional and behavioral disorders in schizophrenia, II: the 'conflict of paradigms' hypothesis . Br J Psychiatry . 1991;158:328-336.Crossref 21. Waddington JL. Tardive dyskinesia in schizophrenia and other disorders: associations with ageing, cognitive dysfunction and structural brain pathology in relation to neuroleptic exposure . Hum Psychopharmacol . 1987;2:11-22.Crossref 22. Waddington JL. Schizophrenia, affective psychosis, and other disorders treated with neuroleptic drugs: the enigma of tardive dyskinesia, its neurobiological determinants, and the conflict of paradigms . Int Rev Neurobiol . 1989;31:297-353. 23. McGlashan TH. The Chestnut Lodge Follow-up Study, I: follow-up methodology and study sample . Arch Gen Psychiatry . 1984;41:573-585.Crossref 24. McGlashan TH. The Chestnut Lodge Follow-up Study, II: long-term outcome of schizophrenia and affective disorders . Arch Gen Psychiatry . 1984;41:586-601.Crossref 25. Fenton WS, McGlashan TH. Natural history of schizophrenia subtypes, I: longitudinal study of paranoid, hebephrenic, and undifferentiated schizophrenia . Arch Gen Psychiatry . 1991;48:969-977.Crossref 26. Fenton WS, McGlashan TH. Natural history of schizophrenia subtypes, II: positive and negative symptoms and long-term course . Arch Gen Psychiatry . 1991;48:978-986.Crossref 27. Carpenter WT, Heinrichs DW, Wagman AMI. Deficit and non-deficit forms of schizophrenia: the concept . Am J Psychiatry . 1988;145:578-583. 28. Wagman AMI, Heinrichs DW, Carpenter WT. Deficit and non-deficit forms of schizophrenia: neuropsychological evaluation . Psychiatry Res . 1987;22:319-330.Crossref 29. Grove WM, Andreasen NC. Simultaneous tests of multiple hypotheses in exploratory research . J Nerv Ment Dis . 1982;170:3-8.Crossref 30. Kay SR, Opler LA, Fishbein A. Positive And Negative Syndrome Scale (PANSS) Rating Manual . Toronto, Ontario: Multihealth Systems Inc; 1992. 31. Fenton WS, McGlashan TH, Heinssen RK. DSM-III versus DSM-III-R criteria for schizophrenia . Am J Psychiatry . 1989;146:686. 32. Klawans HL, Goetz CG, Perlick S. Tardive dyskinesia: review and update . Am J Psychiatry . 1980;137:900-908. 33. Granacher RP. Differential diagnosis of tardive dyskinesia: an overview . Am J Psychiatry . 1981;138:1288-1297. 34. Guy W, ed. Abnormal Involuntary Movement Scale (AIMS). In: ECDEU Assessment Manual for Psychopharmacology, Revised, 1976. Rockville, Md: Alcohol, Drug Abuse, and Mental Health Administration; 1976:534-537. US Dept of Health, Education, and Welfare publication ADM 76-338. 35. Owen DGC, Johnstone EC, Frith CD. Spontaneous involuntary disorders of movement: their prevalence, severity, and distribution in chronic schizophrenics with and without treatment with neuroleptics . Arch Gen Psychiatry . 1982;39:452-461.Crossref 36. Feighner JP, Robins E, Guze SB, Woodruff RA. Diagnostic criteria for use in psychiatric research . Arch Gen Psychiatry . 1972:26:57-63.Crossref 37. Chorfi M, Moussaoui D. Lack of dyskinesias in unmedicated schizophrenics . Psychopharmacology . 1989;97:423.Crossref 38. Spitzer RL, Endicott J, Robins E. Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders . 3rd ed. New York, NY: New York State Psychiatric Institute; 1975. 39. McGlashan TH, Fenton WS. Subtype progression and pathophysiologic deterioration in early schizophrenia . Schizophr Bull . 1993;19:71-84.Crossref 40. Waddington JL. Spontaneous orofacial movements induced in rodents by very long-term neuroleptic drug administration: phenomenology, pathophysiology and putative relationship to tardive dyskinesia . Psychopharmacology . 1990;101:431-447.Crossref 41. Waddington JL. Tardive dyskinesia in schizophrenia and other disorders: association with aging, cognitive dysfunction and structural brain pathology in relation to neuroleptic exposure . Human Psychopharmacol . 1987;2:11-22.Crossref 42. Buchanan RW, Kirkpatrick B, Heinrichs DW, Carpenter WT. Clinical correlates of the deficit syndrome in schizophrenia . Am J Psychiatry . 1990;147:290-294. 43. Kirkpatrick B, Buchanan RW. Anhedonia and the deficit syndrome of schizophrenia . Psychiatr Res . 1989;31:25-30.Crossref 44. Thaker GK, Kirkpatrick B, Buchanan RW, Ellsberry R. Oculomotor abnormalities and their clinical cocorrelates in schizophrenia . Psychopharmacol Bull . 1989;25:491-497. 45. Buchanan RW, Kirkpatrick B, Tamminga CA. Differential patterns of glucose metabolism in deficit and non-deficit schizophrenia . Biol Psychiatry . 1989;25:99A.Crossref 46. Tamminga CA, Thaker GK, Buchanan RW, Kirkpatrick B. Limbic system abnormalities identified in schizophrenia using positron emission tomography with fluorodeoxyglucose and neocortical alterations with the deficit syndrome . Arch Gen Psychiatry . 1992;49:522-530.Crossref 47. Buchanan RW, Breier A, Kirkpatrick B, Elkashef A, Munson RC, Gellad F, Carpenter WT. Structural abnormalities in deficit and non-deficit schizophrenia . Am J Psychiatry . 1993;150:59-65. 48. Caligiuri MP, Lohr JB, Jeste DV. Parkinsonism in neuroleptic-naive schizophrenic patients . Am J Psychiatry . 1993;150:1343-1348. 49. Davis KL, Kahn RS, Ko G, Davidson M. Dopamine in schizophrenia: a review and reconceptualization . Am J Psychiatry . 1991;148:1474-1486. 50. Volkow ND, Wolf AP, Van Gelder P, Brodie JD, Overall JE, Cancro R, Gomez Mont F. Phenomenological correlates of metabolic activity in 18 patients with chronic schizophrenia . Am J Psychiatry . 1987;114:151-158. 51. Liddle PF, Friston KJ, Frith CD, Hirsch SR, Jones T, Frackowiack RSJ. Patterns of cerebral blood flow in schizophrenia . Br J Psychiatry . 1992:160;179-186.Crossref 52. Andreasen NC, Rezai K, Alliger R, Swayze VS, Flaum M, Kirchner P, Cohen G, O'Leary DS. Hypofrontality in neuroleptic-naive patients and in patients with chronic schizophrenia . Arch Gen Psychiatry . 1992:49:943-958.Crossref 53. Wolkin A, Sanfilipo M, Wolf AP, Angrist B, Brokie JD, Rotrosen J. Negative symptoms and hypofrontality in chronic schizophrenia . Arch Gen Psychiatry . 1992;49:959-965.Crossref 54. Simon RI. Ethical and legal issues in neuropsychiatry . In: Yudofsky SC, Hales RE, eds. Textbook of Neuropsychiatry . Washington, DC: American Psychiatric Press Inc; 1992:773-805. 55. Simon RI. Clinical Psychiatry and the Law . 2nd ed. Washington, DC: American Psychiatric Press Inc; 1992.

Journal

Archives of General PsychiatryAmerican Medical Association

Published: Aug 1, 1994

References