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ORIGINAL ARTICLES

PERSONALITY FACTORS IN THE ONSETAND DYNAMIC OF THE FIRST PSYCHOTIC EPISODE

1 2 3Emese Lukacs , Aurel Nireºtean , Dana Cîmpan

INTRODUCTION

In current concerns regarding the first psychotic episode we always find an interest related to the initial period of expression of the vulnerability for psychosis that integrates also the development of predictive markers and prognostic factors. Within this setting the premorbid personality occupies a central position. There are known the mutual conditioning between the personality traits and the psychoses. Therefore the personality pathology and the psychotic one can be considered two areas of the abnormality which affect the human being and his psyche in their whole (1, 2, 3, 4). The mutual interconditioning between them are known

and studied elaborately by various authors. They may interact etiologically, may have a pathoplastic effect on each other or may belong to the same nosologic spectrum which may incorporate also the traits of normal personality (1, 5, 6, 7). Taking into account the progressive alteration of the structure of the personality within the evolutional process of psychoses, these relations are more obvious and – beyond limitations and difficulties – we consider that they may be studied during the early stage of the disease.

THE OBJECTIVES of this study are:-to establish the type of relations between the structure of the premorbid personality seen from a dimensional and

1 MD, Psychiatrist, Psychiatric Clinic No. 2, UMF Târgu Mureº, Department of Psychiatry, Târgu Mureº, Romania2 Senior Psychiatrist, MD, PhD, University Professor, UMF Târgu Mureº, Department of Psychiatry, Târgu Mureº, Romania3 MD, Psychiatrist, Psychiatric Clinic No. 2, UMF Târgu Mureº, Department of Psychiatry, Târgu Mureº, RomaniaReceived February 03, 2012, Revised March 09, 2012, Accepted April 06, 2012

Abstract:All present-day studies regarding the first psychotic episode show an interest about the initial period of expressing vulnerability to psychosis, predictive markers and prognostic factors. In this sense, premorbid personality has a central role. It is known that personality factors and psychoses are interconditioned. When progressive alteration of personality structure in the evolutive process of psychoses is taken into account, these associations are more evident and can therefore be studied in the initial period of the illness.Aims: Establishing the type of relations between the structure of premorbid personality seen from a dimensional and categorical perspective and the characteristics of the first psychotic episode. Method: This study includes patients having a first psychotic episode, in the evidence of the Psychiatry Clinic No. 2 in Târgu-Mureº beginning since 01.01.2007, to whom we have applied the P.A.N.S.S. scale and we assessed personality with SCID II from a categorical perspective, with TCI and DECAS scales from a dimensional perspective. Results: A higher level of accuracy in confirming complexity of the relations between pathological features of personality and the first psychotic episode.Conclusions: Assessing personality at patients having a first psychotic episode – beyond limitations and difficulties – provides us with data which have a significant contribution to anticipate ways of evolution, prognostic and therapeutic compliance in every single case.Key words: first psychotic episode, personality, dimensional and categorical assessment

Rezumat:În preocupãrile actuale legate de primul episod psihotic regãsim mereu interesul legat de perioada iniþialã de exprimare a vulnerabilitãþii pentru psihozã, markerii predictivi ºi factorii de prognostic. În acest sens personalitatea premorbidã ocupã un rol central. Sunt cunoscute condiþionãrile reciproce între factorii de personalitate ºi psihoze. Având în vedere alterarea progresivã a structurii personalitãþii în procesul evolutiv al psihozelor aceste asocieri sunt mai evidente ºi prin urmare pot fi studiate în perioada iniþialã a bolii. Obiective: Stabilirea tipului de raporturi dintre structura personalitãþii premorbide privitã din perspectivã dimensionalã ºi categorialã ºi caracteristicile primului episod psihotic.Metoda: În acest studiu sunt incluºi pacienþi cu prim episod psihotic aflaþi în evidenþa Clinicii Psihiatrie II din Târgu Mureº începând din 01.01.2007, cãrora le-am aplicat în faza psihoticã scala P.A.N.S.S. În faza de remisiune clinicã a primului episod psihotic am evaluat personalitatea din punct de vedere categorial prin SCID II ºi dimensional cu ajutorul scalelor TCI ºi DECAS. Rezultate: Creºterea nivelului de acurateþe în confirmarea raporturilor dintre trãsãturile patologice ale personalitãþii ºi primul episod psihotic. Concluzii: Evaluarea personalitãþii în cazul pacienþilor cu un prim episod psihotic - dincolo de limitãri ºi dificultãþi - furnizeazã date care contribuie semnificativ la prevederea modalitãþii de evoluþie, prognosticului ºi a complianþei terapeutice în fiecare caz în parte. Cuvinte cheie: primul episod psihotic, personalitate, evaluare dimensionalã ºi categorialã

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-categorical perspective, and the characteristics of the first

psychotic episode – prodromal particularities and patterns of onset; -to confirm the progredience of the first psychotic episode to an extended psychotic disorder, of schizophrenic or bipolar affective type, and-to emphasize the manner in which the premorbid personality's dimensions found themselves in the postpsychotic evolution;

MATERIAL AND METHODThis is a prospective study in which are included patients with first psychotic episode registered in the medical records of the Psychiatric Clinic II of Târgu Mureº since 01.01.2007, according to the following criteria: Inclusion Criteria:-patients diagnosed with first psychotic episode -patients to whom we have access at their heteroanamnesis to increase the accuracy level of the study-patients who have given their consent to participate at this studyExclusion criteria: -patients having symptoms secondary to organic pathology or induced by substance abuse-patients with mental retardation-patients with dementiaThe batch has been studied from the perspective of the sociodemographic data. In the psychotic phase, based on the clinical interview, the heteroanamnesis and applying the PANSS scale – Structured Clinical Interview for the Positive and Negative Syndrome Scale – we have assessed the positive, negative, dissociative and affective symptoms which outline the clinical type of the first psychotic episode – schizophrenic, affective or schizoaffective. We have also assessed the onset mode – with positive, negative or mixed symptoms. In the phase of clinical remission of the first psychotic episode, objectified by means of the PANSS scale, we have assessed the personality from a categorical point of view using SCID II - Structured Clinical Interview for DSM-IV Axis II Personality Disorders – and a dimensional point of view by means of TCI scale – Temperament and Character Inventory devised by Cloninger et al., and DECAS – Personality Inventory developed by F.A. Sava (coordinator). We have monitored the presence or the absence of certain accentuated personality traits or premorbid personality disorder from a categorical perspective, the dimensional diagnosis (8), as well as the presence of certain correlations between the personological traits and dimensions and the clinical evolutional peculiarities of the first psychotic episode.Psychometric tests used:SCID II is composed of 119 open questions to which the patient may answer affirmatively or negatively, after which according to the items to which the patient has answered affirmatively – supplementary questions are asked for clarification or there are requested examples from the patient in order to be able to sustain his statements. Subsequently the answers are rated with 1, 2 or 3 depending on the absence or the presence of the

Personality Disorder criteria. There is the possibility to obtain inaccurate information – rated by? –which does not validate the presence of the Personality Disorder criterion (9).The obtained scores aim to one or more personality disorders. TCI – is a battery of tests presented under the form of a self-assessment questionnaire with 240 item true/false answers which rates 7 Descriptors of High Range of the personality or the behavior including 4 dimensions of Temperament – Novelty Seeking (NS), Harm Avoidance (H), Reward Dependence (RD), Persistence (P) and 3 dimensions of Character – Self-Directedness (S), Cooperativeness (C), Self-Transcendence (ST), each of these descriptors being multifaceted. The system offers a detailed description of the positive and negative value of the dimensions (10,11). The DECAS personality inventory is a means of dimensional approach of the personality following the model of the Big Five factors: Openness, Extraversion, Conscientiousness, Agreeableness and Neuroticism. It is one of the few tests that includes three special validation scales which depending on the scores obtained, require caution in the interpretation of the results or in their invalidation (12).

RESULTS Sociodemographic data: A total of 20 patients were assessed, between the ages of 17-38 at the onset of their first psychotic episode – the average age of the batch being 25 years old. Regarding the distribution by gender the female gender is predominant: Women 55%, Men 45%. The provenience environment is predominantly urban (Urban: 75%, Rural: 25%). Most patients have higher education (50%) or high school education (45%) and very few have only secondary education (5%). The characteristics of the first psychotic episode: Most of the patients had a first psychotic episode of schizophrenic type (70%), followed by those with affective or schizoaffective first psychotic episode (30%). Most of the patients had an onset with positive symptoms (45%) or – almost equally – with mixed symptoms (40%), and those who had an onset with negative symptoms being fewer (15%).At the categorical assessment of the personality, applying the SCID II scale, it is emphasized the lack of PD - Personality Disorder in 40% of the cases, presence of PD in 25% and accentuated personality traits in 35% of the cases, on a large typological variety ( Figure 1).

Figure 1. Categorical assessment of the personality - SCID II scale

Emese Lukacs, Aurel Nireºtean, Dana Cîmpan Episode

: Personality Factors In The Onset And Dynamic Of The First Psychotic

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Subsequent to the dimensional assessment of the personality following the pattern of the Big Five by means of DECAS scale, we found: -Moderate (M) low (↓), very low (↓↓) Extroversion in all patients with schizophrenic first psychotic episode-M or very increased (↑↑ ) Extroversion in all patients with affective or schizoaffective first psychotic episode-↓or ↓↓ Neuroticism in all patients with affective or schizoaffective first psychotic episode-M or increased (↑ ) Neuroticism in all patients with schizophrenic first psychotic episode-We have not found correlations in the studied patients between the level representing the Openness, Agreeableness and Conscientiousness dimensions and the peculiarities of the first psychotic episode.After applying the TCI scale, we found: -M, ↑ or ↑↑ Harm Avoidance in 90.9% of the studied patients -↓ o r ↓↓ Reward Dependence in 72.7% of the patients-M, ↓ or ↓↓ Self-Transcendence in 81.8% of them.Those with high or low scores at the 3 dimensions of the character may generate more possible configurations of character within certain third-order level interactions that is between 3 dimensions. Among the 8 possible configurations of the 3 dimensions of the character in this study, we found: -to the combination S ↑, C ↑, ST ↓ - which characterizes the logical and organized persons – corresponds an onset with positive symptoms, without dissociation -the S ↓ , C ↓ , ST ↑ combination characteristic to persons having a disorganized, schizotypal character, who tend to be illogical, trustless, having an unconventional behavior, unstructured to realistic aims – an onset with dissociation, longer hospitalization and higher incidence of relapses -in the case of S ↓, C ↑, ST ↑, which is characteristic to the cyclothymic character – it corresponds the presence of the affective symptoms.

DISCUSSIONSThe sociodemographic data comply with those

confirmed by other studies performed on the field of reference (2, 3). On the studied batch it is confirmed the vulnerability for psychosis of the patients from the urban environment corresponding to the diversity of stress factors, the dynamics of social roles and of the axiological anarchy. The high level of education, although it is not an inclusion criterion, has been proven to be very useful in filling out the self-assessment questionnaires.

Most of the patients had a schizophrenic first psychotic episode, and the fact that the negative symptoms are more poorly represented may be explained also by the difficulty of diagnosis of these patients.

On most of the patients studied from a categorical perspective we found premorbid personological markers, best represented being the Cluster A traits, followed by the obsessive-compulsive ones and the Cluster B mixed traits. The ascertainment corresponds to the fact that most studied patients have a schizophrenic first psychotic episode. It cannot be outlined a certain specific personality disorder that may be related to the first psychotic episode.

The fact that the extroversion level does not present high values on any of the patients with

schizophrenic first psychotic episode and it has not been low on any of the patients with affective or schizoaffective first psychotic episode, pleads for the role of extroversion as affective marker in the first psychotic episode. The low level of the neuroticism in patients with affective or schizoaffective first episode suggests a personality with cyclothyme traits. The increased neuroticism in patients with schizophrenic first psychotic episode could plead for a Cluster A premorbid personality.The assessment of third-order level interactions between the dimensions of character prove having a particular diagnostic contribution by confirming the correspondence between the ways of association of the dimensions and the peculiarities of the onset and clinical-evolutional of the first psychotic episode in the studied patients.

CONCLUSIONS 1.The results presented have a preliminary character being given by the stage corresponding to a limited number of patients. 2.The study is limited by the difficulty of assessing the premorbid personality of the patients with first psychotic episode because of the multitude of the variables involved.3.The categorical assessment of the personality pleads for the fact that there is a great typological diversity, barely usable for prognostic and therapeutic considerations.4.The dimensional assessment seems to be more accurate because it develops with more objectivity the temperamental and character dominants and emphasizes remaining capacities extremely useful in the shaping of the therapeutic approach.5.We are further monitoring the assessment of the correlations confirmed in this stage and their extrapolation in structuring more accurate diagnostic and therapeutic strategies.

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Romanian Journal of Psychiatry, vol. XIV, No.2, 2012