Thesis (PhD)-- Stellenbosch University, 2014. / ENGLISH ABSTRACT: Schizophrenia is a phenotypically heterogeneous disorder believed to have a strong genetic component. Limiting its clinical heterogeneity by means of subtyping may help to shed light on some of the genetic underpinnings of the disease. This study describes the application of factor analysis (FA), latent class analysis (LCA) and factor mixture modeling in a sample of 734 Xhosa-speaking schizophrenic subjects using factor analytically derived variables previously identified in an independent sample of this population. LCA was performed on the following 8 SANS and SAPS items identified by preliminary exploration of the data: eye contact, auditory hallucinations, global hallucinations score, global delusions score, grooming, affective non-responsiveness, spontaneous movement, and commenting voices. A four class model provided the best fit. Classes 1 and 2 were characterized by predominantly positive and predominantly negative symptoms, respectively, class 3 by both positive and negative symptoms and class 4 by few or absent symptoms. A history of cannabis use or abuse increased the probability of a subject being allocated to class 1, while being male made a person more likely to be included in class 2. Factor mixture modelling was performed by first using latent class analysis, then factor analysis and then the factor mixture analysis were done. The fit among these three types were then investigated. The results show that factor mixture modelling uncovered a heterogeneous latent variable structure that fits the data well with the latent classes capturing distinct positive symptom/behaviours and factors capturing severity variations. This study, the first to report on the latent class structure of schizophrenia in a sample of patients from a sub-Saharan African population, supports the universality of specific latent classes across ethnic boundaries. The results further support reports that gender, sibpair status and cannabis use may influence the phenomenology of schizophrenia. The identification of subgroups may represent an intermediate step in the search for endophenotypes of schizophrenia. / AFRIKAANSE OPSOMMING: Skisofrenie is „n psigiatriese steuring met „n heterogene fenotipe en „n vermoedelik sterk genetiese vatbaarheid. Ten einde die lig te werp op die genetiese onderbou van skisofrenie word gepoog om die kliniese heterogenisiteit te beperk deur middel van subgroepering. Hierdie studie beskryf die gebruik van latente klas analise (LKA) in „n groep van 734 Xhosa-sprekendes met skisofrenie. Die LKA word baseer op die gebruik van veranderlikes wat deur middel van faktor analise op simptome in „n onafhanklike studiegroep van Xhosa-sprekendes met skisofrenie verkry is. Die LKA is gedoen op die volgende 8 “SAPS” en “SANS” veranderlikes wat deur voorlopige ondersoek van die data ge-indentifiseer is: oogkontak, gehoorshallusinasies, globale hallusinasie telling, globale waantelling, selfversorging, affektiewe nie-responsiwiteit, spontane beweging en stemme wat kommentaar lewer. „n Vierklas oplossing het die beste passing getoon. Klas 1 en 2 is gekenmerk deur oorwegend positiewe en negatiewe simptome onderskeidelik, klas 3 het beide positiewe en negatiewe simptome gehad en klas 4 het baie min of geen simptome getoon nie. „n Geskiedenis van kannabis gebruik of misbruik het die kans verhoog dat die individue in klas 1 gevind sou word, terwyl manlike geslag as veranderlike die kanse verhoog het vir allokasie in klas 2. Faktor mengsel modelering is gedoen deur eers „n latent klas analise te voltooi, gevolg deur „n faktor analise, en laastens „n factor mengsel analise. Die passing tussen die drie analises is daarna evalueer. Faktor mengsel modelering toon „n heterogene latente klas struktuur wat voldoen aan die passingsvereistes. Die latente klasse blyk spesifieke positiewe simptome/gedrag te verteenwoordig, terwyl die factor grad van erns variasie aandui. Hierdie studie is die eerste om die latente klas struktuur van skisofrenie in „n subsahara-Afrika populasie, die Xhosa, te beskryf. Die resultate onderstreep die universialiteit van die latente struktuur van skisofrenie se simptome oor etniese grense heen. Verder ondersteun die resultate die moontlike rol van geslag, aangetaste sibstatus en kannabis gebruik in skisofrenie se fenomenologie. Die identifisering van die subgroepe mag „n intermediêre stap in die soektog vir endofenotipes van skisofrenie verteenwoordig.

Thesis (PhD)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background The changes in cognition, brain structure, and neurological soft signs which are characteristic of schizophrenia appear to have been present before the onset of the phenotype. They therefore find relevance as potential vulnerability markers of the disease. Neurological soft signs are of particular interest because they can be elicited quickly, reliably and cheaply. They have also been touted as markers of certain characteristics of schizophrenia. The most convincing evidence for these assertions come from prospective longitudinal studies of first episode, medication naive patients with schizophrenia. Most of these studies have been based on wholly Caucasian or mixed samples of Caucasians and other races. The present study provides important reference data on the nature of neurological soft signs in indigenous African subjects and clarifies the trait or state marking signs in this population. Method A total of 84 patients with first episode, schizophrenia, schizo-affective disorder, or schizophreniform disorder meeting criteria in the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders were consecutively recruited. Information on demographic characteristics, personal medical and psychiatric history, as well as family history was obtained at baseline. Neurological assessment was based on the 26 item Neurological Evaluation Scale. An exploratory factor analysis of the items in the scale was conducted using the baseline measurements. The derived sub-sets of neurological soft signs were then followed up longitudinally and in parallel with the ‘functional categories’ of the signs. The study describes the profile of neurological soft signs across the one year course of schizophrenia, as well as their relationship with a wide range of clinical and outcome variables. The severity of the baseline psychopathology was evaluated by administering the Positive and Negative Syndrome Scale. The overall clinical status was assessed using Clinical Global Impression. Additional assessments included the Calvary Depression Scale for Schizophrenia, Birchwood Insight Scale, Social and Occupational Functioning Assessment Scale, and the World Health Organisation Quality of Life Scale (WHO QoL-BREF). Pre-morbid adjustment was assessed using the Pre morbid Adjustment Scale, while extra-pyramidal effect of antipsychotics was assessed using the Extra-pyramidal Symptoms Rating Scale. Assessments were repeated at three monthly intervals for the full 12 months. Results Neurological soft signs were present in 96.4% of the sample at baseline. The signs loaded into a four factor structure: perceptual and motor sequencing (audio-visual integration, fist-edge palm, rhythm tapping, extinction, and right-left confusion), eye movements (synkinesis, convergence, and gaze impersistence), motor co-ordination and graphaesthesia (tandem walk, adventitious flow, and graphaesthesia), as well as stegreognosis. The scores for the perceptual and motor sequencing factor, as well as those for the sequencing of complex motor acts ‘functional category’ were stable across three measurements over 12 months (F=1.26, p=0.287, and F=1.87, p=0.158 respectively). The sequencing of complex motor act signs was not significantly correlated with the clinical and outcome characteristics of schizophrenia. However, other signs, as well as the NES total score were significantly correlated with more severe negative and disorganized psychopathology, as well as poorer outcome in terms of functioning and quality of life. Conclusion Neurological soft signs were present at a high frequency at baseline. A preponderance of the signs was associated with a more severe negative and disorganization psychopathology, as well as a poorer functional outcome and quality of life. Abnormal sequencing of complex motor act signs, and signs of abnormal cognitive processing of perceptual stimuli where resistant to changes in psychopathology, and thus may represent viable trait markers for schizophrenia in this cohort.

Psychiatric morbidity in the postpartum period has been a subject of research for years that has been plagued by much controversy. Most of the studies have come from Western countries. Studies that were done in Africa have concentrated on psychotic disorders in in-patients. A pilot study done by Cheetham et al (1981) at King Edward VIII Hospital found a high incidence of 'transient situational disturbances', which required further investigation. AIMS AND OBJECTIVES: 1. To document the spectrum of psychiatric morbidity in an out-patient population of postpartum Zulu women; 2. To define predictive factors which would identify women 'at risk'; 3. To assess the feasibility of 'Western' screening instruments; 4. To investigate whether 'postpartum blues' occurs in Zulu women. RESEARCH DESIGN A prospective, descriptive study was undertaken. Sample Selection: 177 postpartum Zulu women attending the ' Well-Baby' Clinic at King Edward VIII Hospital were randomly selected for inclusion in the study. Methodology: Three questionnaires: The General Health Questionnaire- 30, Pitt's Questionnaire of Anxiety and Depression and The Kennerley Blues Questionnaire were administered to the subjects. A Structured Clinical Interview DSM-III (SCID) was conducted in those women with symptoms. FINDINGS: 1. The majority of the sample were between the ages of 20 and 30 years, unmarried, with a Senior Primary education and a baby of 20 weeks. 2. 45.76% of the sample had a psychiatric diagnosis, with 18.07% having major depression. Other disorders included: adjustment disorders, schizophrenia and dysthymia. 3. Significant variables using Chi-square analysis were: inadequate antenatal care, a negative response from the partner and the absence of cultural rituals. No association was found with demographic and obstetric variables. 4. T-test analysis showed a correlation between the questionnaires and the SCID. 5. 37.3% had experienced 'postpartum blues'. CONCLUSIONS: 1. The spectrum of psychiatric morbidity is affective in nature and similar to other studies. 2. 'Postpartum blues' does occur in Zulu women. 3. Antenatal screening with 'Western' instruments could reduce psychiatric morbidity. 4. The nomenclature of puerperal disorders is inadequate and needs review. 5. More prospective, community-based research is needed, especially in rural Zulu women. / Thesis (M.Med.)-University of Natal, Durban, 1992.

Cross cultural research on the association between Life Events, Social Support, Religious Affinity, and Depression is limited. In view of the clinical impression that depression is becoming more prevalent in the Indian South African population, a community which is culturally distinct from Anglo-American populations, and the fact that there are no studies on these three variables in the Indian population, a study was planned to investigate the association between Life Events, Social Support, Religious Affinity, and Depression in the Indian South African population. The research design involved the analysis of data on Life Events, Social Support, and Religious Affinity. This data was obtained from a sample of 15 female depressives (which formed the Experimental group) and 15 matched community controls (henceforth designated the Control group). Informed consent was obtained from both sample groups prior to participation in the study. A 50 item Social Readjustment Rating Questionnaire - Chohanls Adaptation (SRRQ-CA), a 4 item Social Support Scale, and a 4 item Religious Affinity Scale was administered to both groups to assess Life Events, Social Support, and Religious Affinity respectively. A t-Test analysis of the scores obtained produced the following major findings: 1. The Experimental group experienced a significantly higher degree of life stress than the Control group. 2. The Experimental group experienced a significantly greater number of life events than the Control group. 3. The Experimental group experienced lower social support than the Control group. This result was not statistically significant. 4. The Experimental group reported less religious affinity than the Control group. This result was not statistically significant. These findings lend themselves to further research in this field and have significant therapeutic implications. / Thesis (M.Med.)-University of Natal, Durban, 1986.

Background Patients infected with the human immunodeficiency virus (HIV), the causative agent of the acquired immunodeficiency syndrome (AIDS), have high rates of psychiatric morbidity. The effects of HIV on the Central Nervous System may lead to psychiatric morbidity even before the appearance of the full-blown AIDS syndrome. Sero-prevalence studies of patients with psychoses have found an estimated 5-20% to be HIV positive. However, sero-prevalence estimates vary from study to study due to the differences in sampling by geographic location, socio-economic class, race and ethnicity, and psychiatric-diagnostic composition. The Republic of South Africa has some of the highest prevalence rates in the world and research in this field is escalating rapidly. However research on HIV in patients with mental illness, particularly psychosis is very sparse. Aim of the study To determine the prevalence of HIV sero-positivity amongst patients admitted to Town Hill hospital presenting with first episode psychosis. Method All patients presenting to Town Hill hospital with first episode of psychotic symptoms were recruited to participate in the study. The treating doctor in collaboration with the multi-disciplinary team made the diagnosis of Psychosis. A total number of 63 patients participated in the study. Results. 23.8% of the patients tested positive for the human immunodeficiency virus. Conclusions. The prevalence of HIV sero-positivity is high amongst patients presenting with first episode psychosis. The HIV epidemic could have an important effect on the aetiology and clinical presentation of psychosis. Recommendations State mental health authorities should pursue the promotion of voluntary HIV testing programs, in patients presenting with first episode psychosis as soon as they are capable of giving informed consent. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2007.

The aim of this study was to document the safeguards inherent in the Mental Health Act (MHA) of 1973, and to examine the extent " to which these are observed in practice. The research was conducted at Lentegeur Hospital in Mitchells Plain, Cape Town. The population consisted of 726 certified patients who were admitted involuntarily (i.e. under sections 9 and 12 of the MHA) from 01 January 1990 to 31 December 1990. Data for each of these patients was collected from the admission register, clinical files, administrative files, and the certified post book. In addition, the official hospital statistics were examined. Measurements obtained included demographic data, the validity of the document contents, the validity of the certification process, and an overall measure of the validity of each of t he certifications taking into account both document contents and observance of the time strictures set out in the MHA. Twenty nine patients (4,0%) were admitted by Urgency (Section 12), and 697 (96,0%) on Reception Order (Section 9). The study focused mainly on the Section 9 patients, because of the small sample size for Urgency admissions. It was found that 609 (87,4%) of the 697 admissions were legally flawed in terms of document contents criteria and the time limits in the certification process. Document content criteria were not fulfilled in: 3,0% of the Applications for Reception Order; 32,1% of Medical Certificates; 20,1% of Reception Orders; and 3,6% of Reports to the Attorney-General. In 40,0% of certifications the Report to the Attorney-General (G2/28) could not be traced. Examination of temporal safeguards revealed that the least satisfactory aspect was the delay in the completion of the post-admission Report to the Attorney-General. It was found that 32,3% of these Reports were not submitted on time. Reasons for the discrepancy ("gap") between legal standards and actual practice are discussed. Recommendations are made which could help minimise or eradicate this "gap". These include suggestions for changes in the document format, for the use of a certification booklet, for stricter control of late and inadequate documentation, and for inservice training of all those involved in the certification process. / Thesis (M.Med.)-University of Natal, Durban, 1993.

Research on stress factors among General Practitioners in relation to burnout is limited. In view of the clinical impression that stress is becoming more prevalent amongst Indian General Practitioners in urban areas, a study was planned to investigate the demographic variables, stress factors in practice and burnout among Indian General Practitioners in the Greater Durban Area. The research design involved the analysis of data on demographic variables, stress factors in practice and burnout. This data was obtained from a sample of 106 Indian General Practitioners in the Greater Durban Area. Informed consent was obtained by a letter that was sent to the General Practitioners. A Demographic Inventory, a 4 item Stress of Practice Questionnaire and the Maslach Burnout Inventory was administered by a postal questionnaire. The analysis of the scores obtained from the Stress of Practice Questionnaire and the Maslach Burnout Inventory provided the following findings: 1. The stress of practice - 6 factors were identified of which 3 were related to demands of the job, work: home interface and workload. 2. The Indian General Practitioners experienced a low to moderate degree of burnout. 3. The correlation of stress factors and Maslach Burnout Inventory subscales were weak. 4. For emotional exhaustion - dimensions of frequency and intensity, some of the stress related factors explained a fair amount of variation but the relationship was not strong. These findings lend themselves to further research in this field and have significant therapeutic implications for both practitioner and their patients. / Thesis (M.Med.)-University of Natal, Durban, 1991.

An exploratory study covering phase 1 stages 1, 2 and 3 only was undertaken in this large hybrid research project to determine perceptions and understandings of the practitioners and the community about mental health problems of children and adolescents in Zambia because so far there is little known about this phenomenon. The aim of this exploratory study was to gain new insights into the phenomenon by undertaking a preliminary investigation to determine priorities for the future post doctoral research before a more structured study to develop the PHC innovative curriculum. The process first 'explored' social reality on the ground to better comprehend the perceptions and understandings of mental health problems of CA and the curricula model preferences as perceived by the practitioners and the community respectively. This was done to appreciate the "reality of practice" on the ground using the Systems, Ecological, and Biopsychosocial theories which underpinned the four field areas of the study which are: Mental Health, Curriculum Development, INSET and Action Research (AR). The total project is open-ended with three (3) phases and eight (8) stages, from the initial exploration of perceptions (phase 1), through reports to government and stakeholders, curriculum development and piloting with health educators (phase 2) and finally implementing the reconstructed curriculum and integration (phase 3) in such a way as to empower primary health workers to themselves do further research. This thesis, covering the initial explorations of perception, encompasses ONLY the first phase and three stages of this larger qualitative research project because of the Higher Education requirements and funding to try to complete in 4 years. This entails literature review of all 4 field areas because in order to orientate the first phase and three stages of such research and to see the implications of results, it is necessary to have a good grounding in all four. The research study process commenced with an orientation and introduction of the context and purpose of the study, followed by the search conferences and focus group meetings using Qualitative Research Design and Methodology. Search conferences, focus group discussions, hospital registers and clinic records were the three sources of data collection. Analysis of Qualitative and Quantitative Data used NVIVO and SPSS 13.0 Statistical Data Analysis Soft ware respectively. The study showed that mental health problems of Children and Adolescents perceived by the community and the practitioners were also referred and recorded in various hospital registers. The analysis of data from hospital records on referred cases further showed that there are serious psychotic mental health disorders in children and adolescents referred for further consultations to hospitals from the community, some of which are: acute psychotic states, with some associated with HIV/Aids. In addition to these psychotic states, epilepsy, drug and alcohol abuse, child defilement, rape cases, mental retardation and conversion disorders particularly in female children/adolescents appeared to be relatively significant mental health concerns and problems in the researched community sites. The conclusion of the study suggests that there were more environment related factors perceived to cause mental health challenges to children and adolescents. This finding further suggests that there are similarities of cases referred from the community with those seen in clinical practice areas. The significance of these findings in the reality of practice, implies that the preferred PRISMS curriculum model to be developed later as a post doctoral activity for 'INSET' of PHC practitioners in Zambia should have deliberate blending of curriculum content with more socio-environment related issues than the current traditional curricula models which are more clinical in structure, process and content. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2007.

There is strong evidence supporting the view that beliefs and attitudes influence health behaviour. Furthermore, cultural and social beliefs also have been shown to influence the way health care facilities are used. Although western medicine plays a dominant role in the mass control of disease, traditional or folk medicine continues to play an important role in the health care of black communities. They therefore, possess unique attitudes, values and beliefs about health and illness which integrally influence their health behaviour. This study aims therefore to: understand phenomenologically the urban African’s perception of illness, disease and health; identify attitudes that directly influence health behaviour: identify “trigger factors” that precipitate health action and isolate factors that contribute to “negative” health behaviour. The sample in this study consisted of 3 groups of urban Africans who were 20 years and older. Group 1 comprised first time attenders to a medical outpatients department Group 2 and Group 3 were sample groups drawn from the Umlazi Township and the Kwa Mashu Township respectively. The Health and Illness Battery in the language of the participants were administered by trained interviewers. This study has demonstrated the following: urban Africans have a personal conception of illness, health and disease that influences their manner of help‐seeking; there are certain attitudes and beliefs that directly influence both positive and negative health behaviour;. there are several health beliefs which interact in a complex way and may lead to medical help‐seeking. Health action was found to be influenced by significant individuals in the subject's environment; demographic variables, such as, age, sex, education and urbanisation strongly influence the health and illness beliefs; these results validated some of the fundamental aspects of the common western health and illness models; the use of services and facilities are determined by the location, accessibility and the quality of services; financial costs, time, transport, lack of community supports, negatively affected helpseeking; symptoms have been identified as a “trigger factor” of help‐seeking. Individuals use other forms of treatments independent of medical treatments. A model of help‐seeking for urban Africans is proposed. / Thesis (Ph.D.)-University of Natal, 1993.

Thesis (DMed (Psychiatry))--University of Stellenbosch, 2007. / This study reports on the effect of seminar education by studying changes in knowledge, attitude and behaviour to haloperidol prescribing patterns of psychiatrists who In summary, this study demonstrated a direct relationship between seminar attendance and changes to selected minimum effective haloperidol dose and duration of treatment. However, seminar attendance did not appear to be a significant factor in changes to antipsychotic class used for treatment and changes in optimal effective haloperidol dose: rather a change in the level of “background” knowledge of participants was most likely responsible. This study also found individual participant characteristic differences in those who did change treatment duration and minimum effective dose. In conclusion, this study showed that the successful integration of international treatment recommendations into daily psychiatric practise could be facilitated by the use of appropriate educational seminars. Not all attendees benefit i.e. “learn”, but those needing to “learn” most do - i.e. those who need to change their prescribing habits most to meet internationally accepted guidelines. The peer exposure provided allows a format for informed discussion and the practise of evidence-based medicine. The judicious use of such seminars should result in better treatment options and outcomes for patients.attended evidence-based schizophrenia seminars presented by the Lundbeck Institute in Denmark. The objectives of the study were two-fold. Firstly, it set out to determine whether changes actually occurred in the post-seminar haloperidol prescribing behaviour of participants. This was done by analysing changes in choice of optimal haloperidol dose (both in acute treatment i.e. most effective dose and maintenance treatment i.e. minimum effective dose), selected duration of treatment (for first- and multi-episode schizophrenia patients) and drug-class used (conventional versus new generation antipsychotic). The study then investigated whether these changes (if they occurred) could be ascribed wholly or in part to the effect of schizophrenia seminar attendance, or whether other factors e.g. scientific progress over time in understanding schizophrenia and its treatment (“background” knowledge) and differences between participant datasets studied (only paired pre- and post-seminar data were used in this study) also played a role. Secondly, it attempted to identify factors predictive of seminar participants changing their haloperidol prescribing behaviour post-seminar i.e. what were the factors that predisposed some attendees to change their prescribing behaviour? This was done by analysing the effect that pre-seminar prescribing behaviour, participant nationality, patient caseload, work experience and workplace environment had on post-seminar behaviour. Results show that changes did occur in post-seminar haloperidol prescribing behaviour, but that they were not always due to an effect of seminar attendance. Only the changes in the minimum effective haloperidol dose and duration of treatment for first- and multi-episode schizophrenia patients could validly be ascribed to the effects of schizophrenia seminar attendance. Furthermore, multivariate analysis of the factors relating to these changes found that a participant was most likely to change their selected minimum effective haloperidol dose to be more in line with internationally accepted standards if they i) selected above the target dose pre-seminar, ii) had a relatively low caseload comprised mainly of schizophrenia patients and iii) came from either Greece, Germany, Britain, Spain, Italy or some other Eastern European country. The single most important factor related to changes in duration of treatment was found to be pre-seminar behaviour: respondents below the recommended duration of treatment increased their duration of treatment significantly.