Cognitive predictors of psychosocial functioning outcome in schizophrenia: a follow-up study of subjects participating in a rehabilitation program

The aims of this prospective study were to explore in subjects with psychosis participating in a rehabilitation program whether cognitive performances at baseline predicted (i) psychosocial functioning over a 15-16 month follow-up; (ii) improvement in psychosocial functioning over the rehabilitation program. Visuo-spatial tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to assess cognitive performance in 55 subjects with schizophrenia spectrum disorders who completed a rehabilitation program. The Multnomah Community Ability Scale (MCAS) was used to measure dimensions of community functioning. One subscale of the Client's Assessment of Strengths, Interests, and Goals (CASIG) provided a measure of subjective quality of life (QoL). Improvement was defined as a 15% or more increase in psychosocial scores between baseline and follow-up. Worse baseline sustained attention predicted better self-rated quality of life, and better baseline visual memory predicted better community functioning over the rehabilitation follow-up period, in particular, higher autonomy in activities of daily living, and less physical and psychiatric symptoms that could interfere with rehabilitation. Baseline cognitive performances predicted community functioning improvement during the follow-up period: visual memory predicted improvement in daily living autonomy and in social competence; sustained attention predicted improvement in behavioral problems (such as medication compliance, collaboration with treatment providers or impulse control) and social competence; planning performances predicted improvement in social competence. These cognitive functions could be specifically targeted in a rehabilitation program aimed at enhancing functioning in those particular dimensions.

Implantation multisite du programme Integrated Psychological Treatment (IPT) pour les personnes souffrant de schizophrénie. Élaboration d’une version renouvelée

Le programme Integrated Psychological Treatment (IPT) de Brenner et al. (1992), d’approche cognitivo-comportementale, a été implanté dans neuf milieux cliniques offrant des services aux personnes souffrant de schizophrénie. Une étude a permis de suivre l’implantation du programme IPT dans chacun des milieux, plus particulièrement d’évaluer le niveau de satisfaction des participants et des intervenants et d’identifier les points forts et les améliorations souhaitées. Les résultats permettent de constater que l’implantation a été un succès pour l’ensemble des neuf milieux. Les intervenants et les participants ont apprécié non seulement la structure hiérarchique qui tient compte davantage des besoins en réadaptation des personnes souffrant de schizophrénie, mais aussi son cadre d’application privilégié qui permet le suivi régulier d’un même groupe de patients pendant une année. Les modifications et ajouts proposés ont permis de développer une version québécoise du programme favorisant davantage l’atteinte des objectifs, particulièrement ceux liés au maintien et à la généralisation des apprentissages dans le contexte de vie réelle des participants.

Differential hemodynamic brain activity in schizophrenia patients with blunted affect during quetiapine treatment

Blood-oxygenation-level-dependent (BOLD) brain changes underlying response to quetiapine were examined using passive viewing of emotionally negative stimuli. Twelve DSM-IV schizophrenia patients with blunted affect (BA+) were scanned before and after 22 weeks of quetiapine treatment. Whole-brain, voxel-based methods were used to assess the differential hemodynamic response to quetiapine. In addition, a post hoc comparison to an independent group of 11 schizophrenia patients without blunted affect (BA-) was performed to compare them with BA+ (postquetiapine) in response to emotion processing. A 22-week treatment with quetiapine resulted in significant clinical improvement in the 12 study completers (mean +/- SD posttreatment PANSS blunted affect score of 5.50 +/- 0.76 at baseline to 2.08 +/- 1.00 at end point; t = 7.78, df = 11, P < 0.0001). Treatment response was associated with significant BOLD changes: increases in prefrontal cortex activation particularly in the right dorsolateral prefrontal cortex (DLPFC, BA 46) and the right anterior cingulate cortex (ACC, BA 32); and in the left putamen, right anterior temporal pole (ATP), and right amygdala. Conversely, before treatment with quetiapine, the same subjects activated the midbrain bilaterally and the right pons. The post hoc conjunctional analyses demonstrated that BA- subjects activated the left ACC, left insula, left ATP (BA 21), left ATP (BA 38), left amygdala, and right medial prefrontal cortex. Quetiapine seems to affect clinical recovery by modulating the functioning of specific brain regions. Unique BOLD changes in the putamen and DLPFC with quetiapine, in the BA+ postquetiapine, may reflect modality-specific effects. Controlled studies are needed to further assess these preliminary findings.

Predictors of quality of life in schizophrenia

The objective of this study was to clarify the relationships between socio-demographics, clinical characteristics, stressors, coping strategies, social support and quality of life (QOL) in 143 patients with a diagnosis of either schizophrenia or schizoaffective disorders. The research design is cross-sectional with repeated measures on the same subjects after a 6-month interval. A regression analysis generated a model that accounts for 50% of the variance in QOL at Time 1 and 43% at Time 2. The best predictors of QOL were two components of social support: attachment and reassurance of worth. Severity of daily hassles, the coping strategy of changing the situation, level of education and life-time hospitalization length were also related to QOL.

Sleep in untreated patients with schizophrenia: a meta-analysis

The present meta-analysis investigated the characteristics of sleep in patients with schizophrenia without neuroleptic treatment at the time of sleep recording. The 20 selected studies included 652 participants (321 patients with schizophrenia and 331 healthy subjects). Effect sizes were evaluated using d values for the following sleep variables: sleep latency (SL), total sleep time (TST), sleep efficiency index (SEI), total awake time (TAT), stage 2 percentage (S2%), stage 4 percentage, slow-wave-sleep percentage, rapid-eye-movement (REM) percentage, and REM latency. The initial meta-analysis revealed that patients with schizophrenia have the following sleep disorders: increased SL, decreased TST, and decreased SEI. A moderator analysis revealed that these sleep disorders were worse for the neuroleptic-withdrawal group relative to the never-treated group. However, only never-treated patients showed significantly increased TAT and diminished S2%. These results confirm that patients with schizophrenia have sleep disorders that are not necessarily a consequence of neuroleptic treatments, suggesting that sleep disorders are an intrinsic feature of schizophrenia. However, it must be noted that some sleep disorders may be amplified by residual effects of neuroleptic withdrawal, while others appear to be dampened by neuroleptic treatment.

The crossover approach to switching antipsychotics: what is the evidence?

Clinicians frequently use a crossover approach in switching antipsychotics, although historically there has been a lack of data addressing the question of switch strategies. To establish if there is now empiric evidence that may guide clinicians in this regard, a MEDLINE search to April 2004 was carried out to identify published, randomized and controlled trials that have addressed this topic. A total of 404 articles were identified in the search, which resulted in the identification of four reports meeting the criteria. The four studies evaluated switching strategies to one of three atypical antipsychotics: aripiprazole, olanzapine (two reports), and ziprasidone. The switching process itself could be subdivided as follows: discontinuation (abrupt vs. gradual); and, replacement (abrupt vs. gradual). Meta-analyses confirmed a lack of difference in outcome, regardless of approach. While a crossover approach does not appear to increase adverse events, the available empiric evidence does not support its clinical superiority on various outcome measures. The existing data therefore argue against the position that a crossover approach in switching antipsychotics represents a 'safer' means of preventing clinical deterioration during the switch.

The relationships between symptom dimensions and dysphoria in schizophrenia

Previous studies have suggested that qualitatively distinct aspects of dysphoria (anxiety and depression) are related to specific dimension of schizophrenia symptomatology. Most of these studies used simple dimensions and dysphoria models, although finer distinctions could help defining specific relationships. This study examined the relationships of distinctive aspects of depression and anxiety (both state and trait) with symptom dimensions. Forty patients with a DSM-IV diagnosis of schizophrenia were assessed for symptoms (SAPS-SANS), trait and state anxiety (STAI) and depression (CDS). Symptoms ratings were summarized as dimensional scores according to a two-, three- or five-dimensional models proposed in the literature. The correlation analysis replicates previous observations that distinct aspects of dysphoria are associated with specific dimensions of schizophrenia, with the exception of disorganization. Moreover, controlling for intercorrelated variables revealed that schizophrenia and dysphoric symptoms might act in combination and/or through indirect links to contribute to illness expression. Our data further suggested that these associations may be best understood in terms of interactions between various processing biases alluded in the most recent cognitive accounts of schizophrenia symptoms.

Brain-behavior relations during motor processing in chronic tic and habit disorder

OBJECTIVE

This study examined electrophysiological indices of preparation (readiness potential, RP) and execution (movement-associated potential, MAP) during automated and controlled reaction time (RT) in 13 chronic tic disorder, 17 habit disorder, and 14 control participants.

BACKGROUND

Both tic and habit disorders are hypothesized to involve states of heightened activation, which could impede initiation and the control of complex motor actions.

METHOD

The electrophysiological signal was recorded from 4 electrodes (Fz, C3, C4, Pz) during a fixed 4-second foreperiod reaction time task.

RESULTS

During automated responses, controls showed a shorter RP peak onset, and during controlled responses a longer MAP peak onset, compared with both clinical groups. The controls were the only group who showed a consistent linear relationship between RP and RT.

CONCLUSIONS

Patients with chronic tic as well as habit disorder may not modulate cortical activation optimally in planning and executing both automated and controlled responses.

Are there common mechanisms in sensation seeking and reality distortion in schizophrenia? A study using memory event-related potentials

A growing literature suggests that the characteristics of sensation seeking and reality distortion expressed in schizophrenia share several mechanisms. In a previous study, the comparison of patients with high vs. low reality distortion using event-related potentials (ERPs) recorded in a recognition memory task for unfamiliar faces identified neural and cognitive anomalies specifically related to the expression of these symptoms. As a follow-up, this study investigated the ERP correlates of sensation seeking in schizophrenia using the same recognition memory protocol. ERPs have been recorded in controls (N=21) and schizophrenia patients separated into high (HSS; N=13) and low (LSS; N=17) scorers according to Zuckerman's Sensation Seeking Scale. The results show a reduced P2a that was found unrelated to reality distortion in the previous study of reality distortion. It identifies interference inhibition impairment as being specifically related to sensation seeking. On the other hand, HSS scorers display enhanced fronto-central and normal P600 effects also found in high reality distortion patients. These results indicate inappropriate context processing and mnemonic binding common to sensation seeking and reality distortion. LSS scorers also display a reduced temporal N300 similar to that found in low reality distortion patients. This anomaly could reflect the lower reactivity to emotionally significant stimuli that underlies anhedonia symptoms. Finally, the N400 effect and a late frontal effect are found in both HSS and LSS. Since they were unrelated to reality distortion, these indices have been related to basic aspects of schizophrenia, e.g., deficient knowledge integration, or other mechanisms, e.g. anxiety or impulsivity. In summary, the present study examines the strategy of investigating variables, such as temperamental characteristics, in addition to symptoms, to show how discrete impairments may contribute to the expression of the illness.

The paradox of quetiapine in obsessive-compulsive disorder

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

Environmental cognitive remediation in schizophrenia: ethical implications of "smart home" technology

OBJECTIVE

In light of the advent of new technologies, we proposed to reexamine certain challenges posed by cognitive remediation and social reintegration (that is, deinstitutionalization) of patients with severe and persistent mental disorders.

METHOD

We reviewed literature on cognition, remediation, smart homes, as well as on objects and utilities, using medical and computer science electronic library and Internet searches.

RESULTS

These technologies provide solutions for disabled persons with respect to care delivery, workload reduction, and socialization. Examples include home support, video conferencing, remote monitoring of medical parameters through sensors, teledetection of critical situations (for example, a fall or malaise), measures of daily living activities, and help with tasks of daily living. One of the key concepts unifying all these technologies is the health-smart home. We present the notion of the health-smart home in general and then examine it more specifically in relation to schizophrenia.

CONCLUSION

Management of people with schizophrenia with cognitive deficits who are being rehabilitated in the community can be improved with the use of technology; however, such technology has ethical ramifications.

Visual search irregularities in schizophrenia depend on display size switching

INTRODUCTION

In past research it has been demonstrated that when performing a visual search task with either one or multiple (4, 7 or 10) stimuli displayed, patients with schizophrenia demonstrate slow response times (RTs) in the display size of one, target-absent (one-absent) condition. The goals of the present investigation were to replicate this effect, and to gain an understanding of the underlying cognitive operations by comparing display-size switch to display-size repeat trials.

METHODS

In two experiments, patients and controls performed a visual search task with either one or four stimuli displayed. In Experiment 1 (one block with mixed switch and repeat trials), RT for display-size switch trials was compared to RT from display-size repeat trials. In Experiment 2, the display-size one and display-size four conditions were run in separate, homogeneous blocks.

RESULTS

The results demonstrate that the one-absent slowing effect was eliminated on repeat trials, regardless of whether the switch and repeat trials were mixed or presented in separate blocks.

CONCLUSIONS

This set of results suggests that a combination of cueing and switching effects may underlie the one-absent slowing observed in patients, such that switching to the one-absent condition is difficult due to insufficient cueing of the relevant cognitive operations. This visual search paradigm is an excellent candidate for inclusion in the development of a neurocognitive profile specific to schizophrenia.

Negative socio-emotional resonance in schizophrenia: a functional magnetic resonance imaging hypothesis

The aim of the present study is to use neuroscience theories about brain function (mirror-neurons MN) to draw inferences about the mechanisms supporting emotional resonance in two different groups of schizophrenia patients (with flat affect FA+ n = 13 and without flat affect FA- n = 11). We hypothesize that FA+ will not activate key brain areas involved in emotional processing. Conversely, FA- will have a functional mirror system for emotional resonance confirmed by activation of the prefrontal cortex and behavioral results. To test this hypothesis, we compared the two groups using blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging (fMRI) displaying a passive visual task (44 negative IAPS pictures and 44 neutral pictures). A random-effects analysis, for schizophrenia patients FA-, revealed significant loci of activation in the left mesial prefrontal (MPFC), right orbitofrontal (OFC) and left anterior cingulate cortices (ACC). Correlational analyses carried out between self-report ratings of negative feelings and BOLD signal changes revealed the existence of positive correlation in the LACC, LMPFC and ROFC. Conversely, FA+ did not show significant activation in the prefrontal cortex. We propose that negative emotional resonance induced by passively viewing negative pictures may be a form of "mirroring" that grounds negative feelings via an experiential mechanism. Hence, it could be argued that FA- were able to 'feel' emotions through this resonance behavior. Conversely, we suggest that the dysfunction seen in the FA+ group is a failure or distortion in the development of the MN system. This could be due to genetic or other endogenous causes, which affected prefrontal cortex MN involved in emotional resonance.

Changes in the neuropsychological correlates of clinical dimensions between the acute and stable phase of schizophrenia

This study was designed to investigate whether the neuropsychological correlates of the symptom dimensions of schizophrenia vary with the clinical state in patients followed from the acute to stable the phase of the illness. Fifteen patients were assessed for symptoms (SAPS-SANS) and undergone a complete neuropsychological assessment at two sessions. The first session (S1) was carried out within six days after admission, i.e., acute phase and the second (S2) at least two month after hospitalization, i.e., stable phase. The data were analyzed using stepwise regression models in which neuropsychological scores were in entered to predict each dimensional score. This analysis was applied on the S1 and S2 data as well as on the S2-S1 difference to assess the neuropsychological predictors of clinical changes. Generally, the results replicate the previous associations between neuropsychological and dimensional measures found in stable patients. In addition, this study shows if each dimension appears to rely on a key structure, symptom variations seems to involve changes in the spread of the dysfunction and/or changes in the connectivity between the key and other regions. The results also suggest that functional changes related to some symptoms dimensions occur to compensate for the dysfunction associated with other symptoms.

On the trail of a cognitive enhancer for the treatment of schizophrenia

The aim of this critical review is to address that the study of cognition and antipsychotics is not always driven by logic and that research into real pro-cognitive drug treatments must be guided by a better understanding of the biochemical mechanisms underlying cognitive processes and deficits. Many studies have established that typical neuroleptic drugs do not improve cognitive impairment. Atypical antipsychotics improve cognition, but the pattern of improvement differs from drug to drug. Diminished cholinergic activity has been associated with memory impairments. Why atypical drugs improve aspects of cognition might lie in their ability to increase dopamine and acetylcholine in the prefrontal cortex. An optimum amount of dopamine activity in the prefrontal cortex is critical for cognitive functioning. Another mechanism is related to procedural learning, and would explain the quality of the practice during repeated evaluations with atypical antipsychotics due to a more balanced blockage of D2 receptors. Laboratory studies have shown that clozapine, ziprasidone, olanzapine, and risperidone all selectively increase acetylcholine release in the prefrontal cortex, whereas this is not true for haloperidol and thioridazine. A few studies have suggested that cholinomimetics or AChE inhibitors can improve memory functions not only in Alzheimer's disease but also in other pathologies. Some studies support the role of decreased cholinergic activity in the cognitive deficits while others demonstrate that decreased choline acetyltransferase activity is related to deterioration in cognitive performance in schizophrenia. Overall, results suggest the hypothesis that the cholinergic system is involved in the cognitive dysfunctions observed in schizophrenia and that increased cholinergic activity may improve these impairments. Furthermore, a dysfunction of glutamatergic neurotransmission could play a key role in cognitive deficits associated with schizophrenia. Further meta-analysis of various clinical trials in this field is required to account for matters on the grounds of evidence-based medicine.

Restoration of frontal activation during a treatment with quetiapine: an fMRI study of blunted affect in schizophrenia

This study investigated changes in cerebral activation related to emotion processing in schizophrenia patients with blunted or flat affect (FA+) during treatment with quetiapine. Using functional magnetic resonance imaging (fMRI), brain activation in 12 FA+ schizophrenia patients during passive viewing of sad film excerpts was studied before and after a median of 5.5-months treatment with quetiapine. Random-effects 'paired sample t-test' analyses of brain activation before quetiapine (contrast=sad-neutral, before-after) revealed significant activation in the brainstem (pons, medulla). After quetiapine, the same contrast showed significant prefrontal activation (BA 9, 10 and 11). Activation of key prefrontal areas involved in emotion processing and significant symptoms improvement as measured by the subjective rating scale and PANSS suggests the potential effect of quetiapine in improving blunted affect related symptoms (i.e., passive withdrawal, emotional withdrawal, social avoidance) in schizophrenia.

Changes in distributed neural circuitry function in patients with first-episode schizophrenia

BACKGROUND

A number of functional brain abnormalities have been reported in schizophrenia, but it remains to be determined which of them represent trait and state markers of the illness.

AIMS

To delineate regional brain dysfunctions that remain stable and those that fluctuate during the course of schizophrenia.

METHOD

A cohort of patients with first-episode schizophrenia and a matched group of control participants underwent functional magnetic resonance imaging on two occasions 6-8 weeks apart during performance of a working memory task. The patients' disease was in partial remission at the second scan.

RESULTS

Relative to control participants, the function of the left dorsolateral prefrontal cortex, left thalamus and right cerebellum remained disturbed in the people with schizophrenia, whereas the dysfunction of the right dorsolateral prefrontal cortex, right thalamus, left cerebellum and cingulate gyrus normalised, with significant reduction in symptoms.

CONCLUSIONS

These results suggest that dysfunction of the left fronto-thalamo-cerebellar circuitry is a relatively stable characteristic of schizophrenia, whereas disturbance of the right circuitry and cingulate gyrusis predominantly a state-related phenomenon.

The crucial role of sustained attention in community functioning in outpatients with schizophrenia

The aim was to explore the pattern of associations between visual cognitive performance and community functioning in a sample of outpatients with schizophrenia participating in a rehabilitation program. Visuo-spatial tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to assess cognitive performances in 88 subjects. The Multnomah Community Ability Scale (MCAS) was used to measure dimensions of community functioning. Our results showed that the sustained attention score was significantly associated with the global community functioning score and with two specific dimensions: "adjustment to living" and "behavioral problems". No association was found between other cognitive indices and MCAS scores. Since the sustained attention task mainly involves the executive component of working memory, these findings suggest that attentional control processes are limiting factors for community functioning in schizophrenia outpatients. Measures of such processes could serve as key indices of disability in clinical practice. Attention and working memory training may be helpful to improve community functioning in subjects with schizophrenia.

Switching atypical antipsychotics: a review

BACKGROUND

Atypical antipsychotics are increasingly used in the treatment of diverse psychiatric disorders; however, there is little information on the 'why, when, and how' of switching between the different atypical antipsychotics currently available.

OBJECTIVE

To review the data on switching and atypical antipsychotics.

METHODS

A literature search was initially conducted using the key words followed by a search of relevant articles including conference abstracts; relevant pharmaceutical companies were also contacted.

RESULTS

Clinical trial data are limited in terms of parameters measured, and case reports describe specific problems. Few studies are based on real world populations of psychiatric patients over the long-term. Careful patient and drug selections matched to a carefully supervised and appropriate cross titration based upon the pharmacodynamic and pharmacokinetic properties of all of the drugs involved is important to avoid potential complications such as re-emergence or worsening of psychosis and withdrawal, rebound, and emergent phenomena including new or uncovered side-effects. Psychoeducation and involvement of patients and caregivers in the process are also necessary for a successful switch.

CONCLUSION

Despite the prevalence of switching in real world clinical practice, there is a paucity of data to guide clinicians with respect to effective and safe strategies. There are no criteria defining a successful switch. With the increasing range and formulations of atypical antipsychotics available, there is a rationale for their early use to avoid the practical problems associated with switching from conventional antipsychotics as well as the opportunity to maintain patients on an optimal atypical antipsychotic monotherapy.