Depressive syndromes in schizophrenic patients under neuroleptic therapy. ANI Study Group Berlin, Düsseldorf, Göttingen, Munich, Federal Republic of Germany

Schizophrenic outpatients (= 364) were assigned at random to three different treatment strategies: (1) continuous medication with neuroleptic drugs, (2) intermittent medication with crisis intervention and (3) intermittent medication with early intervention. Depressive syndromes were rated according to three different scales for depressive syndromes (Brief Psychiatric Rating Scale anxious depression factor, Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie/depression, and the self-rating Paranoid Depression Scale) after 1 and 2 years of treatment. No differences in depression scores were found between the three treatment strategies. Comparisons between patients treated with neuroleptic drugs at the time and patients without neuroleptics revealed significantly higher depression scores in the neuroleptics group in most comparisons. No differences were found between patients treated with low versus high potency neuroleptics and between oral versus depot neuroleptics. However, depression correlated with extrapyramidal symptoms.

Facial expression and emotional face recognition in schizophrenia and depression

Twenty-three acute schizophrenics, 21 acute major depressives (Research Diagnostic Criteria), and 15 normal controls participated in a study on facial expression and emotional face recognition. Under clinical conditions, spontaneous facial expression was assessed according to the affective flattening section of the Scale for the Assessment of Negative Symptoms. Under experimental laboratory conditions involuntary (emotion-eliciting interview) and voluntary facial expression (imitation and simulation of six basic emotions) were recorded on videotape, from which a raterbased analysis of intensity or correctness of facial activity was obtained. Emotional face recognition was also assessed under experimental conditions using the same stimulus material. All subjects were assessed twice (within 4 weeks), controlling for change of the psychopathological status in the patient groups. In schizophrenics, neuroleptic drug influence was controlled by random allocation to treatment with either haloperidol or perazine. The main findings were that schizophrenics and depressives are characterized by different quantitative, qualitative, and temporal patterns of affect-related dysfunctions. In particular, schizophrenics demonstrated a trait-like deficit in affect recognition and in their spontaneous and voluntary facial activity, irrespective of medication, drug type and dosage, or extrapyramidal side-effects. In depressives a stable deficit could be demonstrated only in their involuntary expression under emotion-eliciting interview conditions, whereas in the postacute phase a reduction in their voluntary expression became apparent. Differences in patterns of affect-related behavioral deficits may reflect dysfunctions in different underlying psychobiological systems.

Early serum levels of neuroleptics do not predict therapeutic response in schizophrenia

Thirty-six acute schizophrenics were included in a 28-day open treatment study with the neuroleptic perazine. Peak serum levels of parent drug and its main inactive metabolite desmethyl-perazine were assessed 2 hours after an oral test dose given at the beginning of the study. Whereas peak levels of perazine were not significantly different in treatment responders and nonresponders, desmethyl-perazine was significantly higher in nonresponders. The ratio between desmethyl-perazine and perazine was not predictive of (non-) response to neuroleptic treatment in schizophrenia.

[Behavior analytic approaches of research in psychiatry]

Biologically oriented psychiatric research usually relies more on abstract nosological concepts than on purely descriptive psychopathological syndromes. However, biological validation of psychiatric diagnoses has not been possible so far. More recent findings emphasize the nosological unspecificity, but syndromal specificity of biological data. It seems promising therefore to differentiate psychopathological descriptions more clearly by using objective methods of behavioural assessment and analysis. Concept, methods and examples of this empirical approach will be outlined.

Depressive syndromes in schizophrenic patients after discharge from hospital. ANI Study Group Berlin, Düsseldorf, Göttingen, Munich

A total of 364 schizophrenic outpatients who were stabilized for 3 months on continuous neuroleptic therapy after discharge from the hospital were rated according to three different scales for depressive syndromes (Brief Psychiatric Rating Scale anxious depression factor, AMDP/depression, and the self-rating PD-S depression scale). Between 19.5% and 27.5% of the patients were rated as depressed, or 35.7%-42.8%, when mild depressive syndromes were included. There were low, but significant correlations between demographic or life-event data and depression scores on the self-rating scale, whereas fewer correlations were found on the observer ratings. No associations were found between social adjustment and depression. Moderate correlations were found between measures of the apathetic syndrome and depression ratings, while observer ratings showed higher correlations than the self-rating. High depression scores, especially in the observer ratings, correlated with scales for global psychopathological assessment (CGI, GAS). There were significant correlations between extrapyramidal rigidity and observer rating depression scores, whereas the total amount of neuroleptics given had no influence. These results are interpreted on the basis of hypotheses about depressive syndromes in schizophrenia.

Visuomotor behavior in schizophrenia

The diagnosis of "positive" schizophrenia relies heavily on reported symptoms. Behavioral signs, however, play an important role in "negative" schizophrenia. Their advantage is that they can be assessed objectively and quantitatively. Thus, their measurement can improve both the precision of the diagnostic process and the phenomenological basis of biologically oriented research. The assessment of various types of visuomotor behavior (e.g., eye fixations, saccades, smooth-pursuit eye movements) with different functions and anatomic organization, and of their trait- and state-related disturbances in schizophrenia are an example of this kind of research. Whether analyzed from an interactional or an individual perspective, visuomotor behavior is best understood within a broader neurobiological frame of reference. In combination with brain imaging techniques it is an important tool with which to explore brain behavior relationships in schizophrenia and other related psychoses.

Visual search, eeg, and psychopathology in schizophrenic patients

Twenty acutely admitted schizophrenic inpatients diagnosed according to RDC and 8 normal controls were instructed to search for a randomly located target letter (Z) in ten lists of 284 distractor letters of either rounded or angular shape projected on a screen (23 degrees x 15 degrees). Eye movements were recorded using infrared corneal reflection-pupil centre measurement. Search performance was defined as the search time in seconds from onset of the display until localization of the target. The EEG was recorded simultaneously in schizophrenics, in whom assessment took place shortly after admission and before discharge. The psychopathological status was assessed at the same time with the Brief Psychiatric Rating Scale and the Scale for the Assessment of Negative Symptoms. Search performance was not significantly different in schizophrenics and normal controls, but was heavily affected by target/distractor similarity in both groups. Moreover, search performance in schizophrenics was not significantly affected by illness severity. However, search performance was differently related to negative and positive symptoms. Schizophrenics and normal controls differed with respect to the relationship between search performance and visuomotor microbehaviour. Additionally, two relatively time-stable eye movement patterns in schizophrenics could be distinguished, which were differently related to psychopathology, performance measures and EEG.

Auditory evoked potentials as possible predictors of outcome in schizophrenic outpatients

As part of a follow-up study on long-term neuroleptic treatment, 36 schizophrenic out-patients under neuroleptic treatment were studied in an 'auditory oddball' event-related potential paradigm after a 3-month stabilization phase following clinical discharge. In the first cross-sectional analysis, we evaluated the influences of age and gender and tried to find auditory evoked potential (AEP) variables, which might be promising as potential predictors of the course of illness. Compared with healthy age-matched controls, the patients showed smaller N1/P3-amplitudes. Males and females showed only minor AEP-differences, the amplitude N1/P2 being slightly higher in females. Age correlated positively with the latency P3 and negatively with the latency P2R. The interpeak latency P3-P2R showed the highest correlation with age. Test/re-test reliability was measured and variables with r less than 0.60 were rejected. The amplitudes N1/P2 and N1/P3 showed the highest test/re-test correlations. The more severely disturbed patients (global assessment scale [GAS]-score less than 65) had shorter interpeak latencies P2F-N1F than the less disturbed patients (GAS greater than or equal to 65). Patients with a high rate of relapse tended to have shorter interpeak latencies P2F-N1F than patients with low rates of relapse. Our results indicate that the interpeak latency P2F-N1F has an acceptable test/re-test reliability (C3: r = 0.72; C4: r = 0.80) and is related to clinical variables characterizing the course and outcome of illness. This leads to the hypothesis that a short interpeak latency, P2F-N1F, might be a predictor of poor prognosis.

Topographical distribution of absolute alpha-power in the EEG and psychopathology in schizophrenic outpatients

In 36 schizophrenic outpatients (Research Diagnostic Criteria) under neuroleptic maintenance treatment the EEG was recorded under resting conditions. The absolute alpha-power (7.5-13 Hz) was estimated by Fast Fourier Transform as the mean of 300 2-second epochs for the leads F3/A1, F4/A2, 01/A2 and 02/A2. Two lateralization quotients (anterior, posterior) and two anteriorization quotients (left, right) were calculated from the absolute alpha-power. Clinical status was assessed cross-sectionally with BRPS, GAS and CGI. The main findings are: 1) A linear relationship between the left/right ratio of absolute alpha-power over posterior regions and anxiety/depression--the more the alpha-power is left-lateralized, the higher the anxiety/depression score; 2) a curvilinear, inverted U-shaped relationship between the left/right ratio of absolute alpha-power over posterior regions and the score of schizophrenia-specific symptomatology; 3) the amount of daily neuroleptic dose (mgCPZ) has no impact on EEG-parameters. Results are discussed with respect to hemisphere asymmetry models of psychopathology.

Prediction of neuroleptic on-drug response in schizophrenic in-patients by EEG

The subjects were 34 acutely ill in-patients who met the RDC criteria of schizophrenic psychosis, and 4 EEGs were recorded from each patient before, 2 h and 24 h after oral intake of a single dose of 150 mg perazine, and on the 28th day of the neuroleptic treatment period. As a criterion of clinical response a decrease of at least 66% in the schizophrenia-specific sum score of the Brief Psychiatric Rating Scale on day 28 relative to the baseline value was decided upon. The EEGs were assessed using a newly developed procedure which takes into consideration 4 derivations simultaneously. As we tried to search out EEG variables with predictive value the statistical data analysis underlying our findings should largely by regarded as exploratory. Independent of day, responders (R) showed a tendency towards more low voltage desynchronized epochs (non-A stage) than non-responders (NR). Thus, R exhibited a higher degree of dynamic variability or a broader range of control of the spontaneous vigilance fluctuation (dynamic lability) than NR (dynamic rigidity). Furthermore, R and NR differed with respect to their time-dependent changes of non-A epoch frequencies before medication. While R showed a monotonous increase which is typical for normals, NR did not. Because of considerable inter-individual variability these group differences could not be used for individual prediction of the therapy response. By means of a qualitative data analysis R could be distinguished from NR with regard to various test dose-induced changes of the topographical distribution of absolute alpha power. All the group differentiating variables showed a time course of the same kind: R showed a prompt and ample deflection and the same recovery of baseline; NR, in contrast, showed no significant deflections at all. These findings are in line with the results concerning the dynamics of vigilance and certain claims of earlier authors according to which EEG changeability should be decisive for therapeutic outcome.(ABSTRACT TRUNCATED AT 400 WORDS)

Visuomotor performance of schizophrenic patients and normal controls in a picture viewing task

The eye movements of 20 partially remitted schizophrenic outpatients (ICD-9) under neuroleptic maintenance medication and those of 20 normal controls were recorded using corneal reflection pupil-center measurement. The visuomotor performance during a 1-min picture viewing task was studied on the basis of several eye movement parameters. Clinical evaluation comprised self-ratings (Frankfort Complaint Questionnaire) and observer ratings (BPRS, CGI, GAS), as well as recording of current daily neuroleptic dosage (mg CPZ). The main results are that schizophrenics differ from normals in their correlational pattern of fixation- and movement-related parameters, reflecting two opposite viewing styles in schizophrenics: staring and extensive scanning. Both styles are differently related to clinical symptomatology. There was no strongly marked relationship with neuroleptic dosage.

[Psychophysiology of schizophrenic disorders of attention--concepts, findings and working hypotheses]

Starting from early clinical descriptions according to which there exists a polarity of attentional behavior in schizophrenia, we compare a number of pertinent theoretical concepts put forward up to now. Special attention is given to the question of functional hemispherical asymmetries, and here especially to a working hypothesis according to which the neuropsychological deficits in schizophrenics result from a coordination deficit of two differently lateralized attention systems. Taking into consideration certain neurophysiological (especially electro-encephalographical) findings, we discuss a model which places in opposition sensory intake behaviors and sensory rejection behaviors. Then we give a condensed presentation of relevant findings of our own. In particular, it could be shown that clinical improvement goes along with a certain change of the topographical distribution of absolute alpha-power, and that the intensity of some psychopathological symptoms correlates with the lateralization of posterior absolute alpha-power. Relationships also occurred between psychopathology on the one hand and the performance level in a visuo-motor tracking task or the eye movement behavior recorded during a picture viewing task, on the other. A concluding synopsis, comprising both empirically proven and theoretically postulated relationships, serves to formulate working hypotheses for clinical-psychophysiological correlation studies to be done in the future. In contrast to the current practice of assigning patients to the usual diagnostic subgroups, we advocate from a research-oriented point of view the grouping of those patients who show certain combinations of clinical and psychophysiological signs at a certain moment. Such a procedure holds out a prospect of solving a central problem of schizophrenia research consisting of the considerable intra- and individual variability of findings. Instead of changeable sick persons, defined systems states would be classified. Knowledge of the dynamics of such systems states could contribute to a rational therapy in the individual patient.

Prospective study of course of illness in schizophrenia: Part I. Outcome at 1 year

In a prospective study involving 161 patients discharged from inpatient psychiatric treatment, outcome data were obtained for 93 percent of the patients 1 year after clinic discharge. Sixty-seven percent of the patients were directly interviewed for the followup examination. Outcome data for symptomatology, relapses, employment, and social contacts did not differ significantly for patients with schizophrenic psychoses as compared to those with affective psychoses, neuroses, and other psychiatric diagnoses (predominantly alcohol dependency). A discrepancy between self-ratings and observer-ratings was particularly striking in the group of neuroses at discharge from inpatient treatment. These patients also had comparatively more prominent depressive symptomatology at followup. These findings raise questions about the influence of possibly different levels of intensity in outpatient followup treatment, and about outcome predictors independent of diagnosis. These questions are pursued in Parts II and III.

Prospective study of course of illness in schizophrenia: Part II. Prediction of outcome

In a prospective study of the course of illness of 86 schizophrenic patients (ICD 9), outcome data were obtained for 86 percent 1 year after clinic discharge. The Strauss-Carpenter Outcome Scale (frequency of social contacts, employment duration, symptomatology, and duration of rehospitalization) and the Clinical Global Impressions were used to assess outcome. The prognostic scales developed by Vaillant, Stephens, Phillips (in the abbreviated version by Harris), and Strauss-Carpenter were used as potential outcome predictors at the time of index admission. The findings were as follows: The outcome criteria used correlated at best moderately with one another. Between 60 and 90 percent of the sample were judged to have an unfavorable prognosis on the Vaillant and Stephens scales. In contrast, the outcome was relatively favorable for 50 to 60 percent of the patients. In prognostic validity, the Strauss-Carpenter scale was superior to all of the other scales investigated. However, a prognostic relationship was only established for social outcome. Social outcome dimensions showed the highest prognostic validity (e.g., employment and social contacts). The amount of variance explained by the best predictors was between 12 percent (symptomatology) and 55 percent (employment duration).

Prospective study of course of illness in schizophrenia: Part III. Treatment and outcome

In a prospective study of 86 schizophrenic patients (ICD 9), outcome data were obtained for 86 percent 1 year after clinic discharge. The Strauss-Carpenter outcome scale (frequency of social contacts, employment duration, symptomatology, and duration of rehospitalization) served as the outcome criterion. The Strauss-Carpenter prognostic scale items served as the potential predictors of the course. The followup treatment, which took place during the catamnestic period, was compared with that of other psychiatric diagnostic groups with respect to its continuity and efficiency. The following findings emerged: When compared to patients with neuroses and alcohol dependency, the followup treatment of schizophrenic patients in a large city seems to be better ensured. This is attributed to a clearer concept of treatment for schizophrenic patients. The comparatively favorable outcome of this group of patients seems to be related to this. For the other groups, especially for neurotic disorders, effective treatment concepts have still to be developed and evaluated. Schizophrenic patients receiving continuous neuroleptic medication are rehospitalized significantly less often (28 percent) than those not in continuous treatment (55 percent). This treatment difference is most obvious for patients with multiple admissions. Differences dependent on treatment are not found in other outcome dimensions. However, patients with good heterosexual adjustment profit the most from continuous treatment with neuroleptics in reference to freedom from symptoms. For a more chronic subgroup with a poorer initial level of work adjustment, the functional level deteriorates over the course of illness. Relapse and inpatient readmission are related to retarded recompensation, particularly for chronic patients. This underlines the need for consistent neuroleptic treatment.

Visuomotor tracking performance in schizophrenia: relationship with psychopathological subtyping

30 schizophrenic outpatients (RDC) under neuroleptic maintenance treatment completed a visuomotor tracking task with four degrees of difficulty. The mean efficiency of performance was measured in bit per second from the difference between the target signal and the tracking signal. Clinical assessment was accomplished with the BPRS, CGI, and GAS. Besides generally poorer tracking performance in schizophrenics compared with healthy volunteers the main finding was a relationship between tracking performance and psychopathological subtyping. Negative symptoms were related to a generally lowered task performance, irrespective of task difficulty. However, this effect disappeared by controlling for illness duration. On the other hand, there was a syndrome-specific interaction effect with task difficulty: Schizophrenics with positive symptoms performed poorly, especially in the most difficult task condition. Generally, there was no significant relationship between daily neuroleptic dose and tracking performance. Results are discussed with respect to a differential deficit in attention in schizophrenic subgroups.

Eye movement research with schizophrenic patients and normal controls using corneal reflection-pupil center measurement

The eye movements of 20 partially remitted outpatient schizophrenics (ICD 9), for the most part receiving neuroleptic maintenance medication, and 20 normal controls were recorded using corneal reflection-pupil center measurement. Performance was investigated on the basis of widely varied measurement parameters during a fixation task and a visual search task (list of letters). Psychopathological data were additionally recorded for the group of patients by means of self and observer ratings, current social adjustment, and neuroleptic dosage. The schizophrenic patients showed the tendency to perform more poorly than the normal controls in the eye movement parameters recorded, and there was marked variation in performance within the group of schizophrenic patients. In particular, various abnormalities in fixation performance were connected differentially with individual psychopathological syndromes and neuroleptic dosage. Connections between fixation performance and search performance were found only within the group of patients. They are interpreted as an indicator of disturbed interhemispheric coordination in schizophrenics. Based upon specific pupillary findings one concludes that the processing load imposed on the attentional system by the search task is different for various schizophrenic subgroups.

Multidimensional study of the outcome of schizophrenic patients 1 year after clinic discharge. Predictors and influence of neuroleptic treatment

Several dimensions of the outcome of 86 schizophrenic patients were recorded 1 year after discharge from inpatient index-treatment to complete a prospective study concerning the course of illness (rehospitalization, symptoms, employment and social contacts). When compared with 75 psychiatric patients of other diagnostic groups, no differences were found other than a significantly longer average rehospitalization stay for the schizophrenic patients. Taking prognostic categories and the regularity of neuroleptic therapy conducted during follow-up into account, it was established that the social outcome status of schizophrenic patients is substantially determined by the original level at the time of index-treatment. In contrast, the rate of relapse and readmission depend significantly upon the continuity of neuroleptic treatment. More complex analyses show that particularly for patients already hospitalized several times, successful relapse prophylactic treatment also has a favorable influence upon the patients' symptoms in the sense of a more stable remission. This could be related to the finding that the more chronic patients apparently exhibit a delayed remission when they undergo a relapse. The findings are interpreted to the effect that continuous neuroleptic maintenance therapy is advantageous to the majority of the patients, and should be applied, in view of the fact that alternative therapy procedures such as neuroleptic interval strategies have not yet been sufficiently evaluated.