Olfactory functioning in schizophrenia: relationship to clinical, neuropsychological, and volumetric MRI measures

Deficits in odor identification and detection threshold sensitivity have been observed in schizophrenia but their relationship to clinical, cognitive, and biologic measures have not been clearly established. Our objectives were to examine the relationship between measures of odor identification and detection threshold sensitivity and clinical, neuropsychological, and anatomic brain measures. Twenty-one patients with schizophrenia and 20 healthy controls were administered psychophysical tests of odor identification and detection threshold sensitivity to phenyl ethyl alcohol. In addition, clinical symptom ratings, neuropsychological measures of frontal and temporal lobe function and whole brain MRIs were concurrently obtained. Patients exhibited significant deficits in odor identification but normal detection threshold sensitivity. Poorer odor identification scores were associated with longer duration of illness, increased negative and disorganized symptoms, and the deficit syndrome, as well as impairments in verbal and nonverbal memory. Better odor detection thresholds were specifically associated with first-rank or productive symptoms. Larger left temporal lobe volumes with MRI were associated with better odor identification in controls but not in patients. Given the relevance of the neural substrate, and the evidence of performance deficits, psychophysical probes of the integrity of the olfactory system hold special promise for illuminating aspects of the neurobiology underlying schizophrenia.

Apolipoprotein E genotype and odor identification in schizophrenia

The authors examined Apolipoprotein E (ApoE) genotype frequencies and unirhinal odor identification in 28 schizophrenia patients and 26 healthy comparison subjects. No significant associations between ApoE status and olfaction were observed in either diagnostic group. The authors concluded that olfactory deficits in schizophrenia do not appear to be mediated by the ApoE allele.

Emotional processing in schizophrenia

INTRODUCTION

Persons with schizophrenia have impaired emotional processing, involving experience, expression, and recognition of emotions.

METHODS

This article reviews the historical descriptions and more recent work on emotion processing in schizophrenia.

RESULTS

Although abilities of emotional processing relate directly to interpersonal communication and psychosocial functioning, methodological issues exist in the current body of studies and resultant knowledge, which limit translation to novel treatment options.

CONCLUSIONS

Further improvement in emotion processing in persons with stable schizophrenia are unlikely to result from conventional pharmacotherapy of psychosis. New treatment modalities and behavioural interventions offer possible improvements in quality of life and psychosocial functioning.

Flat affect in schizophrenia: relation to emotion processing and neurocognitive measures

Impaired emotional functioning in schizophrenia is a prominent clinical feature that manifests primarily as flat affect. Studies have examined the perception, experience, and expression of emotions in schizophrenia and reported normal ratings of experience but impaired affect identification. However, the relation between flat affect and performance on facial affect identification and cognitive tasks has not been systematically examined in relation to premorbid adjustment and clinical outcome. We report a prospective study of 63 patients with at least moderate severity of flat affect and 99 patients without flat affect, who were compared on functional domains, emotion processing tasks, and neurocognitive measures. Flat affect was more common in men and was associated with poorer premorbid adjustment, worse current quality of life, and worse outcome at 1-year follow-up. Patients overall performed more poorly on emotion processing tasks, one that required identification of happy and sad emotions and one that required differentiating among intensities within these emotions. They responded inaccurately yet faster than controls for the intensity differentiation task, suggesting a decomposition of the normal relation between accuracy and speed. Flat affect ratings, compared with other negative symptoms, uniquely predicted performance on emotion processing tasks. Patients with flat affect showed greater impairment in both emotion processing tasks, with the most pronounced impairment for the intensity differentiation task. However, the 2 patient groups did not differ in the neurocognitive profile except for verbal memory. We conclude that flat affect is an important clinical feature of schizophrenia that exacerbates the course of illness.

Prognostic variables at intake and long-term level of function in schizophrenia

OBJECTIVE

This study assessed the relationship between symptoms and cognitive measures at intake and functional outcome 2-8 years later (average 3 years) in first-episode and previously treated schizophrenia patients.

METHOD

A composite cognitive score was assessed at intake to determine the influence of cognition on later functional outcome. At intake and follow-up, positive and negative symptoms were assessed with the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms, and affective symptoms were assessed with the Hamilton Depression Rating Scale. Level of function in seven domains (social function, occupational function, independent living, symptom severity, fullness of life, extent of psychiatric hospitalization, and overall level of function) at intake and follow-up was assessed with the Strauss-Carpenter Level of Function scale. The contributions of sex, education, and duration of illness to functional outcome were also examined.

RESULTS

The results indicated that symptoms at intake had distinct patterns of prognostic significance for functional outcome in previously treated patients, compared with first-episode patients. In addition, male and female patients differed in the degree to which initial symptoms were correlated with later function.

CONCLUSIONS

Initial level of function, symptoms, sex, education, and duration of illness are all important predictors for functional outcome in patients with schizophrenia.

Emotion-discrimination deficits in mild Alzheimer disease

OBJECTIVE

Mild Alzheimer disease (AD) preferentially affects temporal lobe regions, which represent important structures in memory and emotional processes. This study investigated emotion discrimination in people with mild AD, versus Caretakers.

METHODS

Twenty AD subjects and 22 caretakers underwent computerized testing of emotion recognition and differentiation. Performances between groups were compared, controlling for possible effects of age and cognitive abilities.

RESULTS

AD subjects showed diminished recognition of happy, sad, fearful, and neutral expressions. They also exhibited decreased differentiation between happy and sad expressions. Controlling for effects of cognitive dysfunction, AD subjects differed on recognition of happy and sad, and differentiation of sad facial expressions, and in error patterns for fearful and neutral faces.

CONCLUSIONS

Diminished abilities for emotion discrimination are present in persons with mild AD. In persons with mild AD, who frequently reside in their own home or with close family, this diminished ability may adversely affect social functioning and quality of life.

Differences in facial expressions of four universal emotions

The facial action coding system (FACS) was used to examine recognition rates in 105 healthy young men and women who viewed 128 facial expressions of posed and evoked happy, sad, angry and fearful emotions in color photographs balanced for gender and ethnicity of poser. Categorical analyses determined the specificity of individual action units for each emotion. Relationships between recognition rates for different emotions and action units were evaluated using a logistic regression model. Each emotion could be identified by a group of action units, characteristic to the emotion and distinct from other emotions. Characteristic happy expressions comprised raised inner eyebrows, tightened lower eyelid, raised cheeks, upper lip raised and lip corners turned upward. Recognition of happy faces was associated with cheek raise, lid tightening and outer brow raise. Characteristic sad expressions comprised furrowed eyebrow, opened mouth with upper lip being raised, lip corners stretched and turned down, and chin pulled up. Only brow lower and chin raise were associated with sad recognition. Characteristic anger expressions comprised lowered eyebrows, eyes wide open with tightened lower lid, lips exposing teeth and stretched lip corners. Recognition of angry faces was associated with lowered eyebrows, upper lid raise and lower lip depression. Characteristic fear expressions comprised eyes wide open, furrowed and raised eyebrows and stretched mouth. Recognition of fearful faces was most highly associated with upper lip raise and nostril dilation, although both occurred infrequently, and with inner brow raise and widened eyes. Comparisons are made with previous studies that used different facial stimuli.

Patient attitudes towards surgically implantable, long-term delivery of psychiatric medicine

The introduction of surgically implantable medication delivery systems provides psychiatric patients with reversible, uninterrupted access to medication for up to 14 months. This study designed and administered a survey to assess patients' attitudes and beliefs towards illness, medication, and this potential new treatment method. The survey included questions about demographics, insight and attitudes towards illness, current and past medication adherence, attitudes towards psychiatric and nonpsychiatric medications, and understanding and attitudes towards surgical implants. The sample of 206 psychiatric patients was almost equally split between favorably and unfavorably considering implants. Patients favorable towards implants ascribed forgetting and failure to refill medication on time as the reasons for missing doses, recognized the benefits of medication in general, and understood that the implant would be inserted under the skin. Favorable consideration of implants was positively correlated with the desire to avoid adverse consequences of missing medicine, stay well, avoid the need for daily oral medications, and decrease family burden. Unfavorable consideration of implants was related to a preference to take medication orally, concern about feeling controlled, unwillingness to try something new, and not understanding that the implant would be placed under the skin. Demographic variables, past/current medications, specific diagnosis, and illness severity did not influence the decision. This survey elucidates patients' attitudes and beliefs towards illness, medication, and surgical implants. The results indicate that a significant proportion of patients recognize the difficulties of medication adherence and the need for better methods to attain therapeutic response. Thus, the study provides impetus for future work in this area.

Symptom and demographic profiles in first-episode schizophrenia

First-episode schizophrenia (FE-SZP) presents a diagnostic challenge because of symptomatic overlap between the various causes of psychosis. An early and accurate diagnosis is important for the implementation of appropriate treatment, for determining prognosis and for identifying research participants. In an effort to facilitate early diagnosis, we followed a group of first-episode psychosis patients with a presumptive diagnosis of schizophrenia who were subsequently diagnosed at 6-month follow-up with either schizophrenia (n=104) or other psychiatric diagnoses (n=19). The two groups-first-episode schizophrenia and first-episode non-schizophrenia-were compared on measures of demographics, symptoms, quality of life, premorbid adjustment and lateral dominance. Odds ratios were calculated for each variable and all significant variables were entered into a multivariate prediction model. The model showed that higher levels of anhedonia and hallucinations increased the odds of a final diagnosis of schizophrenia. This predictive model was validated in a smaller group of patients.

Recognition of facial emotions in neuropsychiatric disorders

Recognition of facial emotions represents an important aspect of interpersonal communication and is governed by select neural substrates. We present data on emotion recognition in healthy young adults utilizing a novel set of color photographs of evoked universal emotions. In addition, we review the recent literature on emotion recognition in psychiatric and neurologic disorders, and studies that compare different disorders.

Facial emotion recognition in schizophrenia: intensity effects and error pattern

OBJECTIVE

The authors used color photographs of emotional and neutral expressions to investigate recognition patterns of five universal emotions in schizophrenia.

METHOD

Twenty-eight stable outpatients with schizophrenia (19 men and nine women) and 61 healthy subjects (29 men and 32 women) completed an emotion discrimination test that presented mild and extreme intensities of happy, sad, angry, fearful, disgusted, and neutral faces, balanced for gender and ethnicity. Analyses evaluated accuracy of identifying emotions as a function of intensity, diagnosis, and gender of poser and rater.

RESULTS

Patients performed worse than comparison subjects on recognition of all emotions and neutral faces combined, including mild and extreme expressions. For specific emotions, patients performed worse on recognition of fearful, disgusted, and neutral expressions. For all emotions except disgust, recognition of extreme intensity was better than recognition of mild intensity. However, patients showed less benefit from increased intensity for all emotions combined, and the difference was most pronounced for fear. Thus, patients were more impaired than healthy comparison subjects in identifying high-intensity expressions, even though this was an easier task than identifying low-intensity expressions. In the comparison of patterns of errors, patients and healthy subjects differed only in misattributions of neutral expressions; patients overattributed disgusted expressions and underattributed happy expressions.

CONCLUSIONS

Patients with schizophrenia were impaired in overall emotion recognition, particularly fear and disgust, and did not benefit from increased emotional intensity. Error patterns indicate that patients misidentified neutral cues as negatively valenced.

Mania following temporal lobectomy

OBJECTIVE

To determine clinical and diagnostic variables that predict the development of mania after temporal lobectomy for treatment of refractory epilepsy.

METHODS

From a large surgical database, 16 patients with new-onset mania after temporal lobectomy were identified. Mania patients were frequency matched for age, gender, and laterality of surgery to 16 temporal lobectomy patients with no postoperative mood disorder. These groups were compared on pre- and postoperative clinical and diagnostic data with each other and with 30 patients with depression after temporal lobectomy. Posthoc analyses compared mania and depression groups with the general surgical database matched for gender and laterality of surgery.

RESULTS

Preoperative evaluations in postoperative mania patients, in particular EEG, were more likely to yield findings of brain dysfunction localizing to the hemisphere contralateral to temporal lobectomy. Right temporal lobectomy was more common in the postoperative mania group. Duration of manic episodes was usually transient, and all but one case remitted within 1 year after onset. In comparison with the control group, mania and depression groups had a higher likelihood for preoperative generalized tonic-clonic seizures and lack of seizure freedom following surgery.

CONCLUSIONS

A limitation of this study was the relatively small number of patients. Despite this, clinical features that distinguish patients at risk for postoperative mania from those with depression and those with no psychiatric illness include bihemispheric abnormalities, in particular bitemporal EEG activity, and right temporal lobectomy.

Postpsychotic depression in schizophrenia patients

Depression is a frequent comorbidity in the course of schizophrenia and is associated with increased mortality from suicide. Postpsychotic depression is defined as the syndrome of major depression occurring following remission of psychotic symptoms in a person with schizophrenia. Various proposed causes, differential diagnosis, and issues regarding management of postpsychotic depression are discussed.

Effect of schizophrenia on frontotemporal activity during word encoding and recognition: a PET cerebral blood flow study

OBJECTIVE

Neuropsychological studies have shown that deficits in verbal episodic memory in schizophrenia occur primarily during encoding and retrieval stages of information processing. The current study used positron emission tomography to examine the effect of schizophrenia on change in cerebral blood flow (CBF) during these memory stages.

METHOD

CBF was measured in 23 healthy comparison subjects and 23 patients with schizophrenia during four conditions: resting baseline, motor baseline, word encoding, and word recognition. The motor baseline was used as a reference that was subtracted from encoding and recognition conditions by using statistical parametric mapping.

RESULTS

Patients' performance was similar to that of healthy comparison subjects. During word encoding, patients showed reduced activation of left prefrontal and superior temporal regions. Reduced left prefrontal activation in patients was also seen during word recognition, and additional differences were found in the left anterior cingulate, left mesial temporal lobe, and right thalamus. Although patients' performance was similar to that of healthy comparison subjects, left inferior prefrontal activation was associated with better performance only in the comparison subjects.

CONCLUSIONS

Left frontotemporal activation during episodic encoding and retrieval, which is associated with better recognition in healthy people, is disrupted in schizophrenia despite relatively intact recognition performance and right prefrontal function. This may reflect impaired strategic use of semantic information to organize encoding and facilitate retrieval.

Association of fear auras with mood and anxiety disorders after temporal lobectomy

PURPOSE

Epilepsy has been associated with increased occurrence of behavioral disorders. Auras reflect abnormal stimulation of brain areas in close proximity to regions from which clinical seizures originate. The purpose of our study was to investigate whether fear auras are associated with a higher rate of mood and anxiety disorders before and 1 year after temporal lobectomy.

METHODS

Twenty-two patients with fear auras were compared with matched groups with other auras and no auras. Neurologic and neuropsychological evaluations before, 1-2 months after, and 1 year after temporal lobectomy were reviewed for mood and anxiety disorders and psychotropic medication treatment. A logistic regression model examined effects of patient group and psychiatric status on postoperative psychiatric status.

RESULTS

The majority of patients in the three groups experienced mood and anxiety disorders before surgery. Mood and anxiety disorders declined in the control, but not in the fear aura group after surgery. Presence of auras at 1 year after surgery was not related to psychiatric outcome. Postoperative mood and anxiety disorders were more common in patients with persistence of seizures and in those in the fear group who were seizure free. The minority of patients in all groups underwent psychotropic treatment before surgery, but the majority with fear auras underwent treatment after surgery.

CONCLUSIONS

Postoperative mood and anxiety disorders were more common in fear aura patients after temporal lobectomy, in particular, if seizure free. Possible mechanisms include the role of the amygdala in fear conditioning, the concepts of forced normalization, and kindling.

Olfactory dysfunction in schizophrenia and temporal lobe epilepsy

BACKGROUND

Schizophrenia and mesial temporal lobe epilepsy (TLE) represent two common brain disorders that share dysfunction of temporo-limbic neural substrates.

OBJECTIVE

We evaluated whether patients with schizophrenia exhibited olfactory performance more similar to right or left temporal lobe epilepsy patients.

METHODS

Odor identification ability and detection threshold sensitivity were measured in 40 patients with schizophrenia, 14 patients with right- and 18 patients with left-temporal lobe epilepsy (TLE) patients, and 25 healthy controls. Odor identification was assessed with the University of Pennsylvania Smell Identification Test (UPSIT) and odor detection threshold sensitivity with a single-staircase procedure using the stimulant phenyl ethyl alcohol (PEA).

RESULTS

Relative to controls, only patients with schizophrenia and right TLE exhibited significant impairment in UPSIT performance. Left TLE patients and controls performed comparably on the UPSIT. Detection threshold sensitivity to PEA did not differ significantly among the four groups.

CONCLUSIONS

These data suggest a greater reliance of olfactory processing on right hemisphere structures and are also consistent with recent neuroimaging studies that have implicated aberrant processing of olfactory information in right hemispheric brain regions in schizophrenia.

Neurosyphilis presenting as schizophrenialike psychosis

OBJECTIVE

The authors present a 30-year-old pregnant and previously healthy woman with sudden onset of agitation, delusions, and frontal lobe dementia. Serum and cerebrospinal fluid findings revealed the presence of untreated syphilis.

BACKGROUND

Neurosyphilis can present a variety of behavioral symptoms, including mania, depression, and psychosis.

METHOD

A neuropsychiatric and neurologic workup was performed before the start of antibiotic treatment. The status of the patient was observed throughout the course of her hospital stay for 7 months. Additionally, a neuropsychological evaluation was administered before treatment, and 2 weeks and 4 months after treatment.

RESULTS

After treatment of neurosyphilis, steady improvements were noted in psychotic and cognitive symptoms. By the end of 7 months, and after discontinuation of antipsychotic medication, no psychiatric symptoms were evident.

CONCLUSIONS

This case emphasizes the importance of considering neurosyphilis in the differential diagnosis of acute psychosis. Furthermore, this case shows the dramatic improvement in psychiatric symptoms and cognitive dysfunction in response to the treatment of neurosyphilis.

Emotion recognition deficit in schizophrenia: association with symptomatology and cognition

BACKGROUND

Previous investigations have found impaired recognition of facial affect in schizophrenia. Controversy exists as to whether this impairment represents a specific emotion recognition deficit when compared with other face recognition control tasks. Regardless of whether the emotion processing deficit is differential, it may uniquely influence other manifestations of schizophrenia. We compared patients and healthy control subjects on computerized tasks of emotion and age recognition. Performances on emotion and age recognition tasks were correlated with cognitive functioning and with symptomatology.

METHODS

Thirty-five patients with schizophrenia and 45 healthy people underwent computerized testing for emotion and age recognition. Participants were assessed neuropsychologically, and patients were rated for positive and negative symptoms.

RESULTS

The patients with schizophrenia performed worse than control subjects on emotion and age recognition without differential deficit. In both groups, we found higher error rates for identification of emotion in female faces and for identification of sad versus happy faces. In schizophrenic patients, emotion but not age recognition correlated with severity of negative and positive symptoms. In healthy control subjects, neither task correlated with cognitive functions. In schizophrenic patients, emotion but not age recognition correlated with attention, verbal and spatial memory, and language abilities.

CONCLUSIONS

This study did not reveal a specific deficit for emotion recognition in schizophrenia; however, our findings lend support to the concept that emotion recognition is uniquely associated in schizophrenia with core symptomatology and cognitive domains.

Marchiafava-Bignami disease: literature review and case report

OBJECTIVE

We postulated that disruption of callosal pathways as occurs in Marchiafava-Bignami disease (MBD) is associated with marked impairment in brain functioning as measured by cognitive assessment and neuroimaging.

BACKGROUND

MBD is considered to be a rare and severe complication of chronic alcoholism. It is characterized by necrosis and subsequent atrophy of the corpus callosum, which is the major brain structure connecting corresponding areas of both hemispheres.

METHODS

We review the existing literature on MBD with respect to conceptualization, theories of pathogenesis, forms of the disease, and neuroimaging and neuropsychological findings. We then present the case of a middle-aged man with MBD who underwent extensive clinical, neuropsychological, and neuroimaging studies.

RESULTS

Neuropsychological evaluation revealed a pattern of severe global dementia. Magnetic resonance imaging showed moderate atrophy of anterior callosal regions and severe atrophy of posterior callosal regions in the setting of cortical and subcortical atrophy. Resting metabolism positron emission tomography revealed decreased glucose metabolism most pronounced in subcortical and mesial frontal regions. The differential diagnosis, function of the corpus callosum, and potential limitations of our case study are discussed.

CONCLUSIONS

On account of the history, clinical presentation, and results of magnetic resonance imaging of the brain, we diagnosed our patient with chronic MBD.

Marital status after epilepsy surgery

PURPOSE

To characterize features influencing marital status in a group of patients with refractory epilepsy before and after epilepsy surgery and to assess the effect of seizure control on marital status after epilepsy surgery.

METHODS

We analyzed marital status in 430 epilepsy surgery patients and in a subset with temporal lobe epilepsy. Marital status was assessed in relation to gender and age of epilepsy onset and compared with marital rates for the U.S. population. Patients who had > or =4 years of postsurgical follow-up were examined for change in marital status after surgery. Those patients who changed marital status were then evaluated for change in employment.

RESULTS

Marital rates were lower than expected in men. Men with onset of epilepsy by age 11 years were less likely to be married than men whose seizures began after age 11 or women whose seizures began at any age. Men and women with temporal lobe epilepsy had higher marriage rates than those with extratemporal lobe epilepsy. More than 4 years after epilepsy surgery (n = 190), patients who had no recurrent seizures were more likely to change marital status (28 of 124, 23%), than those who had recurrent seizures (five of 66, 8%). Seizure-free women were more likely to divorce (n = 9) than were seizure-free men (n = 1). Most men who married were employed (77%), whereas women who divorced were usually unemployed (67%).

CONCLUSIONS

The age at which seizures begin influences later marital status in men, who have reduced marriage rates. The abolition of seizures by epilepsy surgery creates new opportunities for changing social relationships. Location of the epileptic focus may influence psychosocial function.

MMPI-2 characteristics of adults diagnosed with attention deficit disorder

Attention Deficit Disorder (ADD) has been increasingly recognized as extending into adulthood, affecting occupational, interpersonal, and psychological functioning. The Minnesota Multiphasic Personality Inventory (MMPI) and its revision (MMPI-2) have been widely used in the assessment of patients with psychiatric disorders, but few studies have attempted to characterize the personality profiles of individuals with ADD and none have used the MMPI-2. Thirty-three patients with ADD and 33 schizophrenia patients were compared to 46 healthy control subjects on the MMPI-2 validity, clinical and Harris-Lingoes scales. With the exception of significantly lower scores for general affective distress (F), thought disorder (Sc), and paranoia (Pa), ADD subjects demonstrated remarkably similar profiles to those seen in the schizophrenia group. Significant differences between the three groups were found on a majority of the clinical scales, with ADD subjects showing similar profile elevations as schizophrenic subjects on both clinical- and sub-scales. These results were consistent with previous research using the original MMPI in adults with ADD, and confirm that examination of MMPI-2 profiles may be a useful diagnostic aid for this disorder.