Cannabinoid receptor 1 gene polymorphisms and marijuana misuse interactions on white matter and cognitive deficits in schizophrenia

Marijuana exposure during the critical period of adolescent brain maturation may disrupt neuro-modulatory influences of endocannabinoids and increase schizophrenia susceptibility. Cannabinoid receptor 1 (CB1/CNR1) is the principal brain receptor mediating marijuana effects. No study to-date has systematically investigated the impact of CNR1 on quantitative phenotypic features in schizophrenia and inter-relationships with marijuana misuse. We genotyped 235 schizophrenia patients using 12 tag single nucleotide polymorphisms (tSNPs) that account for most of CB1 coding region genetic variability. Patients underwent a high-resolution anatomic brain magnetic resonance scan and cognitive assessment. Almost a quarter of the sample met DSM marijuana abuse (14%) or dependence (8%) criteria. Effects of CNR1 tSNPs and marijuana abuse/dependence on brain volumes and neurocognition were assessed using ANCOVA, including co-morbid alcohol/non-marijuana illicit drug misuse as covariates. Significant main effects of CNR1 tSNPs (rs7766029, rs12720071, and rs9450898) were found in white matter (WM) volumes. Patients with marijuana abuse/dependence had smaller fronto-temporal WM volumes than patients without heavy marijuana use. More interestingly, there were significant rs12720071 genotype-by-marijuana use interaction effects on WM volumes and neurocognitive impairment; suggestive of gene-environment interactions for conferring phenotypic abnormalities in schizophrenia. In this comprehensive evaluation of genetic variants distributed across the CB1 locus, CNR1 genetic polymorphisms were associated with WM brain volume variation among schizophrenia patients. Our findings suggest that heavy cannabis use in the context of specific CNR1 genotypes may contribute to greater WM volume deficits and cognitive impairment, which could in turn increase schizophrenia risk.

Long-term antipsychotic treatment and brain volumes: a longitudinal study of first-episode schizophrenia

CONTEXT

Progressive brain volume changes in schizophrenia are thought to be due principally to the disease. However, recent animal studies indicate that antipsychotics, the mainstay of treatment for schizophrenia patients, may also contribute to brain tissue volume decrement. Because antipsychotics are prescribed for long periods for schizophrenia patients and have increasingly widespread use in other psychiatric disorders, it is imperative to determine their long-term effects on the human brain.

OBJECTIVE

To evaluate relative contributions of 4 potential predictors (illness duration, antipsychotic treatment, illness severity, and substance abuse) of brain volume change.

DESIGN

Predictors of brain volume changes were assessed prospectively based on multiple informants.

SETTING

Data from the Iowa Longitudinal Study.

PATIENTS

Two hundred eleven patients with schizophrenia who underwent repeated neuroimaging beginning soon after illness onset, yielding a total of 674 high-resolution magnetic resonance scans. On average, each patient had 3 scans (≥2 and as many as 5) over 7.2 years (up to 14 years).

MAIN OUTCOME MEASURE

Brain volumes.

RESULTS

During longitudinal follow-up, antipsychotic treatment reflected national prescribing practices in 1991 through 2009. Longer follow-up correlated with smaller brain tissue volumes and larger cerebrospinal fluid volumes. Greater intensity of antipsychotic treatment was associated with indicators of generalized and specific brain tissue reduction after controlling for effects of the other 3 predictors. More antipsychotic treatment was associated with smaller gray matter volumes. Progressive decrement in white matter volume was most evident among patients who received more antipsychotic treatment. Illness severity had relatively modest correlations with tissue volume reduction, and alcohol/illicit drug misuse had no significant associations when effects of the other variables were adjusted.

CONCLUSIONS

Viewed together with data from animal studies, our study suggests that antipsychotics have a subtle but measurable influence on brain tissue loss over time, suggesting the importance of careful risk-benefit review of dosage and duration of treatment as well as their off-label use.

Global white matter abnormalities in schizophrenia: a multisite diffusion tensor imaging study

BACKGROUND

Emerging evidence implicates white matter (WM) abnormalities in the pathophysiology of schizophrenia. However, there is considerable heterogeneity in the presentation of WM abnormalities in the existing studies. The object of this study was to evaluate WM integrity in a large sample of patients with first-episode (FE) and chronic schizophrenia in comparison to matched control groups. Our goal was to assess whether WM findings occurred early in the illness or whether these abnormalities developed with the illness over time.

METHODS

Participants included 114 patients with schizophrenia (31 FE and 83 chronic patients) and 138 matched controls. High-resolution structural and diffusion tensor images were obtained on all participants. Measures of fractional anisotropy (FA) were calculated for the 4 cortical lobes and the cerebellum and brain stem.

RESULTS

FA was significant lower in patients vs controls in the whole brain and individually in the frontal, parietal, occipital, and temporal lobes. FA was not significantly different in the brain stem or cerebellum. FA differences were significant only in patients with chronic schizophrenia and not in the FE group.

CONCLUSIONS

We found global differences in the WM microstructure in patients with chronic but not FE schizophrenia. These findings suggest progressive alterations in WM microstructure.

The lifetime trajectory of schizophrenia and the concept of neurodevelopment

Defining the lifetime trajectory of schizophrenia and the mechanisms that drive it is one of the major challenges of schizophrenia research. Kraepelin assumed that the mechanisms were neurodegenerative (“dementia praecox”), and the early imaging work using computerized tomography seemed to support this model. Prominent ventricular enlargement and increased cerebrospinal fluid on the brain surface suggested that the brain had atrophied. In the 1980s, however, both neuropathological findings and evidence from magnetic resonance imaging (MRI) provided evidence suggesting that neurodevelopmental mechanisms might be a better explanation. This model is supported by both clinical and MRI evidence, particularly the fact that brain abnormalities are already present in first-episode patients. However, longitudinal studies of these patients have found evidence that brain tissue is also lost during the years after onset. The most parsimonious explanation of these findings is that neurodevelopment is a process that is ongoing throughout life, and that schizophrenia occurs as a consequence of aberrations in neurodevelopmental processes that could occur at various stages of life.

Fully automated analysis using BRAINS: AutoWorkup

The BRAINS (Brain Research: Analysis of Images, Networks, and Systems) image analysis software has been in use, and in constant development, for over 20 years. The original neuroimage analysis pipeline using BRAINS was designed as a semiautomated procedure to measure volumes of the cerebral lobes and subcortical structures, requiring manual intervention at several stages in the process. Through use of advanced image processing algorithms the need for manual intervention at stages of image realignment, tissue sampling, and mask editing have been eliminated. In addition, inhomogeneity correction, intensity normalization, and mask cleaning routines have been added to improve the accuracy and consistency of the results. The fully automated method, AutoWorkup, is shown in this study to be more reliable (ICC ≥ 0.96, Jaccard index ≥ 0.80, and Dice index ≥ 0.89 for all tissues in all regions) than the average of 18 manual raters. On a set of 1130 good quality scans, the failure rate for correct realignment was 1.1%, and manual editing of the brain mask was required on 4% of the scans. In other tests, AutoWorkup is shown to produce measures that are reliable for data acquired across scanners, scanner vendors, and across sequences. Application of AutoWorkup for the analysis of data from the 32-site, multivendor PREDICT-HD study yield estimates of reliability to be greater than or equal to 0.90 for all tissues and regions.

Three-dimensional morphometric analysis of brain shape in nonsyndromic orofacial clefting

Previous studies report structural brain differences in individuals with nonsyndromic orofacial clefts (NSOFC) compared with healthy controls. These changes involve non-uniform shifts in tissue volume within the cerebral cortex and cerebellum, suggesting that the shape of the brain may be altered in cleft-affected individuals. To test this hypothesis, a landmark-based morphometric approach was utilized to quantify and compare brain shape in a sample of 31 adult males with cleft lip with or without cleft palate (CL/P), 14 adult males with cleft palate only (CPO) and 41 matched healthy controls. Fifteen midline and surface landmarks were collected from MRI brain scans and the resulting 3D coordinates were subjected to statistical shape analysis. First, a geometric morphometric analysis was performed in three steps: Procrustes superimposition of raw landmark coordinates, omnibus testing for group difference in shape, followed by canonical variates analysis (CVA) of shape coordinates. Secondly, Euclidean distance matrix analysis (EDMA) was carried out on scaled inter-landmark distances to identify localized shape differences throughout the brain. The geometric morphometric analysis revealed significant differences in brain shape among all three groups (P < 0.001). From CVA, the major brain shape changes associated with clefting included selective enlargement of the anterior cerebrum coupled with a relative reduction in posterior and/or inferior cerebral portions, changes in the medio-lateral position of the cerebral poles, posterior displacement of the corpus callosum, and reorientation of the cerebellum. EDMA revealed largely similar brain shape changes. Thus, compared with controls, major brain shape differences were present in adult males with CL/P and CPO. These results both confirm and expand previous findings from traditional volumetric studies of the brain in clefting and provide further evidence that the neuroanatomical phenotype in individuals with NSOFC is a primary manifestation of the defect and not a secondarily acquired characteristic.

G72 influences longitudinal change in frontal lobe volume in schizophrenia

Schizophrenia is a neurodevelopmental psychiatric disorder characterized by a variety of structural brain abnormalities that appear to progress across the course of illness. Schizophrenia also is highly heritable, and one gene that has emerged as a possible susceptibility factor is G72. G72 influences brain development and activity by an as-yet unclear mechanism, and multiple studies have reported associations between G72 and schizophrenia. We were interested in linking these domains of investigation by determining whether G72 also influences the rate of longitudinal structural brain changes in individuals with schizophrenia. As part of the Iowa Longitudinal Study of Recent Onset Psychoses, we genotyped four G72 polymorphisms previously associated with schizophrenia in 110 subjects with schizophrenia or schizoaffective disorder from whom we had obtained two brain MRI scans an average of 3 years apart. The four polymorphisms captured three haplotypes, one of which was strongly associated with an increased rate of frontal lobe volume decrement. This same haplotype was also associated with more severe psychotic symptoms at the time of the second scan. These data thus suggest that variation in G72 modulates the progressive brain changes that characterize schizophrenia.

WITHDRAWN: Erratum to "Does function follow form?: Methods to fuse structural and functional brain images show decreased linkage in schizophrenia" [NeuroImage 49 (2010) 2626-2637]

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Does function follow form?: methods to fuse structural and functional brain images show decreased linkage in schizophrenia

When both structural magnetic resonance imaging (sMRI) and functional MRI (fMRI) data are collected they are typically analyzed separately and the joint information is not examined. Techniques that examine joint information can help to find hidden traits in complex disorders such as schizophrenia. The brain is vastly interconnected, and local brain morphology may influence functional activity at distant regions. In this paper we introduce three methods to identify inter-correlations among sMRI and fMRI voxels within the whole brain. We apply these methods to examine sMRI gray matter data and fMRI data derived from an auditory sensorimotor task from a large study of schizophrenia. In Method 1 the sMRI-fMRI cross-correlation matrix is reduced to a histogram and results show that healthy controls (HC) have stronger correlations than do patients with schizophrenia (SZ). In Method 2 the spatial information of sMRI-fMRI correlations is retained. Structural regions in the cerebellum and frontal regions show more positive and more negative correlations, respectively, with functional regions in HC than in SZ. In Method 3 significant sMRI-fMRI inter-regional links are detected, with regions in the cerebellum showing more significant positive correlations with functional regions in HC relative to SZ. Results from all three methods indicate that the linkage between gray matter and functional activation is stronger in HC than SZ. The methods introduced can be easily extended to comprehensively correlate large data sets.

Antipsychotic dose equivalents and dose-years: a standardized method for comparing exposure to different drugs

BACKGROUND

A standardized quantitative method for comparing dosages of different drugs is a useful tool for designing clinical trials and for examining the effects of long-term medication side effects such as tardive dyskinesia. Such a method requires establishing dose equivalents. An expert consensus group has published charts of equivalent doses for various antipsychotic medications for first- and second-generation medications. These charts were used in this study.

METHODS

Regression was used to compare each drug in the experts' charts to chlorpromazine and haloperidol and to create formulas for each relationship. The formulas were solved for chlorpromazine 100 mg and haloperidol 2 mg to derive new chlorpromazine and haloperidol equivalents. The formulas were incorporated into our definition of dose-years such that 100 mg/day of chlorpromazine equivalent or 2 mg/day of haloperidol equivalent taken for 1 year is equal to one dose-year.

RESULTS

All comparisons to chlorpromazine and haloperidol were highly linear with R(2) values greater than .9. A power transformation further improved linearity.

CONCLUSIONS

By deriving a unique formula that converts doses to chlorpromazine or haloperidol equivalents, we can compare otherwise dissimilar drugs. These equivalents can be multiplied by the time an individual has been on a given dose to derive a cumulative value measured in dose-years in the form of (chlorpromazine equivalent in mg) x (time on dose measured in years). After each dose has been converted to dose-years, the results can be summed to provide a cumulative quantitative measure of lifetime exposure.

A method to fuse fMRI tasks through spatial correlations: applied to schizophrenia

Single task analysis methods of functional MRI brain data, though useful, are not able to evaluate the joint information between tasks. Data fusion of multiple tasks that probe different cognitive processes provides knowledge of the joint information and may be important in order to better understand complex disorders such as schizophrenia. In this article, we introduce a simple but effective technique to fuse two tasks by computing the histogram of correlations for all possible combinations of whole brain voxels. The approach was applied to data derived from healthy controls and patients with schizophrenia from four different tasks, auditory oddball (target), auditory oddball (novel), Sternberg working memory, and sensorimotor. It was found that in four out of six task combinations patients' intertask correlations were more positively correlated than controls', in one combination the controls showed more positive correlations and in another there was no significant difference. The robustness of this result was checked with several testing techniques. The four task combinations for which patients had more positive correlation occurred at different scanning sessions and the task combination that showed the opposite result occurred within the same scanning session. Brain regions that showed high intertask correlations were found for both groups and regions that correlated differently between the two groups were identified. The approach introduced finds interesting results and new differential features that cannot be achieved through traditional methods.

Investigation of relationships between fMRI brain networks in the spectral domain using ICA and Granger causality reveals distinct differences between schizophrenia patients and healthy controls

Functional network connectivity (FNC) is an approach that examines the relationships between brain networks (as opposed to functional connectivity (FC) that focuses upon the relationships between single voxels). FNC may help explain the complex relationships between distributed cerebral sites in the brain and possibly provide new understanding of neurological and psychiatric disorders such as schizophrenia. In this paper, we use independent component analysis (ICA) to extract the time courses of spatially independent components and then use these in Granger causality test (GCT) to investigate causal relationships between brain activation networks. We present results using both simulations and fMRI data of 155 subjects obtained during two different tasks. Unlike previous research, causal relationships are presented over different portions of the frequency spectrum in order to differentiate high and low-frequency effects and not merged in a scalar. The results obtained using Sternberg item recognition paradigm (SIRP) and auditory oddball (AOD) tasks showed FNC differentiations between schizophrenia and control groups, and explained how the two groups differed during these tasks. During the SIRP task, secondary visual and cerebellum activation networks served as hubs and included most complex relationships between the activated regions. Secondary visual and temporal lobe activations replaced these components during the AOD task.

Basic helix-loop-helix transcription factor NEUROG1 and schizophrenia: effects on illness susceptibility, MRI brain morphometry and cognitive abilities

Transcription factors, including the basic helix-loop-helix (bHLH) family, regulate numerous genes and play vital roles in controlling gene expression. Consequently, transcription factor mutations can lead to phenotypic pleiotropy, and may be a candidate mechanism underlying the complex genetics and heterogeneous phenotype of schizophrenia. Neurogenin1 (NEUROG1; a.k.a. Ngn1 or Neurod3), a bHLH transcription factor encoded on a known schizophrenia linkage region in 5q31.1, induces glutamatergic and suppresses GABAergic neuronal differentiation during embryonic neurodevelopment. The goal of this study is to investigate NEUROG1 effects on schizophrenia risk and on phenotypic features of schizophrenia. We tested 392 patients with schizophrenia or schizoaffective disorder and 226 healthy normal volunteers for association with NEUROG1. Major alleles on two NEUROG1-associated SNPs (rs2344484-C-allele and rs8192558-G-allele) were significantly more prevalent among patients (p<or=.0018). Approximately 80% of the sample also underwent high-resolution, multi-spectral magnetic resonance brain imaging and standardized neuropsychological assessment. There were significant rs2344484 genotype main effects on total cerebral gray matter (GM) and temporal GM volumes (p<or=.05). C-allele-carrier patients and healthy volunteers had smaller total cerebral GM and temporal GM volumes than their respective T-homozygous counterparts. rs2344484-C-allele was further associated with generalized cognitive deficits among schizophrenia patients but not in healthy volunteers. Our findings replicate previous association between NEUROG1 and schizophrenia. More importantly, this is the first study to examine brain morphological and neurocognitive correlates of NEUROG1. rs2344484-C-allele may affect NEUROG1's role in transcription regulation such that brain morphology and cognitive abilities are altered resulting in increased susceptibility to develop schizophrenia.

Sex differences in parietal lobe morphology: relationship to mental rotation performance

Structural magnetic resonance imaging (MRI) studies of the human brain have reported evidence for sexual dimorphism. In addition to sex differences in overall cerebral volume, differences in the proportion of gray matter (GM) to white matter (WM) volume have been observed, particularly in the parietal lobe. To our knowledge there have been no studies examining the relationship between the sex differences in parietal lobe structure and function. The parietal lobe is thought to be involved in spatial ability, and particularly involved in mental rotation. The purpose of this study is to examine whether sex differences in parietal lobe structure are present, and if present to relate these differences to performance on the mental rotations test (MRT). We found that women had proportionately greater gray matter volume in the parietal lobe compared to men, and this morphologic difference was disadvantageous for women in terms of performance on the MRT. In contrast, we found that men compared to women had proportionately greater parietal lobe surface area, and this morphologic difference was associated with a performance advantage for men on mental rotation. These findings support the possibility that the sexual dimorphism in the structure of the parietal lobe is a neurobiological substrate for the sex difference in performance on the mental rotations test.

The relationship between creativity and mood disorders

Research designed to examine the relationship between creativity and mental illnesses must confront multiple challenges. What is the optimal sample to study? How should creativity be defined? What is the most appropriate comparison group? Only a limited number of studies have examined highly creative individuals using personal interviews and a noncreative comparison group. The majority of these have examined writers. The preponderance of the evidence suggests that in these creative individuals the rate of mood disorder is high, and that both bipolar disorder and unipolar depression are quite common. Clinicians who treat creative individuals with mood disorders must also confronta variety of challenges, including the fear that treatment may diminish creativity, in the case of bipolar disorder, hovt/ever, it is likely that reducing severe manic episodes may actually enhance creativity in many individuals.

A Review of Challenges in the Use of fMRI for Disease Classification / Characterization and A Projection Pursuit Application from Multi-site fMRI Schizophrenia Study

Functional magnetic resonance imaging (fMRI) is a fairly new technique that has the potential to characterize and classify brain disorders such as schizophrenia. It has the possibility of playing a crucial role in designing objective prognostic/diagnostic tools, but also presents numerous challenges to analysis and interpretation. Classification provides results for individual subjects, rather than results related to group differences. This is a more complicated endeavor that must be approached more carefully and efficient methods should be developed to draw generalized and valid conclusions out of high dimensional data with a limited number of subjects, especially for heterogeneous disorders whose pathophysiology is unknown. Numerous research efforts have been reported in the field using fMRI activation of schizophrenia patients and healthy controls. However, the results are usually not generalizable to larger data sets and require careful definition of the techniques used both in designing algorithms and reporting prediction accuracies. In this review paper, we survey a number of previous reports and also identify possible biases (cross-validation, class size, e.g.) in class comparison/prediction problems. Some suggestions to improve the effectiveness of the presentation of the prediction accuracy results are provided. We also present our own results using a projection pursuit algorithm followed by an application of independent component analysis proposed in an earlier study. We classify schizophrenia versus healthy controls using fMRI data of 155 subjects from two sites obtained during three different tasks. The results are compared in order to investigate the effectiveness of each task and differences between patients with schizophrenia and healthy controls were investigated.

Smoking status as a potential confound in the BOLD response of patients with schizophrenia

BACKGROUND

Functional magnetic resonance imaging (FMRI) studies comparing schizophrenia patients and controls may have been confounded by the vascular effects of heavier long-term cigarette use in patients.

METHODS

The blood oxygen level dependent (BOLD) response to a simple sensorimotor task was compared between schizophrenia patient with a smoking history (mean 17 pack years) and carefully matched patient non-smokers and control non-smokers.

RESULTS

Group differences in activation magnitude and spatial extent were non-significant.

CONCLUSIONS

Typical smoking histories in schizophrenia patients do not significantly confound FMRI results in simple sensorimotor tasks when patient demographics are carefully controlled.

Investigating connectivity between the cerebellum and thalamus in schizophrenia using diffusion tensor tractography: a pilot study

Connections of the cortical-thalamic-cerebellar-cortical regions provide a framework for studying the neural substrates of schizophrenia. A novel diffusion tensor tractography method was used to evaluate the differences in white matter connectivity between 12 patients with schizophrenia and 10 controls. For the tract tracing, we focused on the connection between the cerebellum and the thalamus. Fractional anisotropy (FA) measures along the fiber tracks were compared between patients and the control sample. Fiber tracts located between the cerebellar white matter and the thalamus exhibit a reduced FA in patients with schizophrenia in comparison with controls. The FA values along the defined fiber tracts were not overall reduced but exhibited a reduction in the anisotropy in the region in the superior cerebellar peduncles projecting towards the red nucleus.

The role of the cerebellum in schizophrenia

For many years the cerebellum has been considered to serve as a coordinator of motor function. Likewise, for many years schizophrenia has been considered to be a disease that primarily affects the cerebrum. This review summarizes recent evidence that both these views must be revised in the light of emerging evidence about cerebellar function and the mechanisms of schizophrenia. Evidence indicating that the cerebellum plays a role in higher cortical functions is summarized. Evidence indicating that cerebellar abnormalities occur in schizophrenia is also reviewed. These suggest interesting directions for future research.

Theory of mind and schizophrenia: a positron emission tomography study of medication-free patients

BACKGROUND

"Theory of mind" (TOM) refers to the ability to attribute mental states (ie, beliefs and goals) to one's self and others and to recognize that behaviors are guided by these mental states. This capacity, critical for social competence, is impaired in schizophrenia. We undertook a study of TOM in a group of patients with schizophrenia and healthy controls.

METHOD

We used positron emission tomography to identify the neural circuits recruited during a verbal task that required participants to attribute mental states to a character in a story of their creation. The comparison task consisted of reading aloud a neutral story, controlling for the speech component of the task.

RESULTS

Patients and controls generated the same percentage of TOM utterances. However, the two groups had markedly different patterns of brain activation. Compared with controls, patients had a lower blood flow in multiple regions in the left hemisphere including the frontal and visual association cortices, posterior hippocampus, and insula. The flow was also lower in contralateral areas in the lateral cerebellum and vermis, thalamus, and posterior insula. On the other hand, the flow was higher in the patients predominantly in the right hemisphere, including multiple frontal and parietal regions, insula, visual association cortex, and pulvinar.

DISCUSSION

The areas of lower flow are consistent with previous studies indicating impairment in recruiting cortical-cerebellar circuitry in schizophrenia. The areas of higher flow may reflect a need to draw on the right hemisphere to compensate for deficits in left hemisphere networks that include frontal cortex, anterior cingulate, cerebellum, and thalamus.

Theory of mind and schizophrenia: a positron emission tomography study of medication-free patients

BACKGROUND

"Theory of mind" (TOM) refers to the ability to attribute mental states (ie, beliefs and goals) to one's self and others and to recognize that behaviors are guided by these mental states. This capacity, critical for social competence, is impaired in schizophrenia. We undertook a study of TOM in a group of patients with schizophrenia and healthy controls.

METHOD

We used positron emission tomography to identify the neural circuits recruited during a verbal task that required participants to attribute mental states to a character in a story of their creation. The comparison task consisted of reading aloud a neutral story, controlling for the speech component of the task.

RESULTS

Patients and controls generated the same percentage of TOM utterances. However, the two groups had markedly different patterns of brain activation. Compared with controls, patients had a lower blood flow in multiple regions in the left hemisphere including the frontal and visual association cortices, posterior hippocampus, and insula. The flow was also lower in contralateral areas in the lateral cerebellum and vermis, thalamus, and posterior insula. On the other hand, the flow was higher in the patients predominantly in the right hemisphere, including multiple frontal and parietal regions, insula, visual association cortex, and pulvinar.

DISCUSSION

The areas of lower flow are consistent with previous studies indicating impairment in recruiting cortical-cerebellar circuitry in schizophrenia. The areas of higher flow may reflect a need to draw on the right hemisphere to compensate for deficits in left hemisphere networks that include frontal cortex, anterior cingulate, cerebellum, and thalamus.