Neurophysiological correlates of impaired facial affect recognition in individuals at risk for schizophrenia

BACKGROUND

Impairments in facial affect recognition are well documented in individuals suffering from schizophrenia. The aim of the present study was to characterize potential impairments in affect recognition and their electrophysiological correlates in at-risk individuals. Such characterization should add to the question whether the neural processes underlying facial affect recognition deficits might be part of a basic neural dysfunction reflecting a vulnerability factor of schizophrenia.

METHODS

To test facial affect recognition, a digitized series of pictures of facial affect, previously used in related studies, was presented to 37 at-risk individuals and 32 healthy controls. Simultaneously, event-related potentials (ERPs) were recorded to investigate electrophysiological activity during the task.

RESULTS

At-risk individuals showed significant impairments in facial affect recognition and reduced amplitudes in the ERP components P100, N170, and N250. Furthermore, prodromal signs in these individuals were associated with a poorer task performance and a diminished N250 amplitude.

CONCLUSIONS

The findings suggest that impairments in facial affect recognition precede the onset of the initial psychotic episode. The impairments are associated with neurophysiological abnormalities similar to those observed in manifest schizophrenia and therefore may serve as indicators of vulnerability for developing schizophrenia.

Electrophysiological correlates of planning and monitoring in first episode schizophrenia

The aim of this study was to investigate the functional basis of frequently described cognitive deficits in schizophrenia patients by exploring the electrophysiological correlates of planning processes during performance of the Trail-Making Test-B (TMT-B). Via concurrent recording of behavioral test performance, exploratory eye movements and electrical brain activity functional components critical for task performance were extracted and characterized. Participants comprised 12 first episode patients and 12 matched healthy controls who were examined with concurrent infrared oculography and electroencephalography (EEG) while they carried out a computerized TMT-B. The performance process was segmented into planning and monitoring phases based on the interaction of eye and hand movements. Brain electrical activity was analyzed using low-resolution electromagnetic brain tomography (LORETA). During planning fixations compared to monitoring fixations, both groups showed enhanced current density in dorsolateral prefrontal cortex, cingulate gyrus and inferior parietal lobe. Concurrent with poorer performance, schizophrenia patients exhibited hypoactivity within prefrontal brain areas during planning. Thus, poorer performance in schizophrenia seems to be attributable to impaired planning behavior based on hypoactivity of prefrontal areas, involved in the temporal scheduling of deliberate actions as well as visuomotor integration.

Training of affect recognition (TAR) in schizophrenia--impact on functional outcome

Deficits in facial affect recognition as one aspect of social cognitive deficits are treatment targets to improve functional outcome in schizophrenia. According to preliminary results antipsychotics alone show little effects on affect recognition. A few randomized intervention studies have evaluated special psychosocial treatment programs on social cognition. In this study, the effects of a computer-based training of affect recognition were investigated as well as its impact on facial affect recognition and functional outcome, particularly on patients' quality of life. Forty clinically stabilized schizophrenic patients were randomized to a six-week training on affect recognition (TAR) or treatment as usual including occupational therapy (TAU) and completed pre- and post-treatment assessments of emotion recognition, cognition, quality of life and clinical symptoms. Between pre- and post treatment, the TAR group achieved significant improvements in facial affect recognition, in particular in recognizing sad faces and, in addition, in the quality of life domain social relationship. These changes were not found in the TAU group. Furthermore, the TAR training contributes to enhancing some aspects of cognitive functioning and negative symptoms. These improvements in facial affect recognition and quality of life were independent of changes in clinical symptoms and general cognitive functions. The findings support the efficacy of an affect recognition training for patients with schizophrenia and the generalization to social relationship. Further development is needed in the impact of a psychosocial intervention in other aspects of social cognition and functional outcome.

A promoter variant of SHANK1 affects auditory working memory in schizophrenia patients and in subjects clinically at risk for psychosis

Mutations in postsynaptic scaffolding genes contribute to autism, thus suggesting a role in pathological processes in neurodevelopment. Recently, two de novo mutations in SHANK3 were described in schizophrenia patients. In most cases, abnormal SHANK3 genotype was also accompanied by cognitive disruptions. The present study queries whether common SHANK variants may also contribute to neuropsychological dysfunctions in schizophrenia. We genotyped five common coding or promoter variants located in SHANK1, SHANK2 and SHANK3. A comprehensive test battery was used to assess neuropsychological functions in 199 schizophrenia patients and 206 healthy control subjects. In addition, an independent sample of 77 subjects at risk for psychosis was analyzed for replication of significant findings. We found the T allele of the SHANK1 promoter variant rs3810280 to lead to significantly impaired auditory working memory as assessed with digit span (12.5 ± 3.6 vs. 14.8 ± 4.1, P < .001) in schizophrenia cases, applying strict Bonferroni correction for multiple testing. This finding was replicated for forward digit span in the at-risk sample (7.1 ± 2.0 vs. 8.3 ± 2.0, P = .044). Previously, altered memory functions and reduced dendritic spines and postsynaptic density of excitatory synapses were reported in SHANK1 knock-out mice. Moreover, the atypical neuroleptic clozapine was found to increase SHANK1 density in rats. Our findings suggest a role of SHANK1 in working memory deficits in schizophrenia, which may arise from neurodevelopmental changes to prefrontal cortical areas.

The effects of combined acamprosate and integrative behaviour therapy in the outpatient treatment of alcohol dependence: a randomized controlled trial

AIMS

The aim of this randomized, controlled, multisite trial was to evaluate the efficacy of combined treatment with integrative behaviour therapy (IBT) and acamprosate on drinking behaviour in detoxified alcohol-dependent patients.

METHODS

A total of 371 patients were randomized to one of the three treatment conditions: IBT plus acamprosate, IBT plus placebo, or supportive counselling ('treatment as usual', TAU) plus acamprosate. The main outcome was success rate, i.e., rate of abstinence plus improvement according to the criteria of Feuerlein and Küfner (1989), at the end of the six-month treatment phase and at the subsequent six-month follow-up. Drinking status was validated by blood parameters (CDT, GGT, and MCV). Data were analyzed by an intent-to-treat model and missing data were classified as relapse.

RESULTS

The success rates at the end of treatment under both TAU plus acamprosate (37.7%) and IBT plus placebo (48%) almost reached the levels derived from the literature. However, adding acamprosate to IBT did not result in the expected increase in success rate (IBT plus acamprosate: 47.6%), and success rates did not differ significantly between groups. Similarly, there was no significant difference between treatment success rates at follow-up.

CONCLUSION

The results suggest that the combination of acamprosate and IBT is not more effective than treatment with either IBT or acamprosate alone. However, the two acamprosate conditions differed in success rate by about 10%, which might constitute a clinically relevant though statistically non-significant effect.

Negative symptoms of schizophrenia as primary target of cognitive behavioral therapy: results of the randomized clinical TONES study

Clinical studies on cognitive behavioral therapy (CBT) that include schizophrenia patients primarily on the basis of negative symptoms are uncommon. However, those studies are necessary to assess the efficacy of CBT on negative symptoms. This article first gives an overview of CBT on negative symptoms and discusses the methodological problems of selecting an adequate control group. Furthermore, the article describes a clinical study (the TONES-Study, ISRCTN 25455020), which aims to investigate whether CBT is specifically efficacious for the reduction of negative symptoms. This multicenter randomized clinical trial comparing CBT with cognitive remediation (CR) for control of nonspecific effects is depicted in detail. In our trial, schizophrenia patients (n = 198) participated in manualized individual outpatient treatments. Primary outcome is the negative syndrome assessed with the positive and negative syndrome scale, analyzed with multilevel linear mixed models. Patients in both groups moderately improved regarding the primary endpoint. However, against expectation, there was no difference between the groups after treatment in the intention to treat as well as in the per-protocol analysis. In conclusion, psychotherapeutic intervention may be useful for the reduction of negative symptoms. However, there is no indication for specific effects of CBT compared with CR.

Social-cognitive remediation in schizophrenia: generalization of effects of the Training of Affect Recognition (TAR)

In the last decade, several social cognitive remediation programs have been developed for use in schizophrenia. Though existing evidence indicates that such programs can improve social cognition, which is essential for successful social functioning, it remains unclear whether the improvements generalize to social cognitive domains not primarily addressed by the intervention and whether the improved test performance transfers into everyday social functioning. The present study investigated whether, beyond its known effects on facial affect recognition, the Training of Affect Recognition (TAR) has effects on prosodic affect recognition, theory of mind (ToM) performance, social competence in a role-play task, and more general social and occupational functioning. Thirty-eight inpatients with a diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to 6 weeks of treatment with the TAR--primarily targeted at facial affect recognition-or Cognitive Remediation Training (CRT)--primarily targeted at neurocognition. Intention-to-treat analyses found significantly larger pre-post improvements with TAR than with CRT in prosodic affect recognition, ToM, and social competence and a trend effect in global social functioning. However, the effects on ToM and social competence were no longer significant in the smaller group of patients who completed treatment according to protocol. Results suggest that TAR effects generalize to other social cognitive domains not primarily addressed. TAR may also enhance social skills and social functioning, although this has to be confirmed. Results are discussed with regard to the need to improve functional outcome in schizophrenia against the background of current evidence from other social cognitive remediation approaches.

Neuropsychological profiles in different at-risk states of psychosis: executive control impairment in the early--and additional memory dysfunction in the late--prodromal state

Impairments in neuropsychological functioning have been described in subjects clinically at high risk for psychosis, but the specific cognitive deficits in different clinical high-risk groups remain to be elucidated. The German Research Network on Schizophrenia employs a heuristic 2-stage model: a putatively late prodromal state (LPS), characterized by the onset of attenuated positive or brief psychotic symptoms, and an early prodromal state (EPS), mainly characterized by the presence of basic symptoms, which are predictive for psychosis within the next 10 years. A total of 205 subjects met the criteria for either an EPS or an LPS of psychosis and were assessed with a comprehensive neuropsychological test battery. Neurocognitive profiles of high-risk groups were compared with data of 87 healthy controls comparable with regard to gender, age, and premorbid verbal IQ. Patients in the LPS were impaired in all neurocognitive domains (memory/learning, executive control/processing speed, and working memory) examined, with memory being the worst. Deficits were less pronounced in patients in the EPS, with a specific deficit in the executive control/processing speed domain. Consistent with a progressive neurodevelopmental disorder, some cognitive abilities were already impaired in patients in the EPS, followed by further deterioration in the LPS. Specifically, deficits in executive control functioning were related to the presence of basic symptoms, indicating a vulnerability for psychosis. Memory deficits were associated with the onset of psychotic symptoms indicating further disease progression in the trajectory to psychosis and, thus, may be useful in predicting psychosis and targeting early intervention.

Novel schizophrenia risk gene TCF4 influences verbal learning and memory functioning in schizophrenia patients

BACKGROUND

Recently, a role of the transcription factor 4 (TCF4) gene in schizophrenia has been reported in a large genome-wide association study. It has been hypothesized that TCF4 affects normal brain development and TCF4 has been related to different forms of neurodevelopmental disorders. Schizophrenia patients exhibit strong impairments of verbal declarative memory (VDM) functions. Thus, we hypothesized that the disease-associated C allele of the rs9960767 polymorphism of the TCF4 gene led to impaired VDM functioning in schizophrenia patients.

METHOD

The TCF4 variant was genotyped in 401 schizophrenia patients. VDM functioning was measured using the Rey Auditory Verbal Learning Test (RAVLT).

RESULTS

Carriers of the C allele were less impaired in recognition compared to those carrying the AA genotype (13.76 vs. 13.06; p = 0.049). Moreover, a trend toward higher scores in patients with the risk allele was found for delayed recall (10.24 vs. 9.41; p = 0.088). The TCF4 genotype did not influence intelligence or RAVLT immediate recall or total verbal learning.

CONCLUSION

VDM function is influenced by the TCF4 gene in schizophrenia patients. However, the elevated risk for schizophrenia is not conferred by TCF4-mediated VDM impairment.

Training of affect recognition (TAR) and its neurophysiological correlates in schizophrenia

Background

Schizophrenia patients exhibit impairments in facial affect recognition associated with neurophysiological abnormalities. Using the Training of Affect Recognition (TAR) developed by our group behavioural performance in facial affect recognition improved significantly in schizophrenia patients [1]. Purpose of the presented work was to identify the underlying mechanisms and associated generators of neuroelectric activity.

Methods

In a randomized controlled (waiting group) design 19 schizophrenia patients received TAR. Concomitant to facial affect recognition performance, ERPs were recorded and analyzed with respect to underlying generators of cortical activity using low resolution brain electromagnetic tomography (LORETA) software.

Results

Schizophrenia patients showed noticeable deviations in neuroelectric correlates of emotion recognition associated with poorer performance in the administered task. As a result of TAR treatment no significant changes in event related potentials were found. However, LORETA results showed a significant increase of activity within relevant brain areas, specific for the processing stages associated with facial emotion recognition (N170 and P240).

Conclusions

EEG findings of the present study indicate that neurophysiologic abnormalities corresponding with poorer performance in schizophrenia patients can be attenuated by training.

Social cognition in schizophrenia: Impairments and treatment approaches

Impairments in cognitive processes underlying social interaction (i.e. “social cognition”) have increasingly attracted interest in schizophrenia research during the last years. These impairments concern various components of social cognition, exist relatively independent from impairments in basic cognition and from clinical psychopathology, are already present at the onset of the disorder, and can even be detected in persons at high risk of developing schizophrenia. As social cognitive impairments are closely related to poor functional outcome, and because longitudinal studies have proven the stability of social cognitive impairments across the course of the disorder despite clinically efficacious traditional treatment, various specialized treatment and rehabilitation programs targeting social cognitive impairments have been developed during the last years. These programs differ significantly with regard to the conceptualization of the impairments and the required treatment strategies, i.e. whether the impairments are suggested to be represent cognitive “deficits” or cognitive “biases” requiring remediation vs. debiasing approaches. Moreover the programs differ with regard to the scope of cognitive subcomponents addressed, i.e. whether the program focuses on only one social cognitive subcomponent like affect recognition or whether several subcomponents are addressed in parallel. As the evaluation of such programs is still in an infant stage there is still debate about the most efficacious approach.

This presentation will give an overview on social cognitive impairments and on respective treatment strategies, before the subsequent presentations will exemplify three treatment programs, which may help schizophrenia patients to overcome their impairments in social cognition and social functioning.

A targeted remediation approach: The training of affect recognition (TAR)

Introduction

An increasing number of studies is focusing on general deficits in patients with schizophrenia in identifying, differentiating and recalling facial emotions which significantly impairs the patient's psychosocial functioning and quality of life.

Objectives

These impairments seem not to be affected by conventional treatment. According to preliminary results antipsychotics alone show only little effects on social cognition.

Aims

The present study investigated the efficacy of a computer based training focussing on facial affect recognition (Training of Affect recognition TAR, Wölwer et al. 2005) for the remediation of social cognitive dysfunctions.

Methods

Effects on social cognition were tested with the Vienna Emotion Recognition Task (VERT-K, Pawelak 2004). Neurocognitive performance was assessed by the Wisconsin Card Sorting Test (WCST Heaton et al. 1993). Additional assessments were tests of alertness, vigilance and working memory (TAP Zimmermann and Fimm 2002), positive and negative symptoms (PANSS Kay et al. 1987), Beck Depression Scale (BDI Beck 1964) and Quality of Life (WHOQOL-Bref WHOQOL Group 1998).

Results

In comparison to the TAU group, the TAR group achieved significant improvements in affect recognition in general as well as in recognizing sad faces (p < 0.01) (Fig.2). In addition, we found significant improvements for the TAR group in regard to vigilance and Quality of Life (p < 0.05).

Conclusions

Treatment with new antipsychotics alone leads only to limited effects on social cognition and functioning. A specific combined treatment of new antipsychotics and TAR leads to improved cognition and emotional performance with additional positive effects on functional outcome.

Preliminary study of emotion recognition using facial affect cards of the training of affect recognition program (TAR) in Spanish population

Introduction

Social cognition is presently an important focus in rehabilitation of patients wish schizophrenic psychoses. Emotion recognition in one of its different components, the Training of Affect Recognition (TAR) is a therapy program specifically developed aiming at improving affect recognition.

Objectives

To test if the material of the TAR program in terms a series of facial affect cards is reliable for emotion recognition in a Spanish control population.

Methods

A sample of Spanish control subjects were shown the TAR's series of facial affect cards. It includes the following emotions: happiness, sadness, surprise, fear, angry and disgust, and the neutral facial affect. Reliability was assessed by means of the kappa coefficient. Kappa values higher than 0.4 were considered reliable, the following criterion was accepted: kappa values < 0.4, low reliability; 0.4 to 0.75, moderate reliability; > 0.76, strong reliability.

Results

The sample was formed by subjects from the general population with no previous history of psychiatric disorders (n = 20). The following kappa values were obtained: happiness, 0.8406 (CI 0.7744–0.9068), sadness, 0.6171 (CI 0.5377–0.6964), surprise, 0.6582 (CI 0.5859–0.7304), fear, 0.4509 (CI 0.3569–0.5448), angry, 0.6252 (CI 0.5464–0.7040), disgust, 0.7700 (CI 0.6943–0.8456), neutral, 0.5534 (CI 0.4663–0.6404).

Conclusions

In a preliminary study in a sample of 20 Spanish control subjects using the TAR's series of facial affect cards, the six basic emotions and the neutral facial affect were recognized with at least a moderate reliability. A strong reliability was obtained in happiness and disgust, and a moderate reliability in surprise, angry, sadness, neutral, fear.

Relapse prevention in first-episode schizophrenia--maintenance vs intermittent drug treatment with prodrome-based early intervention: results of a randomized controlled trial within the German Research Network on Schizophrenia

OBJECTIVE

After acute treatment of the first illness episode in schizophrenia, antipsychotic maintenance treatment is recommended for at least 1 year. Evidence for the optimal subsequent treatment is still scarce. Targeted intermittent treatment was found to be less effective than continuous treatment at preventing relapse in multiple episode patients; however, a post hoc analysis of our own data from a previous study suggested comparable efficacy of the 2 treatment approaches in first-episode patients. The current study was therefore designed to compare prospectively the relapse preventive efficacy of further maintenance treatment and targeted intermittent treatment in patients with ICD-10-diagnosed first-episode schizophrenia.

METHOD

A randomized controlled trial was conducted within the German Research Network on Schizophrenia. Entry screening took place between November 2000 and May 2004. After 1 year of antipsychotic maintenance treatment, stable first-episode patients were randomly assigned to 12 months of further maintenance treatment or stepwise drug discontinuation and targeted intermittent treatment. In case of prodromal symptoms of an impending relapse, patients in both groups received early drug intervention, guided by a decision algorithm. The primary outcome measure was relapse (increase in the Positive and Negative Syndrome Scale positive score > 10, Clinical Global Impressions-Change score ≥ 6, and decrease in Global Assessment of Functioning score > 20 between 2 visits).

RESULTS

Of 96 first-episode patients, only 44 were eligible for the assigned treatment (maintenance treatment, n = 23; intermittent treatment, n = 21). The rates of relapse (19% vs 0%; P = .04) and deterioration (up to 57% vs 4%; P < .001) were significantly higher in the intermittent treatment group than in the maintenance treatment group, but quality-of-life scores were comparable. Intermittent treatment patients received a significantly lower amount of antipsychotics (in haloperidol equivalents; P < .001) and tended to show fewer side effects, particularly extrapyramidal side effects.

CONCLUSIONS

Maintenance treatment is more effective than targeted intermittent treatment in preventing relapse, even in stable first-episode patients after 1 year of maintenance treatment, and should be the preferred treatment option. However, about 50% of patients remain stable at a significantly lower drug dose and show fewer side effects, and a substantial proportion refuse maintenance treatment. Alternative long-term treatment strategies, including targeted intermittent treatment, should therefore be provided in individual cases.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00159120.

Cognitive behavioural therapy versus supportive therapy for persistent positive symptoms in psychotic disorders: the POSITIVE Study, a multicenter, prospective, single-blind, randomised controlled clinical trial

BACKGROUND

It has been demonstrated that cognitive behavioural therapy (CBT) has a moderate effect on symptom reduction and on general well being of patients suffering from psychosis. However, questions regarding the specific efficacy of CBT, the treatment safety, the cost-effectiveness, and the moderators and mediators of treatment effects are still a major issue. The major objective of this trial is to investigate whether CBT is specifically efficacious in reducing positive symptoms when compared with non-specific supportive therapy (ST) which does not implement CBT-techniques but provides comparable therapeutic attention.

METHODS/DESIGN

The POSITIVE study is a multicenter, prospective, single-blind, parallel group, randomised clinical trial, comparing CBT and ST with respect to the efficacy in reducing positive symptoms in psychotic disorders. CBT as well as ST consist of 20 sessions altogether, 165 participants receiving CBT and 165 participants receiving ST. Major methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, analysis by intention to treat, data management using remote data entry, measures of quality assurance (e.g. on-site monitoring with source data verification, regular query process), advanced statistical analysis, manualized treatment, checks of adherence and competence of therapists. Research relating the psychotherapy process with outcome, neurobiological research addressing basic questions of delusion formation using fMRI and neuropsychological assessment and treatment research investigating adaptations of CBT for adolescents is combined in this network. Problems of transfer into routine clinical care will be identified and addressed by a project focusing on cost efficiency.

DISCUSSION

This clinical trial is part of efforts to intensify psychotherapy research in the field of psychosis in Germany, to contribute to the international discussion on psychotherapy in psychotic disorders, and to help implement psychotherapy in routine care. Furthermore, the study will allow drawing conclusions about the mediators of treatment effects of CBT of psychotic disorders.

A coding variant of the novel serotonin receptor subunit 5-HT3E influences sustained attention in schizophrenia patients

Sustained attention as measured by the Continuous Performance Test (CPT) has proved a valuable endophenotype for schizophrenia. Recently pharmacological studies suggested a role of the serotonin (5-HT) 3 receptor in schizophrenia. The 5-HT3 receptors are the only ligand-gated ion channels within the 5-HT receptor family. Applying an endophenotype approach, we investigated a potential impact of the genes of the 5-HT3A and 5-HT3B subunits as well as the novel 5-HT3C, 5-HT3D, and 5-HT3E subunits on CPT performance in subjects with schizophrenia. The study included 196 patients with schizophrenia, 113 of their parents, and 205 healthy controls recruited from community registers. Sustained attention was assessed with the Continuous Performance Test-Identical Pairs (CPT-IP). Assessing functional and coding variants of the 5-HT3 receptor subunit genes, we found the GG genotype of the 5-HT3E subunit gene (rs7627615; Thr86Ala) to be associated with better attentional capacities in subjects with schizophrenia and healthy controls. This study provides additional evidence for a role of the serotonergic system and the 5-HT3 receptor in schizophrenia.

Effects of 10 Hz repetitive transcranial magnetic stimulation (rTMS) on clinical global impression in chronic schizophrenia

We conducted a randomized, sham-controlled repetitive transcranial magnetic stimulation (rTMS) study in chronic schizophrenia in-patients (n=35) to evaluate the therapeutic efficacy of 10 Hz stimulation. Patients, who were on stable antipsychotic treatment, were randomly assigned to the active or sham condition. In the active rTMS group, ten sessions with a total of 10,000 stimuli were applied over the left dorsolateral prefrontal cortex at 110% of motor threshold. The sham group received corresponding sham stimulation. Clinical improvement was measured by the Clinical Global Impression scale (primary outcome measure), the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Symptom Scale (PANSS; secondary outcome measures). Between-group comparisons revealed no significant differences in clinical outcome variables. Only a subgroup of patients with pronounced negative symptoms developed some clinical improvement as indicated by significant changes in the GAF-scale. Besides there is some evidence for a more favourable clinical outcome within this subgroup after rTMS in the CGI-S and PANSS negative scale, too. In line with earlier investigations, our results suggest a moderate - potentially clinically relevant - treatment effect of prefrontal 10 Hz rTMS stimulation in chronic patients. However, in our study this beneficial effect was restricted to subjects with pronounced negative symptoms.

CLINICAL TRIAL REGISTRATION INFORMATION

ClinicalTrial.gov Identifier: NCT00169689, http://www.clinicaltrials.gov.

DAOA/G72 predicts the progression of prodromal syndromes to first episode psychosis

The genetic factors determining the progression of prodromal syndromes to first episode schizophrenia have remained enigmatic to date. In a unique prospective multicentre trial, we assessed whether variants at the D-amino acid oxidase activator (DAOA)/G72 locus influence progression to psychosis. Young subjects with a prodromal syndrome were observed prospectively for up to 2 years to assess the incidence of progression to schizophrenia or first episode psychosis. Of the 82 probands with a prodromal syndrome, 21 probands experienced progression to psychosis within the observation period. Assessment of nine common variants in the DAOA/G72 locus yielded two variants with the predictive value for symptom progression: all four probands with the rs1341402 CC genotype developed psychosis compared with 17 out of 78 probands with the TT or CT genotypes (chi(2) = 12.348; df = 2; p = 0.002). The relative risk for progression to psychosis was significantly increased in the CC genotype: RR = 4.588 (95% CI = 2.175-4.588). Similarly, for rs778294, 50% of probands with the AA genotype, but only 22% of probands with a GG or GA genotype progressed to psychosis (chi(2) = 7.027; df = 2; p = 0.030). Moreover, haplotype analysis revealed a susceptibility haplotype for progression to psychosis. This is one of the first studies to identify a specific genetic factor for the progression of prodromal syndromes to schizophrenia, and further underscores the importance of the DAOA/G72 gene for schizophrenia.

The tolerability of rTMS treatment in schizophrenia with respect to cognitive function

INTRODUCTION

The purpose of this study was to assess tolerability and safety of high-frequency rTMS with regard to cognitive performance when conducted as "add-on" treatment in chronic schizophrenia in-patients (n=32).

METHODS

Patients, who were on stable antipsychotic treatment, were randomly assigned to verum or sham condition (double-blind). In the verum group, ten sessions of 10 Hz rTMS with a total of 10 000 stimuli were applied over the left dorsolateral prefrontal cortex (PFC) at 110% of motor threshold over a period of two weeks. The sham group received corresponding sham stimulation. RTMS effects on cognitive performance were assessed with a neuropsychological test battery consisting of the following tests: trail making test A and B (TMT), Wisconsin card sorting test (WCST), D2 attention task and the "short test of general intelligence" (KAI).

RESULTS

No statistically significant deterioration of cognitive performance was observed as a result of rTMS treatment. Moreover it was shown that in the verum group patients with a less favourable performance on the WCST at baseline tend to improve after rTMS treatment with regard to psychopathology as opposed to patients in the control group.

DISCUSSION

The stability of cognitive function suggests good tolerability of rTMS treatment in schizophrenia. The absence of evidence for cognitive deterioration could be due to low and short stimulation parameters.

Repetitive transcranial magnetic stimulation for the treatment of negative symptoms in residual schizophrenia: rationale and design of a sham-controlled, randomized multicenter study

Current meta-analysis revealed small, but significant effects of repetitive transcranial magnetic stimulation (rTMS) on negative symptoms in patients with schizophrenia. There is a need for further controlled, multicenter trials to assess the clinical efficacy of rTMS on negative symptoms in schizophrenia in a larger sample of patients. The objective of this multicenter, randomized, sham-controlled, rater- and patient-blind clinical trial is to investigate the efficacy of 3-week 10-Hz high frequency rTMS add on to antipsychotic therapy, 15 sessions per 3 weeks, 1,000 stimuli per session, stimulation intensity 110% of the individual motor threshold) of the left dorsolateral prefrontal cortex for treating negative symptoms in schizophrenia, and to evaluate the effect during a 12 weeks of follow-up. The primary efficacy endpoint is a reduction of negative symptoms as assessed by the negative sum score of the positive and negative symptom score (PANSS). A sample size of 63 in each group will have 80% power to detect an effect size of 0.50. Data analysis will be based on the intention to treat population. The study will be conducted at three university hospitals in Germany. This study will provide information about the efficacy of rTMS in the treatment of negative symptoms. In addition to psychopathology, other outcome measures such as neurocognition, social functioning, quality of life and neurobiological parameters will be assessed to investigate basic mechanisms of rTMS in schizophrenia. Main limitations of the trial are the potential influence of antipsychotic dosage changes and the difficulty to ensure adequate blinding.

Training of affect recognition in schizophrenia: Neurobiological correlates

Recently, a standardized program for training of affect recognition (TAR) was developed which has demonstrated efficacy and specificity with respect to behavioral performance. The effects of the TAR on the cerebral correlates were evaluated using repeated fMRI event-related measurements in a group of schizophrenia patients (n=10) before and after TAR treatment six weeks apart. A second patient group without training (n=10, treatment as usual, TAU) as well as healthy subjects (n=10) were investigated at equivalent time points. Schizophrenia patients were shown to be differentially impaired in the identification of the emotional aspects of facial expressions (but not age discrimination) when compared with healthy participants. A specific improvement in the increased number of correct identifications was observed in trained patients only. In parallel, an increase in activation was noted in the left middle and superior occipital lobe, the right inferior and superior parietal cortex, and the inferior frontal cortex bilaterally in TAR patients compared to the TAU group. These activation changes in TAR patients correlated with their behavioral improvement, further corroborating the positive effect of training. Specific training effects are seen to correspond with cerebral effects, probably reflecting a more efficient use of attentional, perceptual, or cognitive strategies.

Neuregulin 1 ICE-single nucleotide polymorphism in first episode schizophrenia correlates with cerebral activation in fronto-temporal areas

The Neuregulin (NRG1) gene has been associated with schizophrenia, but its functional implications are largely unknown. Our aim was to assess differential brain activation between patients carrying an at-risk allele on the Neuregulin 1 gene and patients without this genetic risk. Neural signal changes between 14 first episode schizophrenia patients with the at risk allele (SNP8NRG221533) from the Icelandic core haplotype and 14 without were measured with fMRI during a working memory task. Patients without the at risk allele showed greater activations (P < 0.05; corrected) in the left hippocampus, precuneus and cerebellum, as well as the right anterior cingulate. Brain regions previously associated with the pathology of Schizophrenia are differentially affected in those with a genetic at risk status in the NRG1 gene. Heterogeneity of structural and functional measures within patients characterized by clinical phenotypes may be in part due to this genetic variation.

The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia

BACKGROUND

The consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia.

OBJECTIVE

The study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied.

METHODS

Eighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately.

RESULTS

Patient and therapist alliance ratings were not significantly correlated (r=0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d=0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings.

CONCLUSION

The findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.

Neuropsychological impairments predict the clinical course in schizophrenia

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.