Dose equivalence of the antipsychotic drugs

Predictors of aggression on the psychiatric inpatient service

Patients with severe mental illness are at increased risk to commit acts of aggression in the inpatient hospital setting. Aggressive behaviors have severe negative consequences for the patient, victims, clinical staff, and the therapeutic community as a whole. While risk factors of community and inpatient aggression overlap, many predictive factors diverge between the two settings. For example, while medication noncompliance has been a robust predictor of community aggression, this factor has little predictive value for inpatient settings where patients' pharmacotherapy is closely monitored. Relatively fewer investigators have examined a wide range of predictive factors associated with aggressive acts committed on the psychiatry inpatient service, often with conflicting results. The present study examined demographic, clinical, and neurocognitive performance predictors of self, other, object, and verbal aggressiveness in 118 acute inpatients. Results revealed that the arrival status at the hospital (voluntary vs involuntary), female gender, and substance abuse diagnosis were predictors of verbal aggression and aggression against others. Impaired memory functioning also predicted object aggression. Fewer symptoms, combined with higher cognition functioning, however, were significant predictors of self-aggressive acts committed on the inpatient service. The need for relating predictors of specific types of aggressiveness in schizophrenia is discussed.

Insular cortex abnormalities in schizophrenia: Relationship to symptoms and typical neuroleptic exposure

BACKGROUND

The insular cortex is a limbic integration region engaged in emotional and cognitive functions. Previously, we found that neuroleptic-naive subjects had abnormally small insular volumes compared with control subjects, with volume directly related to severity of psychotic symptoms.

METHODS

To further investigate insular cortex abnormalities and their functional correlates, we measured insular gray matter volume and cortical surface size, using magnetic resonance images among 30 patients with schizophrenia and a matched control group. The sample was designed to represent a variety of phenomenologic profiles to provide sufficient variance in multiple measures, including severity of illness and exposure to neuroleptics (typical only).

RESULTS

There were no significant differences in morphology between patients and control subjects; however, among patients, psychotic symptoms were inversely correlated with insular volume, replicating our previous finding in neuroleptic-naive subjects. Neuroleptic exposure had a specific effect on insular morphology: increasing drug exposure (measured in dose-years) correlated with larger insular volume.

CONCLUSIONS

This effect of neuroleptic exposure might account for the lack of difference in structural measures in this more chronic sample, whereas the initial study on neuroleptic-naive subjects showed group differences. Further research is needed to investigate the potential relationship between changes in insula volume from neuroleptic exposure and clinical outcome.

Ultrastructural alterations in hippocampal mossy fiber synapses in schizophrenia: A postmortem morphometric study

Synapses formed between mossy fibers, the axons of hippocampal dentate granular cells, and the dendrites of CA3 pyramidal neurons are important links within the trisynaptic circuitry. Abnormalities in this circuitry are associated with the failure of schizophrenics to integrate affective experience with higher cognitive function, and with disturbances in memory and spatial learning processes. The abnormalities include reduced size and altered dendritic arborization of CA3 pyramidal neurons. In addition, decreased expression and binding activity of glutamate receptors have been reported, predominantly in the CA3 region of the hippocampus. These findings suggest that there are disturbed neuronal processes and connections in the hippocampus of schizophrenics. An electron microscope morphometric study of synaptic contacts between mossy fiber axon terminals (MFT) and branched dendritic spines of pyramidal neurons in stratum lucidum of the CA3 region of the hippocampus was performed in 10 normal controls and 9 age-matched chronic schizophrenics (postmortem delay 3-9 h). Schizophrenic cases with predominantly positive symptoms had a significantly reduced volume fraction of spines (-35%, P < 0.05), total number of invaginated spines (-47%, P < 0.01), and number of spines forming synapses (-32%, P < 0.05) per MFT compared with the control group. No effects of postmortem delay, age, duration of disease, or neuroleptic exposure were found. These data may reflect decreased efficacy of mossy fiber synapses in the CA3 hippocampal region in schizophrenics with predominantly positive symptoms. These data are in line with the neurodevelopmental hypothesis of schizophrenia.

Temporal pole morphology and psychopathology in males with schizophrenia

A dysfunction of the paralimbic system has been implicated in the pathophysiology of schizophrenia. The temporal pole (TP) is a relevant component of the paralimbic circuit. Functional and structural imaging studies have shown circumscribed abnormalities in the TP. Subjects were 30 controls and 30 schizophrenia patients. Cortical surface size and gray matter volume of the TP were accurately measured to explore the morphology of the TP cortex and the relationship of TP measures to clinical variables in patients with schizophrenia. Correlations between structural measures and clinical dimensions, duration of illness, and cumulative neuroleptic exposure were determined. Neither macroscopic abnormalities in the TP nor differences in the pattern of asymmetry were demonstrated. The TP volume was correlated negatively to the psychotic and disorganized dimension scores. No other significant correlations were found. No morphological abnormalities in the TP were found in patients with schizophrenia. Interestingly, a reduction in the TP volume, a higher-order multimodal association cortex, was associated with the severity of disorganized and psychotic symptoms.

Changes in caudate volume after exposure to atypical neuroleptics in patients with schizophrenia may be sex-dependent

BACKGROUND

Changes in the volume of the caudate nucleus over time in patients with schizophrenia has been shown to be directly related to neuroleptic exposure. Few studies have evaluated caudate volume in subjects with schizophrenia who were neuroleptic naive at intake and treated exclusively with atypical neuroleptics.

METHODS

Fourteen patients were matched by gender to 14 healthy controls and were evaluated over time using MRI. The patients were neuroleptic naïve at intake and at follow-up had been treated exclusively with atypical neuroleptics. Difference scores were calculated for caudate volumes. Neuroleptic exposure was quantified using a dose-years formula.

RESULTS

There was no difference between patients and controls in the amount of change over time in the volume of the caudate. However, the female patients had a negative correlation (r= - 0.74) between drug exposure and volume change while the male patients had a positive correlation (r = 0.63). Therefore, there was a significant gender effect on the relationship between atypical neuroleptic exposure and changes in the structure of the caudate over time (test for difference in correlations: z = 2.39, p = 0.016).

CONCLUSIONS

The change in caudate nucleus volume over time with exposure to atypical neuroleptics may be sex-dependent. Atypical neuroleptic expsoure was associated with volume increase over time in the males, while exposure in females was associated with volume decrement over time.

Creatine kinase BB in brain in schizophrenia

Creatine kinase (CK) is responsible for the creatine/creatine phosphate level which that is known to alter in the brain of patients with schizophrenia. A comparative estimation of CK enzymatic activity and immunoreactivity of CK BB was carried out in readily soluble extracts from frontal cortex, anterior and posterior cingulate cortex, hippocampus and cerebellum from brains of individuals with schizophrenia versus normal controls. CK activity was determined using a commercial diagnostic kit. CK BB immunoreactivity was evaluated by ECL -immunoblotting using monoclonal antibody. A drastic drop of CK activity and CK BB immunoreactivity was observed in all the examined brain areas in schizophrenia patients compared to controls (p<0.01), with the maximum drop in the cerebellum. The reduction was independent of age, postmortem interval or chlorpromazine equivalent. The decreased level of CK BB in schizophrenia was confirmed by purification of CK BB from brains of patients with schizophrenia and control brains: the yield of the purified enzyme was significantly lower in schizophrenia, wherein molecular masses of CK B-subunits were equal. Possible causes and consequences of the decrease in CK BB level observed in brain of patients with schizophrenia are discussed.

Glutamine synthetase and glutamate dehydrogenase in the prefrontal cortex of patients with schizophrenia

Basing primarily on the facts of altered levels of glutamate neurotransmitter, its receptors and transporters in schizophrenic brain, the "glutamatergic hypothesis" of schizophrenia has been broadened into the field of brain glutamate metabolism. Significantly changed levels of glutamine synthetase (GS) and glutamate dehydrogenase (GDH), the key enzymes involved in glutamine-glutamate cycling between neurons and glia, have been found in the prefrontal cortex (area 10) of patients with schizophrenia compared to controls (P<.01). The data were obtained by enzymatic activity determinations as well as immunoreactivity level evaluations for GS, glutamine synthetase-like protein (GSLP), and three GDH isoenzymes in brain extracts by immunoblotting using specific polyclonal and monoclonal antibodies. Inverse changes in amounts of proteins of GS and GSLP, as well as elevation in amounts of GDH isoenzymes have been observed in schizophrenia. The presented results provide evidence for the impairment of glutamate metabolism and, in turn, abnormalities in functioning of the glutamate-glutamine cycle in the frontal cortex of patients with schizophrenia.

Cognitive inhibition and thought disorder in schizophrenia

In schizophrenia, inhibitory control is reported to be disturbed and has been associated with formal thought disorder (TD). The negative priming task (NP) is used as a measure for inhibition; however, controversial results are found in the literature. The aim of this study was to evaluate cognitive inhibition in schizophrenia and TD. Additionally, the influence of the course of disease and of medication were evaluated. The NP was used to compare TD patients (n = 17) with non-TD (n = 19) and healthy controls (n = 21). Results showed similar performance among TD and non-TD patients, and controls. No influence of the course of disease or medication was found. Our results are in line with recent studies, where patients, irrespective of TD, show normal performance in the NP.

Risk factors in neuroleptic malignant syndrome. A case-control study

OBJECTIVE

To determine whether environmental temperature, agitation, neuroleptic use, mental retardation, and affective disorders were risk factors for neuroleptic malignant syndrome (NMS).

METHOD

Cases and age- and sex-matched psychiatric controls admitted to a regional acute psychiatric unit over a 10-year period.

RESULTS

Both uni- and multivariate analysis revealed statistically significant differences between patients with NMS (n=15) and controls (n=45) with regard to the presence of mental retardation, psychomotor agitation, and a number of variables relating to neuroleptic use (newly introduced or increased, intramuscular administration, and dosage). We found no differences between NMS patients and psychiatric controls in respect of changes in environmental temperature.

CONCLUSION

Our study supports the need for caution when using intramuscularly administered, abruptly increasing, high-dose neuroleptics, particularly in mentally retarded or agitated patients, regardless of environmental temperature.

Increased susceptibility to auditory conditioning in hallucinating schizophrenic patients: a preliminary investigation

Auditory hallucinations have been elicited in the laboratory after repeated pairings of a tone (unconditioned stimulus) with a light (conditioned stimulus), until the presentation of the light alone resulted in subjects hearing the tone. This auditory sensory-conditioning phenomenon was first reported in normal subjects over a half-century ago. But the model remains, to date, untested in actively hallucinating patients. If sensory-conditioning mechanisms actually mediate the occurrence of clinical hallucinations, one would expect that hallucinating patients would more readily acquire and be more resistant to extinguish a conditioned hallucination than nonhallucinating psychotic patients. The present study examined the susceptibility of 15 hallucinating and 15 nonhallucinating acute schizophrenic inpatients to acquire and maintain a sensory-conditioned hallucination response. Consistent with the auditory sensory-conditioning model, evidence suggests that hallucinating patients acquire and maintain sensory-conditioned hallucinations more quickly than their nonhallucinating counterparts. Results are discussed in terms of hallucinators' susceptibility to sensory conditioning and suggestibility as important factors underlying hallucinatory behavior. The findings are interpreted with respect to the behavioral mechanisms underlying psychotic symptom formation.

Clinical risk factors for neuroleptic malignant syndrome

Pharmacological risk factors for neuroleptic malignant syndrome (NMS) are better defined than clinical risk factors. We examined the psychopathological status preceding the onset of NMS in 20 patients. We evaluated four key psychiatric symptoms (psychomotor agitation, catatonia, disorganization and confusion) and grouped them into definite clinical syndromes. Six patients presented with an acute and severe catatonic syndrome, with all the four key psychiatric symptoms. Twelve patients presented with an acute and severe disorganized psychotic episode, with two or three key psychiatric symptoms, but not catatonia. Our study suggests that a clinical syndrome of acute disorganization, in addition to acute catatonia, is a potential clinical risk factor for NMS. The two syndromes, which can occur in the context of different mental disorders, are related to each other as both implicate alteration in behavioural monitoring, and were, in our experience, unresponsive to neuroleptics. In conclusion, we hypothesize that the recognition of these two syndromes should reduce NMS occurrence. We recommend a judicious use of neuroleptics not only in patients with acute catatonia, but also in patients with acute disorganization.

CSF thyrotropin-releasing hormone concentrations differ in patients with schizoaffective disorder from patients with schizophrenia or mood disorders

OBJECTIVE

To determine if there were differences in CSF-TRH concentrations among several acute major psychiatric disorders and to investigate the effects of antipsychotic treatment on CSF-TRH levels.

METHOD

CSF-TRH concentrations were measured in 62 psychiatric inpatients during an acute phase of illness after a drug-free period. CSF-TRH measurements were repeated in 14 of these patients after 4 weeks of antipsychotic treatment.

RESULTS

Post-hoc tests (Tukey HSD) revealed significant differences among patients with schizoaffective disorder and both schizophrenia (P<0.03) and major depression (P<0.01). There were no significant differences between pre and posttreatment levels of CSF-TRH in the 14 patients treated with conventional agents for 4 weeks (1.54 pg/ml vs. 1.47 pg/ml). However, patients with a reduction in CSF-TRH concentration had a significantly better symptom response measured by the Brief Psychiatric Rating Scale (BPRS) positive factor (61% in six subjects) vs. those who had an increase in posttreatment CSF-TRH (29% in eight subjects; t=2.2; d.f.=12; P<0.04).

CONCLUSIONS

These results provide further evidence for a neuromodulatory role for TRH and suggest a re-examination of its behavioral effects and interactions with brain neurotransmitter systems relevant to major psychotic and mood disorders.

Electron microscopy of oligodendroglia in severe mental illness

Qualitative electron microscopy was performed to verify whether brain pathology in schizophrenia and bipolar disorder is associated with alterations of oligodendroglial cells and myelinated fibers. Ultrastructural signs of apoptosis and necrosis of oligodendroglial cells were found in the prefrontal area 10 and the caudate nucleus in both schizophrenia and bipolar disorder. Damage of myelin sheath lamellae, with the formation of concentric lamellar bodies, were detected in both brain structures in schizophrenia. There was also a significant decrease in the area of the nucleus and the volume density of mitochondria in oligodendrogliocytes in the caudate nucleus and in the prefrontal cortex in schizophrenia, as compared to normal controls. Volume density of heterochromatin was significantly increased (+14%) in the caudate nucleus in schizophrenia. The density of concentric lamellar bodies (as an indicator of damage of myelinated fibers) was dramatically increased (4.5-fold) in the caudate nucleus in schizophrenia, as compared to controls, and was positively correlated with volume density of heterochromatin. Multiple regression analysis and analysis of covariance demonstrated that these changes could not be explained by the effects of postmortem delay, age, neuroleptic medication, or gender. Pathology of oligodendroglia might be an essential feature of severe mental disorders.

Stroop interference and facilitation effects in first-episode schizophrenic patients

In the Stroop test, interference occurs in naming the print color of a word when the word is itself the name of another color. Facilitation occurs when the word is the same as the print color. Previous studies on selective attention in schizophrenia using the Stroop interference effects have yielded contradicting results. Constraints included limited sample size and the recruitment of medicated chronic patients. We studied the Stroop interference and facilitation effects in a relatively large sample of first-episode schizophrenic patients (n=56), a substantial proportion of whom were medication-naïve (n=30) at the time of initial testing. We have also carried out longitudinal follow-up assessments when patients reached a clinically stable state, as well as 4months after recovery from the episode. We found that the Stroop interference effect was not increased in first-episode schizophrenic patients, whether medication-naïve or not. This effect did not change over the follow-up period. In addition, we detected an increase in Stroop facilitation effect in medicated schizophrenic patients, but only in the initial assessment soon after they had received medication. After sustained treatment, the increase in facilitation was normalized. These observations supported previous findings of a normal Stroop interference effect amongst schizophrenic patients. The increased facilitation effect for patients in their early phase of treatment (but not later) may represent an acute effect of anti-psychotic medication. Its nature and significance require further investigation.

Working memory in schizophrenia and mania: correlation with symptoms during the acute and subacute phases

OBJECTIVE

The aims of this study were to examine working memory in the acute subacute phase of schizophrenia and mania and to examine correlations between working memory and specific symptom domains.

METHOD

Visuospatial working memory and symptom profiles were assessed in three groups (schizophrenia group, n= 19; mania, n= 12; controls, n= 19) on two occasions separated by 4 weeks.

RESULTS

Both patient groups had significant deficits on working memory compared to the well controls and the schizophrenia and mania groups were equally impaired. All groups showed equivalent improvement over time. In the patient groups, impaired working memory was significantly correlated with the presence of both negative symptoms and positive thought disorder.

CONCLUSION

Impaired working memory is found in both schizophrenia and mania during the acute subacute phases. Further research is required in order to clarify the neurocognitive mechanisms linking impaired working memory with both negative symptoms and positive thought disorder.

An MRI study of midbrain morphology in patients with schizophrenia: relationship to psychosis, neuroleptics, and cerebellar neural circuitry

BACKGROUND

The midbrain contains the perikarya of all the dopamine neurons in the human brain. Although other neurochemicals may well be involved, dopamine dysregulation is central in the pathophysiology of psychosis. Despite this, few imaging studies have evaluated the morphology of the midbrain.

METHODS

Using high-resolution magnetic resonance imaging, morphology of three posterior fossa and brain stem structures were measured: midbrain, pons, and medulla. The patient sample consisted of 50 men with schizophrenia, matched by gender and age to 50 healthy control subjects.

RESULTS

Patients had significantly smaller midbrain measures compared with control subjects. There were no differences between groups in measures of pons or medulla. Furthermore, midbrain size was significantly and inversely correlated with positive symptoms and cumulative neuroleptic exposure, but not with negative or disorganized symptoms. After controlling for the effect of cumulative neuroleptic exposure, the relationship between midbrain morphology and positive symptoms remained significant.

CONCLUSIONS

Midbrain morphology of patients with schizophrenia is abnormal, being smaller in patients compared with control subjects. Although this appears to be specifically related to psychotic symptoms, there is also a robust medication effect, with greater exposure to neuroleptics being associated with greater morphologic abnormality. We discuss the role of dopaminergic dysregulation and possible neural circuit involvement.

Insight changes in acute psychotic episodes: a prospective study of Hong Kong Chinese patients

Insight impairment occurs commonly in psychotic disorders (including mood episodes with psychotic symptoms). The aim of the present study is to measure changes of insight over the course of a psychotic episode and to investigate its relationships with symptoms and neurocognitive functions, as well as psychosocial factors. Insight was assessed at weekly intervals in 80 consecutive inpatients presenting with a psychotic episode by using a Chinese translation of the Scale to Assess Unawareness of Mental Disorder (SUMD). The relationships between insight change and other variables were explored. Modest but significant changes in insight were found in both directions with clinical resolution of psychotic symptoms. In particular, insight "declined" as symptoms improved in a number of patients. In addition, changes in insight score correlated with changes in Wisconsin Card Sorting Test (WCST) performance. More changes in insight (in either direction) tended to occur in younger patients. These results indicated that adequate control of psychotic symptoms and improvement in neuropsychological functioning might be associated with better insight recovery.

Learning and memory impairment in cocaine-dependent and comorbid schizophrenic patients

Impairments in verbal learning and memory functioning have been found to be cardinal features among individuals with schizophrenia as well as among non-schizophrenic cocaine abusers. Cognitive deficits in these areas, moreover, have been associated with poor treatment response and short-term outcome. Little is known, however, about the acute effects of cocaine abuse on schizophrenic patients' learning and memory functioning. Consequently, a potentially reversible and treatable source of cognitive impairment has been virtually ignored. The present study examined the extent of verbal learning and memory impairment in a group of cocaine-dependent schizophrenic patients (n=42) and a group of non-schizophrenic cocaine-dependent patients (n=21) within 72 h of the last cocaine use using the California Verbal Learning Test (CVLT). Schizophrenic patients (n=34) without any substance-use disorders were also tested in an identical time frame and served as a comparison group. Results revealed that all groups demonstrated significant learning and memory impairment relative to CVLT published age and gender corrected norms. Both cocaine-dependent and non-substance abusing schizophrenic groups presented a very similar pattern of impaired learning and recall performance across all CVLT task domains. Comorbid patients, in contrast, presented with marked deficits in their ability to learn and recall verbal information relative to either schizophrenic or cocaine-only groups. Moreover, the cocaine-abusing schizophrenic patients showed significant forgetfulness of the information that they did acquire during delayed recall conditions. The performance deficits exhibited by cocaine-abusing schizophrenic patients differed not only in relative severity of impairment, but also qualitatively in their increased rates of forgetfulness of acquired information. These results are interpreted in terms of the neurobiological substrates of learning and memory and the neurobiological impact of cocaine on schizophrenic patients' cognition during the early phase of inpatient hospitalization. These results suggest that comorbid patients should be targeted for specialized remediation efforts at the beginning phases of inpatient treatment.

Altered adhesion, proliferation and death in neural cultures from adults with schizophrenia

The causes of schizophrenia are unknown, but there is evidence linking subtle deviations in neural development with schizophrenia. Embryonic brain development cannot be studied in an adult with schizophrenia, but neurogenesis and early events in neuronal differentiation can be investigated throughout adult life in the human olfactory epithelium. Our past research has demonstrated that neuronal cultures can be derived from biopsy of the human adult olfactory epithelium. In the present study, we examined mechanisms related to neurogenesis and neuronal differentiation in adults with schizophrenia versus well controls. Forty biopsies were collected under local anaesthesia from ten individuals with DSM III-R schizophrenia and ten age- and sex-matched well controls. All patients, except one, were receiving antipsychotic medication at the time of the biopsy. Immunostaining for neuronal markers indicated that neurogenesis occurred in the biopsies from both patients and controls since all contained cells expressing tubulin and/or olfactory marker protein. The major findings of this study are: 1. biopsies from patients with schizophrenia showed a significantly reduced ability to attach to the culture slide: 29.9% of patient biopsies attached compared to 73.5% of control biopsies; 2. biopsies from patients with schizophrenia had a significantly greater proportion of cells undergoing mitosis: 0.69% in the patients compared to 0.29% in the controls; and 3. dopamine (10 microM) significantly increased the proportion of apoptotic cells in the control cultures but significantly decreased the proportion in patients' cultures.

A comparison of the effect of five phenothiazines on hepatic CYP isoenzymes in rats

We examined the influence of five phenothiazine derivatives on the activity and the expression of hepatic cytochrome P450 (CYP) 1A, 2B, 2C6, 2C11, 2E1 and 3A2 in male Sprague-Dawley rats. Twenty mg/kg of phenothiazine, chlorpromazine, and thioridazine, or 1 mg/kg of trifluoperazine and perphenazine was administered intraperitoneally for 4 consecutive days. Phenothiazine increased the total CYP content and induced CYP1A, CYP2B, and CYP3A. Western blot analysis showed marked induction of CYP1A1 by phenothiazine. Chlorpromazine induced CYP2B, and CYP3A without a significant increase in the CYP content. Thioridazine decreased the total CYP content and reduced CYP2C11, CYP2E1, and CYP3A. Neither trifluoperazine nor perphenazine significantly altered the catalytic activity or the protein level of any enzyme examined. These results suggest that the antipsychotic phenothiazine derivatives examined here hardly affect CYP1A at the pharmacological doses, while phenothiazine does induce it. Although a relatively short period and small dose of administration might counteract the influence, trifluoperazine and perphenazine have less effect on CYP subfamilies than chlorpromazine or thioridazine.

Change in basal ganglia volume over 2 years in patients with schizophrenia: typical versus atypical neuroleptics

OBJECTIVE

For many years, it has been assumed that medications affect brain chemistry and physiology but not structure. Recent reports suggest that neuroleptic medication changes basal ganglia volume. To explore this possibility, the authors assessed for basal ganglia volume change in individuals who had their basal ganglia structures delineated and measured on magnetic resonance scans at the beginning and end of a 2-year period and who received neuroleptic medication during this time.

METHOD

The basal ganglia volumes of 23 male patients with schizophrenia spectrum disorders were measured from manual traces delineating the caudate and lenticular nucleus on magnetic resonance images at admission and 2 years later. Patients' neuroleptic exposure was calculated over the 2 years by using a dose-year formula.

RESULTS

During the 2-year period, mean basal ganglia volume of patients receiving predominantly typical neuroleptics increased, while the opposite was observed for patients receiving mostly atypical neuroleptics. Correlation analysis for the entire group showed a positive relationship between the 2-year exposure to typical neuroleptic medication and change in basal ganglia volume and the reverse for exposure to atypical neuroleptics.

CONCLUSIONS

In this group, basal ganglia volume increased following exposure to typical neuroleptics and decreased following exposure to atypical neuroleptics.

Clinical and pharmacologic risk factors for neuroleptic malignant syndrome: a case-control study

BACKGROUND

Pharmacologic and clinical risk factors for neuroleptic malignant syndrome have been suggested. High neuroleptic dose, rapid dosage increase, and parenteral administration were identified as risk factors in a case-control study; however, there are limited data regarding potential clinical risk factors.

METHODS

To examine potential clinical risk factors, we conducted a case-control study, comparing 12 cases to 24 controls, all treated with neuroleptics at our center. In addition to examining previously postulated pharmacologic risk factors, we also assessed for presence of psychomotor agitation, confusion, disorganization, and catatonia.

RESULTS

Significant differences were found between cases and controls for psychomotor agitation, confusion, disorganization, catatonia, mean and maximum neuroleptic dose, parenteral neuroleptic injections, neuroleptic dose increase within 5 days of the episode, magnitude of neuroleptic dose increase from initial dose, and extrapyramidal signs.

CONCLUSIONS

This study demonstrated that psychopathological features such as psychomotor agitation, confusion, disorganized behavior, and catatonia may be risk factors for the neuroleptic malignant syndrome, in addition to pharmacologic risk factors and extrapyramidal signs, including akathisia. In clinical practice, careful monitoring for prodromal signs of neuroleptic malignant syndrome is required during neuroleptic treatment of patients with psychomotor agitation, confusion, and/or disorganization, while in the presence of catatonia these drugs should be avoided.

Naltrexone augmentation of neuroleptics in schizophrenia

This study was conducted to determine whether the addition of naltrexone to ongoing neuroleptic treatment would facilitate the reduction in positive or negative symptoms in patients with schizophrenia. Twenty-one patients meeting DSM-III criteria for schizophrenia were enrolled; all patients had been stabilized for at least 2 weeks on their dosage of neuroleptic medicine before entering the study. Patients were randomized to receive either placebo or naltrexone 200 mg/day for 3 weeks in addition to their neuroleptic. Patients randomized initially into the placebo arm were crossed over to receive naltrexone in a single-blind fashion for 3 additional weeks. All patients were rated weekly with the Brief Psychiatric Rating Scale (BPRS). Fifteen patients received placebo and six received naltrexone in the first 3 weeks. No significant effects of naltrexone on total BPRS scores or BPRS subscale scores were observed. Patients who received naltrexone on a single-blind basis at the end of the placebo-controlled trial demonstrated a transient exacerbation in negative symptoms as reflected by the total BPRS score and the BPRS Withdrawal-Retardation subscale score. Repeated-measures analysis of variance (ANOVA) on the BPRS total score of the subsequent treatment with naltrexone showed a trend for a significance in the drug by time effect. Repeated-measures ANOVA on the BPRS Withdrawal-Retardation subscale of the subsequent treatment with naltrexone showed a significant drug by time effect. The current data failed to indicate a clinical benefit when naltrexone was added to the neuroleptic regimen. Other potential applications of naltrexone in schizophrenia are addressed.

Calgary Depression Scale for Schizophrenia: a study of the validity of a French-language version in a population of schizophrenic patients

The Calgary Depression Scale for Schizophrenia (CDSS) is a nine-item structured interview scale developed by Addington et al. to assess depression in schizophrenics. This paper describes the testing of the reliability and validity of the French version of the CDSS in a population of 70 schizophrenic patients. The validity of the CDSS as a measure of depression was confirmed; a single factor accounted for 41% of the variance of the nine items. The total score on the CDSS was strongly correlated with those on the Montgomery-Asberg Depression Rating Scale (MADRS), the Hamilton Depression Rating Scale (HDRS) and also the G6 item (depression) of the Positive and Negative Syndrome Scale (PANSS). The correlation with the Psychomotor Retardation Scale (ERD) total score was much less significant and was better with the 'subjective' subscore. The internal consistency was good, with a Cronbach's alpha of 0.79. A high level of inter-rater reliability was observed (weighted kappa values were >0.75 in all cases). The CDSS has a lower stability over time than other depression scales. It is a simple, quick and reliable scale for assessing depression in schizophrenic populations.

Thought disorder and executive ability

A neurocognitive model of thought disorder is proposed that links: (1) impaired ability to establish set with poverty of speech; (2) impaired ability to maintain set with positive thought disorder; and (3) impaired ability to shift sets with perseveration in speech. The aim of this study is to examine performance on tests sensitive to set ability in patients prone to thought disorder. Patients with schizophrenia (n = 36), mania (n = 18) and a well control group (n = 20) were assessed on two occasions separated by 4 weeks. Testing included: a free speech sample, Controlled Oral Word Association test, Stroop test, Wisconsin Card Sort test, and the Trail Making test. Impaired ability to maintain set in the face of interference was correlated with positive thought disorder, impaired ability to establish set was correlated with poverty of speech, and impaired ability to shift set was associated with perseveration in speech. The associations between impaired set ability and types of thought disorder support a neurocognitive model implicating impaired executive ability in the pathogenesis of thought disorder.

Performance on tests sensitive to impaired executive ability in schizophrenia, mania and well controls: acute and subacute phases

AIMS

To compare the performance of schizophrenia, mania and well control groups on tests sensitive to impaired executive ability, and to assess the within-group stability of these measures across the acute and subacute phases of psychoses.

METHOD

Recently admitted patients with schizophrenia (n = 36), mania (n = 18) and a well control group (n = 20) were assessed on two occasions separated by 4 weeks. Tests included: the Controlled Oral Word Association Test, the Stroop Test, the Wisconsin Card Sort Test, and the Trail Making Test.

RESULTS

The two patient groups were significantly impaired on the Stroop Test at both time points compared to the control group. Significant group differences were also found for the Trail Making Test at Time 1 and for the Wisconsin Card Sort Test at Time 2. When controlled for practice effect, significant improvements over time were found on the Stroop and Trail Making tests in schizophrenia group and on WCST Categories Achieved in the mania group.

DISCUSSION

Compared to controls, the patient groups were impaired on measures related to executive ability. The pattern of improvement on test scores between the acute and subacute phases differed between patients with schizophrenia versus patients with mania.

Blink rate, neurocognitive impairments, and symptoms in schizophrenia

This study addresses the relationship between blink rate (as a measure of central dopaminergic activity), symptoms, neuropsychological performance, as well as neurological signs in schizophrenia. Blink rate between schizophrenic patients and a matched control group was compared in both "relaxed" and "attentive" conditions. Blink rate was increased in schizophrenic patients in the "relaxed" condition but not in the "attentive" condition. The relationship between blink rate and clinical variables was examined in a larger sample of 204 patients. In both "relaxed" and "attentive" conditions, blink rate was related to "hallucinations," "anxiety," negative symptoms, and neuroleptic dosage. Attention was a significant predictor only in the "relaxed" condition. No other significant correlation was found between blink rate, neuropsychological impairments, and neurological signs. These findings suggest that blink rate is not related to neurocognitive impairments in schizophrenia.

Neurological signs, age, and illness duration in schizophrenia

Although increased prevalence of neurological signs in schizophrenia may reflect the presence of subtle brain dysfunctions, it is not clear whether there is progressive deterioration in such neurological function as the illness advances. This study compared neurological signs in patients with different durations of illness, controlling for age and education level. No deterioration in neurological signs as a function of illness duration was observed. Although there was an increase in neurological signs with age, there was a parallel increase in a control group. In addition, no change in the profile of subgroups of neurological signs was detected. These data provide further evidence for the stability of neurological dysfunction in schizophrenia. The findings are discussed in the context of the developmental origin of neurological dysfunction in schizophrenia.

Psychosis and vulnerability to ECT-induced seizures

Medical records of patients with major depressive disorders who had received electroconvulsive therapy (ECT) for the first time were studied to test the hypothesis that psychotic patients are more vulnerable to seizures than nonpsychotic patients. This hypothesis was based on studies suggesting a putative purinergic deficiency in psychosis. Results showed that the duration of ECT-induced seizures as a measure of seizure vulnerability was significantly longer in psychotic than in nonpsychotic depressive patients. The association applied for the first ECT as well as for the course of eight ECTs. These findings were still present when covariates such as age, electrical energy applied, dosage of methohexital and succinylcholine, and psychotropic medications such as neuroleptics, benzodiazepines, and tricyclics were included in the statistical analysis. The results are discussed in the context of the role of neurotransmitters such as glutamate, gamma-aminobutyric acid, adenosine, and dopamine on seizure vulnerability and psychosis.

Prefrontal neuropsychological impairment and illness duration in schizophrenia: a study of 204 patients in Hong Kong

Previous studies investigating the progression of neuropsychological impairment in schizophrenia have yielded conflicting results. We compared prefrontal neuropsychological function and other cognitive performance in a larger sample of schizophrenic patients with different duration of illness. The inclusion of a normal control group also allowed the effect of age to be taken into account. Performance in the Wisconsin Card Sorting Test (WCST) and semantic fluency were both impaired at an early stage in the illness and did not significantly deteriorate as the illness duration increased. Against this background there was preliminary evidence for deterioration in verbal memory function. The data support a lack of progression in prefrontal dysfunction and in most other cognitive domains.

Anhedonia and negative symptomatology in chronic schizophrenia

The relationships between negative symptomatology and anhedonia have been studied on 61 subjects who had Research Diagnostic Criteria for chronic schizophrenia. Negative symptomatology was rated by the negative subscales of the Kay Positive and Negative Syndrome Scale (PANSS) and of the Brief Psychiatric Rating Scale (BPRS). Anhedonia was rated by the Physical Anhedonia Scale of Chapman (PAS), the Fawcett-Clark Pleasure Capacity Scale-Physical Pleasure (FCPCS-PP), and the social interest subscale (SIS) of the Nurse Observation Scale for Inpatients (NOSIE-30). Pearson correlations were calculated between negative and anhedonia scales. Schizophrenics were dichotomized first into negatives and positives using the composite score of the PANSS, and second into low and high negatives using the negative subscale of the PANSS. For each dichotomy, the corresponding subgroups were compared on anhedonia scales using Student's test. The results have shown no significant correlations between negative and anhedonia scales (PAS and FCPCS-PP). There were no significant differences concerning the PAS and the FCPCS-PP between negative and positive subgroups of schizophrenics and between low- and high-negative subgroups. Anhedonia is not a negative symptom. Our results confirm the reported studies on subjective experiences in schizophrenia. A search for more restricted forms of schizophrenia characterized by severe anhedonia is needed.

A subscale for negative symptoms from the Comprehensive Psychopathological Rating Scale (CPRS): a comparison with the Schedule for Assessment of Negative Symptoms (SANS)

The Comprehensive Psychopathological Rating Scale (CPRS) was used to determine symptomatology in 145 schizophrenic patients. In 40 of these patients the Schedule for Assessment of Negative Symptoms (SANS) was also applied in order to determine which items in the CPRS represent negative schizophrenic symptoms. Of the patients, 115 were drug-free and 30 were treated with major tranquilizers at the time of the rating. A principal component analysis with oblique solution and Varimax rotation grouped the items from CPRS into ten factors. These factors were subsequently correlated to the total scores of the SANS. When a factor showed a positive correlation with the SANS, the individual items within the factor were examined for correlation to both the subscales and the total SANS scores. Of the 33 items, 5 used in the CPRS showed a positive correlation with the SANS and were therefore considered to represent negative symptomatology in schizophrenia. These items were withdrawal, reduced speech, lack of appropriate emotions, slowness of movements and indecision. The items were grouped as a negative symptom subscale in the CPRS.

Conventional neuroleptics and rehabilitation in schizophrenic patients

Nowadays, the rehabilitation of schizophrenic patients is a major issue for psychiatry. Regarding the role of conventional neuroleptics, the following points will be considered in this paper: the role of neuroleptics in the number, length and frequency of hospitalisations; the role of neuroleptics in the number, degree and length of relapses; the clinical effects of neuroleptics focusing particularly on their disinhibitory action, the most controversial and least studied of the clinical effects of these drugs; and the side effects, which have been intensively studied and particularly criticised during these last years, leading to the development of new drugs discussed in the next article. All the published data relating to the psychosocial profile of schizophrenic patients clearly demonstrate the need for further research in order to improve the familial, social and professional rehabilitation of these patients

Sexual disorders in nonacute psychiatric outpatients

One hundred schizophrenics and 58 patients with an affective psychosis who were in relatively stable condition and were being treated as outpatients, as well as 30 patients receiving dermatological treatment, were questioned in a semistructured interview about their sexual history. Forty-nine percent of schizophrenics, 36.2% of those with affective disorders, and 13.3% of control patients had a sexual dysfunction. The most frequent form experienced by psychiatric patients was hypoactive sexual desire disorder. Underlying causes were presumed to be multifactorial in most cases (expert rating). The patients most frequently affected by sexual dysfunctions were schizophrenics on neuroleptic medication, whereas schizophrenic patients not on any medication had fewer dysfunctions and control patients were only minimally affected. Neither the nature of the psychopharmaceuticals nor the dose level had a specific influence on the frequency of sexual dysfunctions.

Memory and social skill in schizophrenia: the role of gender

The relationship between social skill and memory was examined in a group of patients with schizophrenia and schizoaffective disorder. There were few or no differences between male and female patients in history of the illness, symptomatology, memory, and other cognitive factors, or social skill. Despite the absence of differences, impaired memory was related to poorer social skills for the women, but not the men. Reanalysis of data on social skill and memory from an earlier study (Mueser et al., 1991) revealed a similar pattern of results. The findings suggest that the contribution of cognitive factors to impaired social competence in schizophrenia may differ in men and women. Alternatively, the results may reflect sampling bias, whereby more severely ill women are studied than men, relative to their respective populations.

The Cambridge Neurological Inventory: a clinical instrument for assessment of soft neurological signs in psychiatric patients

A schedule (the Cambridge Neurological Inventory) has been constructed for standardized neurological assessment of psychiatric patients. Normative data and data resulting from its application to a group of patients with schizophrenia are reported. The instrument is comprehensive, reliable, and easy to administer. In conjunction with other forms of clinical assessment, it may be useful for identifying soft neurological signs and other patterns of neurological impairment relevant to neurobiological localization and prognosis in schizophrenia and other psychiatric disorders.

Factors affecting rehospitalisation rates of chronic schizophrenic patients living in the community

Eighty-eight [corrected] patients selected from a depot neuroleptic clinic in the hospital outpatients department were assessed clinically on various demographic and clinical variables with a view to determining the factors that may contribute to high rates of rehospitalisation amongst schizophrenics in remission. It was found that rehospitalisation rates during the preceding 5 years correlated with an early age of onset of illness, severity of positive and affective symptoms, current neuroleptic dose and total AIMS score, all reflecting the severity of underlying psychotic disorder and the neuroleptic treatment required to treat the psychosis. Poor compliance with neuroleptic prophylaxis was not found to be of importance in contributing to high relapse rates in this sample. It was concluded that patients who repeatedly relapse may do so because of the clinical characteristics of their illness.

New antipsychotics in schizophrenia: the French experience

Since the beginning of the neuroleptics in 1952, French psychiatrists have proposed a classification of neuroleptics, taking into account the pharmacological and therapeutic differences between these drugs. They distinguished 3 different clinical effects of neuroleptics: sedative effects, effects on the positive symptoms of schizophrenia and effects on the negative symptoms. The effect of some neuroleptics on negative symptoms is recognized by the international community, which considers clozapine to be effective. In France, in most cases, the indication of clozapine is still refractory paranoid schizophrenia. The effect of this atypical neuroleptic on other types of schizophrenic patient is not well known. Remoxipride appears to be as effective in treating psychotic symptoms and to have fewer side effects than haloperidol. Remoxipride is effective for both positive and negative symptoms. Loxapine has been prescribed in France since 1980. Its pharmacological profile is close to that of clozapine: it has dopamine (D2), histamine (H1), serotonin (5-HT2) and adrenergic (alpha 1)-blocking activities. Its best indication seems to be paranoid schizophrenia, although some data suggest bipolar action. The bipolar action of some new neuroleptics is illustrated by amisulpride, a substitute benzamide derivative. The originality of this molecule lies in its two opposite actions at two distinct doses. Doses of 600-1200 mg/day are effective against positive symptoms; 50-150 mg/day improves negative symptoms. This latter effect could be mediated by activation of the dopamine system.(ABSTRACT TRUNCATED AT 250 WORDS)

Antideficit properties of neuroleptics

The antidelusion effect, in the antiproductive sense of the term, represents the essential property of neuroleptics in research and publications in the United States. In France and in other European countries, however, a particular effect was observed early on that received various labels: disinhibitor, stimulant, antiautistic and anti-deficit, and that involved the beneficial action of certain neuroleptics on the negative symptoms of schizophrenia. The first period, ranging from 1952 to 1976, was characterized by a number of clinical observations and attempts at classification. In the second period, 1976 to 1984, much work was done in pharmacology and biochemistry. In the third period, 1984 to 1989, double-blind studies confirmed, among others, the disinhibiting effect, first of low doses of sulpiride and then of amisulpiride.

Current cannabis use and tardive dyskinesia

The aim of this study was to examine the relationship between substance abuse and tardive dyskinesia (TD) in 51 chronic, neuroleptic-treated, community outpatients with a DSM-III-R diagnosis of schizophrenia. In the presence of a clinical researcher, subjects completed a questionnaire on past and current alcohol and drug use, and provided information pertaining to variables which have, in the past, been implicated in the development of TD: smoking habits, caffeine consumption, and current neuroleptic dose. Subjects were also administered the Abnormal Involuntary Movement Scale (AIMS) in an interview format with either two or three trained raters present in the room. Consistent with previous reports, our results indicated a trend for females and older patients with a longer duration of illness to show elevated scores on the AIMS. In a hierarchical multiple regression analysis, however, cannabis use was found to correlate best with the presence of TD, out-ranking other putative factors.

Mapping schizophrenic negative symptoms onto measures of the patient's speech: set correlational analysis

We describe a system designed to assess the speech behaviors that inform clinicians about their patients' negative symptoms. Measures are formed into scales to reflect the patient's Pausing, Speech Rate, and Dyadic Interaction with the interviewer. Using set correlation, we examined the associations between the acoustic scales and the clinician's ratings of Flat Affect, Alogia, and Asociality. Over half of the multivariance in the clinical scales was accounted for by the acoustic scales. Unique isomorphisms between the acoustic and rating scales were found for: Dyadic Interaction with Flat Affect; Pause Production with Alogia; and Rate with Asociality.

Self-regulation of slow cortical potentials in psychiatric patients: schizophrenia

Slow cortical potentials (SCPs) are considered to reflect the regulation of attention resources and cortical excitability in cortical neuronal networks. Impaired attentional functioning, as found in patients with schizophrenic disorders, may covary with impaired SCP regulation. This hypothesis was tested using a self-regulation paradigm. Twelve medicated male schizophrenic inpatients and 12 healthy male controls received continuous feedback of their SCPs, during intervals of 8 s each, by means of a visual stimulus (a stylized rocket) moving horizontally across a TV screen. The position of the feedback stimulus was a linear function of the integrated SCP at each point in time during the feedback interval. Subjects were required to increase or reduce negative SCPs (referred to pretrial baseline) depending on the presentation of a discriminative stimulus. The correct response was indicated by the amount of forward movement of the feedback stimulus and by monetary rewards. Schizophrenics participated in 20 sessions (each comprising 110 trials), while controls participated in 5 sessions. Compared with the healthy controls, schizophrenics showed no significant differentiation between negativity increase and negativity suppression during the first sessions. However, in the last 3 sessions, patients achieved differentiation similar to controls, demonstrating the acquisition of SCP control after extensive training.

Treatment with neuroleptics: the patient's perspective

Sixty-one acute schizophrenic patients were questioned on the effects ascribed subjectively by them to their neuroleptic medication and on their rating of neuroleptic therapy. Although negative effects ascribed to the medication outnumbered positive effects by 3 to 1, the global rating was predominantly positive. Patients approving of neuroleptic therapy reported favourable changes under medication significantly more often than patients with a rejecting attitude. There was, however, no significant difference between the two groups in the frequency with which negatively experienced effects of medication were described.

Proton magnetic resonance spectroscopy of the brain in schizophrenic and affective patients

Water-suppressed 1H magnetic resonance spectra were recorded from two brain regions of psychiatric patients and normal volunteers. The two regions studied were (a) the basal ganglia structures surrounding the anterior horn of the lateral ventricle and (b) the occipital cortex. N-Acetylaspartate (NAA), phosphocreatine-creatine (PCr-Cr), choline and inositol resonances were seen in both regions. Ratios of metabolite peak integrals to PCr-Cr peak integral were calculated for each spectrum. To control for partial volume effects, comparisons between patients and controls were made only from identical regions i.e. basal ganglia vs basal ganglia, and likewise for occipital cortex. Metabolite ratios from the occipital region of patients were similar to those from the occipital region of normal subjects. Bipolar patients being treated with lithium had elevated NAA/PCr-Cr in the basal ganglia region when compared to normals. These patients also demonstrated elevated choline/PCr-Cr and inositol/PCr-Cr ratios in the basal ganglia region.

Gender differences in cognition in schizophrenia

Gender differences in cognition were investigated in schizophrenic inpatients and outpatients using the Dementia Rating Scale. Females displayed greater impairment on Attention and Conceptualization than males. Gender interacted with patient group for construction: females performed worse than males among inpatients and better among outpatients. Results may be related to the atypically early age of onset of females relative to males; attention to sampling and selection biases is needed in evaluating gender differences in cognition in schizophrenia.

Factors affecting compliance with depot injection treatment in the community

This study investigated aspects of the community psychiatric care of psychotic patients living in inner city areas, and especially those of Afro-Caribbean ethnicity. Ethnicity was not found to be a major factor affecting compliance with depot injections. More important were variables such as time since first treatment and sex. Defaulters from treatment were more likely to be subsequently admitted to hospital.