The timing of brain morphological changes in schizophrenia and their relationship to clinical outcome

Longitudinal assessment of ventricular volume trajectories in early-stage schizophrenia: evidence of both enlargement and shrinkage

BACKGROUND

Lateral ventricular enlargement represents a canonical morphometric finding in chronic patients with schizophrenia; however, longitudinal studies elucidating complex dynamic trajectories of ventricular volume change during critical early disease stages are sparse.

METHODS

We measured lateral ventricular volumes in 113 first-episode schizophrenia patients (FES) at baseline visit (11.7 months after illness onset, SD = 12.3) and 128 age- and sex-matched healthy controls (HC) using 3T MRI. MRI was then repeated in both FES and HC one year later.

RESULTS

Compared to controls, ventricular enlargement was identified in 18.6% of patients with FES (14.1% annual ventricular volume (VV) increase; 95%CI: 5.4; 33.1). The ventricular expansion correlated with the severity of PANSS-negative symptoms at one-year follow-up (p = 0.0078). Nevertheless, 16.8% of FES showed an opposite pattern of statistically significant ventricular shrinkage during ≈ one-year follow-up (-9.5% annual VV decrease; 95%CI: -23.7; -2.4). There were no differences in sex, illness duration, age of onset, duration of untreated psychosis, body mass index, the incidence of Schneiderian symptoms, or cumulative antipsychotic dose among the patient groups exhibiting ventricular enlargement, shrinkage, or no change in VV.

CONCLUSION

Both enlargement and ventricular shrinkage are equally present in the early stages of schizophrenia. The newly discovered early reduction of VV in a subgroup of patients emphasizes the need for further research to understand its mechanisms.

Magnetic resonance imaging of brain anomalies in adult and pediatric schizophrenia patients: Experience of a Romanian tertiary hospital

Schizophrenia is a severe mental illness with a significant impact on the life of both the patient and the patient's family. Magnetic resonance imaging has proven a useful tool for studying structural changes of the brain in schizophrenia. However, interpreting the published literature presents several challenges. Despite thorough research in recent years, which has included anatomopathological, imaging, electrophysiological, and genetic studies, the intimate pathophysiological mechanisms of this disease are not yet fully elucidated. The present study included patients with schizophrenia diagnosed in the psychiatric clinics from the ‘Prof. Dr. Alexandru Obregia’ Clinical Psychiatry Hospital between September 2019 and December 2020. Three Tesla magnetic resonance neuroimaging studies were performed. In a significant number of cases, the neuroimaging studies showed association of cerebral modifications such as enlargement of the Virchow spaces, lesions of the white matter with demyelinating appearance, and inflammatory sinus reactions. Cortical atrophy and hemosiderotic spots were present in a statistically significant proportion in the patient group with an age range of 29-61 years. MRI is indicated as a useful technique in the follow-up process of schizophrenia patients. However, whether the anomalies revealed in this disorder can be utilised as diagnostic biomarkers is still being debated.

Magnetic resonance imaging in schizophrenia: Luxury or necessity? (Review)

Schizophrenia, one of the most common psychiatric disorders, with a worldwide annual incidence rate of approximately 0.3-0.7%, known to affect the population below 25 years of age, is persistent throughout lifetime and includes people from all layers of society. With recent technological progress that allows better imaging techniques, such as the ones provided by computed tomography and particularly magnetic resonance imaging (MRI), research on schizophrenia imaging has grown considerably. The purpose of this review is to establish the importance of using imaging techniques in the early detection of brain abnormalities in patients diagnosed with schizophrenia. We reviewed all articles which reported on MRI imaging in schizophrenia. In order to do this, we used the PubMed database, using as search words ‘MRI’ and ‘schizophrenia’. MRI studies of first episode patients and chronic patients, suggest reduction of the whole brain volume. Enlargement of lateral ventricles was described as positive in 15 studies out of 19 and was similar to findings in chronic patients. Moreover, for the first episode patients, all data collected point to important changes in medial temporal lobe structures, diminished hippocampal volume, the whole frontal lobe, asymmetry in prefrontal cortex, diminished volume in cingulate, corpus callosum, and cavum septum pellucidum reported abnormalities. MRI is recommended as an important tool in the follow-up process of patients with schizophrenia. Yet, it is still under debate whether the abnormalities described in this condition are able to be used as diagnostic biomarkers.

Cerebral investigation of healthy siblings of schizophrenics

Computed tomography (CT) studies have demonstrated that lateral ventricular size measured by ventricular brain ratio (VBR), as well as third ventricle width, is statistically enlarged in schizophrenics. Moreover, these cerebral abnormalities differ according to symptomatology evaluated with a positive and negative symptom scale. The aim of this study was to investigate, using CT scans, healthy siblings of schizophrenics, and relate the results to their ill siblings. Nineteen healthy siblings of 12 previously studied schizophrenics underwent CT scans, which were compared to those of their related schizophrenic sibling and to 17 unrelated control subjects. The results showed that in ten of 12 families, schizophrenics have larger ventricles (lateral and third ventricles) than their healthy siblings. Ventricular enlargement of healthy siblings was correlated with severity of negative symptoms of their ill sibling. Implications of a familial contribution for ventricular size and negative symptoms are discussed.

Neuroprogression across the Early Course of Psychosis

Psychotic disorders are severe, debilitating, and even fatal. The development of targeted and effective interventions for psychosis depends upon on clear understanding of the timing and nature of disease progression to target processes amenable to intervention. Strong evidence suggests early and ongoing neuroprogressive changes, but timing and inflection points remain unclear and likely differ across cognitive, clinical, and brain measures. Additionally, granular evidence across modalities is particularly sparse in the "bridging years" between first episode and established illness-years that may be especially critical for improving outcomes and during which interventions may be maximally effective. Our objective is the systematic, multimodal characterization of neuroprogression through the early course of illness in a cross-diagnostic sample of patients with psychosis. We aim to (1) interrogate neurocognition, structural brain measures, and network connectivity at multiple assessments over the first eight years of illness to map neuroprogressive trajectories, and (2) examine trajectories as predictors of clinical and functional outcomes. We will recruit 192 patients with psychosis and 36 healthy controls. Assessments will occur at baseline and 8- and 16-month follow ups using clinical, cognitive, and imaging measures. We will employ an accelerated longitudinal design (ALD), which permits ascertainment of data across a longer timeframe and at more frequent intervals than would be possible in a single cohort longitudinal study. Results from this study are expected to hasten identification of actionable treatment targets that are closely associated with clinical outcomes, and identify subgroups who share common neuroprogressive trajectories toward the development of individualized treatments.

Heritability of Neuropsychological Measures in Schizophrenia and Nonpsychiatric Populations: A Systematic Review and Meta-analysis

Schizophrenia is characterized by neuropsychological deficits across many cognitive domains. Cognitive phenotypes with high heritability and genetic overlap with schizophrenia liability can help elucidate the mechanisms leading from genes to psychopathology. We performed a meta-analysis of 170 published twin and family heritability studies of >800 000 nonpsychiatric and schizophrenia subjects to accurately estimate heritability across many neuropsychological tests and cognitive domains. The proportion of total variance of each phenotype due to additive genetic effects (A), shared environment (C), and unshared environment and error (E), was calculated by averaging A, C, and E estimates across studies and weighting by sample size. Heritability ranged across phenotypes, likely due to differences in genetic and environmental effects, with the highest heritability for General Cognitive Ability (32%-67%), Verbal Ability (43%-72%), Visuospatial Ability (20%-80%), and Attention/Processing Speed (28%-74%), while the lowest heritability was observed for Executive Function (20%-40%). These results confirm that many cognitive phenotypes are under strong genetic influences. Heritability estimates were comparable in nonpsychiatric and schizophrenia samples, suggesting that environmental factors and illness-related moderators (eg, medication) do not substantially decrease heritability in schizophrenia samples, and that genetic studies in schizophrenia samples are informative for elucidating the genetic basis of cognitive deficits. Substantial genetic overlap between cognitive phenotypes and schizophrenia liability (average rg = -.58) in twin studies supports partially shared genetic etiology. It will be important to conduct comparative studies in well-powered samples to determine whether the same or different genes and genetic variants influence cognition in schizophrenia patients and the general population.

Structural neuroimaging across early-stage psychosis: Aberrations in neurobiological trajectories and implications for the staging model

OBJECTIVE

This review critically examines the structural neuroimaging evidence in psychotic illness, with a focus on longitudinal imaging across the first-episode psychosis and ultra-high-risk of psychosis illness stages.

METHODS

A thorough search of the literature involving specifically longitudinal neuroimaging in early illness stages of psychosis was conducted. The evidence supporting abnormalities in brain morphology and altered neurodevelopmental trajectories is discussed in the context of a clinical staging model.

RESULTS

In general, grey matter (and, to a lesser extent, white matter) declines across multiple frontal, temporal (especially superior regions), insular and parietal regions during the first episode of psychosis, which has a steeper trajectory than that of age-matched healthy counterparts. Although the ultra-high-risk of psychosis literature is considerably mixed, evidence indicates that certain volumetric structural aberrations predate psychotic illness onset (e.g. prefrontal cortex thinning), while other abnormalities present in ultra-high-risk of psychosis populations are potentially non-psychosis-specific (e.g. hippocampal volume reductions).

CONCLUSION

We highlight the advantages of longitudinal designs, discuss the implications such studies have on clinical staging and provide directions for future research.

Progressive disability and prefrontal shrinkage in schizophrenia patients with poor outcome: A 3-year longitudinal study

INTRODUCTION

Schizophrenia is a severe disabling disorder with heterogeneous illness courses. In this longitudinal study we characterized schizophrenia patients with poor and good outcome (POS, GOS), using functional and imaging metrics. Patients were defined in accordance to Keefe's criteria (i.e. Kraepelinian and non-Kraepelinian patients).

METHODS

35 POS patients, 35 GOS patients and 76 healthy controls (H) underwent clinical, functioning and magnetic resonance imaging (MRI) assessments twice over three years of follow-up. Information on psychopathology, treatment, disability (using the World Health Organization Disability Assessment Scale II, WHO-DAS-2) and prefrontal morphology was collected. Dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC) were manually traced.

RESULTS

At baseline, subjects with POS showed significantly decreased right dorsolateral prefrontal cortex (DLPFC) white matter volumes (WM) compared to healthy controls and GOS patients (POS VS HC, p<0.001; POS vs GOS, p=0.03), with shrinkage of left DLPFC WM volumes at follow up (t=2.66, p=0.01). Also, POS patients had higher disability in respect to GOS subjects both at baseline and after 3years at the WHO-DAS-2 (p<0.05).

DISCUSSION

Our study supports the hypothesis that POS is characterized by progressive deficits in brain structure and in "real-life" functioning. These are particularly notable in the DLPFC.

Neuropeptide Y, social function and long-term outcome in schizophrenia

There is a lack of biomarkers in schizophrenia and the mechanisms underlying the observed deficits in social functioning are poorly understood. This cohort study aimed to explore whether neurotransmitter neuropeptide Y (NPY) in cerebrospinal fluid (CSF) from patients with schizophrenia is correlated to social function and clinical variables. A further aim was to determine whether baseline levels of NPY were associated with subsequent 3-year outcome. Fifty-six consecutively admitted patients with schizophrenia were included and underwent lumbar puncture and symptom ratings before antipsychotic treatment. NPY levels in CSF were determined by radioimmunoassay. Social function (Social Competence and Social Interest) was assessed by Nurses' Observation Scale for Inpatient Evaluation while psychiatric symptoms were rated using the Comprehensive Psychopathological Rating Scale. Three-year outcome was assessed with the Strauss-Carpenter Outcome Scale. Cross-sectional analysis showed a correlation between level of NPY and Social Competence at index admission (r(s)=0.37, p<0.05). The longitudinal analysis (i.e., at the 3-year follow-up) indicated that, for each standard deviation increase in baseline NPY, there was an increased risk of being unemployed (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.07-3.82), having moderate or severe symptoms (OR 3.09, CI 1.30-7.32) or being hospitalized at least 6 months the previous year (OR 3.24, CI 1.09-9.64). However, NPY was not correlated to Social Interest or clinical variables at index admission. In conclusion, NPY levels in CSF are correlated to Social Competence and seem to predict some aspects of longitudinal outcome in schizophrenia.

Localized differences in caudate and hippocampal shape are associated with schizophrenia but not antipsychotic type

Caudate and hippocampal volume differences in patients with schizophrenia are associated with disease and antipsychotic treatment, but local shape alterations have not been thoroughly examined. Schizophrenia patients randomly assigned to haloperidol and olanzapine treatment underwent magnetic resonance imaging (MRI) at 3, 6, and 12 months. The caudate and hippocampus were represented as medial representations (M-reps); mesh structures derived from automatic segmentations of high resolution MRIs. Two quantitative shape measures were examined: local width and local deformation. A novel nonparametric statistical method, adjusted exponentially tilted (ET) likelihood, was used to compare the shape measures across the three groups while controlling for covariates. Longitudinal shape change was not observed in the hippocampus or caudate when the treatment groups and controls were examined in a global analysis, nor when the three groups were examined individually. Both baseline and repeated measures analysis showed differences in local caudate and hippocampal size between patients and controls, while no consistent differences were shown between treatment groups. Regionally specific differences in local hippocampal and caudate shape are present in schizophrenic patients. Treatment-related related longitudinal shape change was not observed within the studied timeframe. Our results provide additional evidence for disrupted cortico-basal ganglia-thalamo-cortical circuits in schizophrenia.

CLINICAL TRIAL INFORMATION

This longitudinal study was conducted from March 1, 1997 to July 31, 2001 at 14 academic medical centers (11 in the United States, one in Canada, one in the Netherlands, and one in England). This study was performed prior to the establishment of centralized registries of federally and privately supported clinical trials.

Progressive loss of cortical gray matter in schizophrenia: a meta-analysis and meta-regression of longitudinal MRI studies

Cortical gray matter deficits have been found in patients with schizophrenia, with evidence of progression over time. The aim of this study was to determine the extent of progressive cortical gray matter volume changes over time in schizophrenia, their site and time of occurrence, and the role of potential moderators of brain changes. English language articles published between 1 January 1983 and 31 March 2012 in the MEDLINE and EMBASE databases were searched. Longitudinal magnetic resonance imaging studies comparing changes in cortical gray matter volume over time between patients with schizophrenia and healthy controls were included. Hedges g was calculated for each study. Analyses were performed using fixed- and random-effects models. A subgroup analysis was run to explore the pattern of brain changes in patients with first-episode schizophrenia. A meta-regression statistic was adopted to investigate the role of potential moderators of the effect sizes (ESs). A total of 19 studies, analyzing 813 patients with schizophrenia and 718 healthy controls, were included. Over time, patients with schizophrenia showed a significantly higher volume loss of total cortical gray matter, left superior temporal gyrus (STG), left anterior STG, left Heschl gyrus, left planum temporale and posterior STG bilaterally. Meta-analysis of first-episode schizophrenic patients showed a more significant pattern of progressive loss of whole cerebral gray matter volume involving the frontal, temporal and parietal lobes, and left Heschl gyrus compared with healthy controls. Clinical, pharmacologic and neuroradiological variables were found to be significant moderators of brain volume changes in patients with schizophrenia. The meta-analysis demonstrates that progressive cortical gray matter changes in schizophrenia occur with regional and temporal specificity. The underlying pathological process appears to be especially active in the first stages of the disease, affects the left hemisphere and the superior temporal structures more and is at least partly moderated by the type of pharmacological treatment received.

Gray matter volume decreases in elderly patients with schizophrenia: a voxel-based morphometry study

BACKGROUND

Aged patients (>50 years old) with residual schizophrenic symptoms differ from young patients. They represent a subpopulation with a more unfavorable Kraepelinian course and have an increased risk (up to 30%) for dementia of unknown origin. However, our current understanding of age-related brain changes in schizophrenia is derived from studies that included less than 17% of patients who were older than 50 years of age. This study investigated the anatomical distribution of gray matter (GM) brain deficits in aged patients with ongoing schizophrenia.

METHODS

Voxel-based morphometry was applied to 3D-T1 magnetic resonance images obtained from 27 aged patients with schizophrenia (mean age of 60 years) and 40 age-matched normal controls.

RESULTS

Older patients with schizophrenia showed a bilateral reduction of GM volume in the thalamus, the prefrontal cortex, and in a large posterior region centered on the occipito-temporo-parietal junction. Only the latter region showed accelerated GM volume loss with increasing age. None of these results could be accounted for by institutionalization, antipsychotic medication, or cognitive scores.

CONCLUSIONS

This study replicated most common findings in patients with schizophrenia with regard to thalamic and frontal GM deficits. However, it uncovered an unexpected large region of GM atrophy in the posterior tertiary cortices. The latter observation may be specific to this aged and chronically symptomatic subpopulation, as atrophy in this region is rarely reported in younger patients and is accelerated with age.

Role of CpG context and content in evolutionary signatures of brain DNA methylation

DNA methylation is essential in brain function and behavior; therefore, understanding the role of DNA methylation in brain-based disorders begins with the study of DNA methylation profiles in normal brain. Determining the patterns and scale of methylation conservation and alteration in an evolutionary context enables the design of focused but effective methylation studies of disease states. We applied an enzymatic-based approach, Methylation Mapping Analysis by Paired-end Sequencing (Methyl-MAPS), which utilizes second-generation sequencing technology to provide an unbiased representation of genome-wide DNA methylation profiles of human and mouse brains. In this large-scale study, we assayed CpG methylation in cerebral cortex of neurologically and psychiatrically normal human postmortem specimens, as well as mouse forebrain specimens. Cross-species human-mouse DNA methylation conservation analysis shows that DNA methylation is not correlated with sequence conservation. Instead, greater DNA methylation conservation is correlated with increasing CpG density. In addition to CpG density, these data show that genomic context is a critical factor in DNA methylation conservation and alteration signatures throughout mammalian brain evolution. We identify key genomic features that can be targeted for identification of epigenetic loci that may be developmentally and evolutionarily conserved and wherein aberrations in DNA methylation patterns can confer risk for disease.

Human brain changes across the life span: a review of 56 longitudinal magnetic resonance imaging studies

There is consistent evidence that brain volume changes in early and late life. Most longitudinal studies usually only span a few years and include a limited number of participants. In this review, we integrate findings from 56 longitudinal magnetic resonance imaging (MRI) studies on whole brain volume change in healthy individuals. The individual longitudinal MRI studies describe only the development in a limited age range. In total, 2,211 participants were included. Age at first measurement varied between 4 and 88 years of age. The studies included in this review were performed using a large range of methods (e.g., different scanner protocols and different acquisition parameters). We applied a weighted regression analysis to estimate the age dependency of the rate of relative annual brain volume change across studies. The results indicate that whole brain volume changes throughout the life span. A wave of growth occurs during childhood/adolescence, where around 9 years of age a 1% annual brain growth is found which levels off until at age 13 a gradual volume decrease sets in. During young adulthood, between ∼18 and 35 years of age, possibly another wave of growth occurs or at least a period of no brain tissue loss. After age 35 years, a steady volume loss is found of 0.2% per year, which accelerates gradually to an annual brain volume loss of 0.5% at age 60. The brains of people over 60 years of age show a steady volume loss of more than 0.5%. Understanding the mechanisms underlying these plastic brain changes may contribute to distinguishing progressive brain changes in psychiatric and neurological diseases from healthy aging processes. Hum Brain Mapp, 2012. © 2011 Wiley Periodicals, Inc.

Longitudinal imaging studies in schizophrenia: the relationship between brain morphology and outcome measures

Imaging studies have tried to identify morphological outcome measures of schizophrenia in the last two decades. In particular, longitudinal studies have reported a correlation between larger ventricles, decreased prefrontal volumes and worse outcome. This would potentially allow to isolate subtypes of schizophrenia patients with a worse prognosis and more evident biological impairments, ultimately helping in designing specific rehabilitation interventions.

The lifetime trajectory of schizophrenia and the concept of neurodevelopment

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

Morphometrical and morphological analysis of lateral ventricles in schizophrenia patients versus healthy controls

The goal of this report was to highlight lateral ventricle morphology and volume differences between schizophrenia patients and matched controls. Subjects identified as suitable for analysis comprised 15 schizophrenia patients and 15 healthy subjects. The method applied is three-dimensional (3D) volume rendering starting from structural magnetic resonance imaging (MRI) studies of selected ventricular regions. Differences between groups relative to the global ventricular system and its subdivisions were found. Total lateral ventricle volume, right ventricle volume and left ventricle volume were all higher in schizophrenia patients than in controls; unilateral differences between the two groups were also outlined (right ventricle volume>left ventricle volume in schizophrenia patients vs. healthy subjects). Furthermore, occipital and frontal horn enlargement was found in schizophrenia patients compared with normal controls, but the difference in the temporal horn was not statistically significant. A substantial difference was noted in lateral ventricle morphology between the two groups. Our findings were consistent with the literature and may shed light on some of the discrepancies in previous reports on differences in lateral ventricle volume enlargement.

Progressive lateral ventricular enlargement in schizophrenia: a meta-analysis of longitudinal MRI studies

BACKGROUND

Lateral ventricular enlargement is one of the most consistent findings in patients with schizophrenia; however whether progressive ventricular dilation occurs during the course of the illness has been controversial. To clarify this we conducted a meta-analysis of longitudinal studies measuring the lateral ventricles in patients with schizophrenia and a control group.

METHODS

The MEDLINE database was searched from 1980 to 2009 for longitudinal MRI studies of patients with schizophrenia. We identified 13 studies that measured the lateral ventricles in both patients and controls and these were included in a random effects meta-analysis. The effect of various clinical variables was investigated in a meta-regression analysis.

RESULTS

Patients showed evidence of progressive ventricular enlargement after illness onset greater than that seen in controls (effect size=0.45, 95%CI 0.19-0.71, p=0.0006). A sub-analysis of chronic patients with schizophrenia with a mean duration of illness of 7.6 years at baseline scan also showed progressive ventricular enlargement (p=0.002). The results were robust to inclusion criteria, and no significant effect of age of onset, duration of illness, or age at baseline scan, was found in the meta-regression analysis.

CONCLUSIONS

The meta-analysis shows progressive changes in ventricular volume a number of years after illness onset and challenges an exclusively neurodevelopmental model of schizophrenia.

Brain surface contraction mapped in first-episode schizophrenia: a longitudinal magnetic resonance imaging study

Schizophrenia is associated with structural brain abnormalities, but the timing of onset and course of these changes remains unclear. Longitudinal magnetic resonance imaging (MRI) studies have demonstrated progressive brain volume decreases in patients around and after the onset of illness, although considerable discrepancies exist regarding which brain regions are affected. The anatomical pattern of these progressive changes in schizophrenia is largely unknown. In this study, MRI scans were acquired repeatedly from 16 schizophrenia patients approximately 2 years apart following their first episode of illness, and also from 14 age-matched healthy subjects. Cortical Pattern Matching, in combination with Structural Image Evaluation, using Normalisation, of Atrophy, was applied to compare the rates of cortical surface contraction between patients and controls. Surface contraction in the dorsal surfaces of the frontal lobe was significantly greater in patients with first-episode schizophrenia (FESZ) compared with healthy controls. Overall, brain surface contraction in patients and healthy controls showed similar anatomical patterns, with that of the former group exaggerated in magnitude across the entire brain surface. That the pattern of structural change in the early course of schizophrenia corresponds so closely to that associated with normal development is consistent with the hypothesis that a schizophrenia-related factor interacts with normal adolescent brain developmental processes in the pathophysiology of schizophrenia. The exaggerated progressive changes seen in patients with schizophrenia may reflect an increased rate of synaptic pruning, resulting in excessive loss of neuronal connectivity, as predicted by the late neurodevelopmental hypothesis of the illness.

Workshop on defining the significance of progressive brain change in schizophrenia: December 12, 2008 American College of Neuropsychopharmacology (ACNP) all-day satellite, Scottsdale, Arizona. The rapporteurs' report

In 1990 a satellite session of the American College of Neuropsychopharmacology (ACNP) Annual Meeting was held that focused on the question of whether progressive changes in brain structure occur in schizophrenia and this session raised considerable controversy. Eighteen years later, on December 12, 2008, after much data have since accumulated on this topic, a group of approximately 45 researchers gathered after the annual ACNP meeting to participate in a similar workshop on several unresolved questions still remaining: (1) How strong and consistent is the evidence? (2) Is there anatomic specificity to changes and is it disease specific or subject specific? (3) What is the time course? (4) What is the underlying pathophysiology (i.e. is it central to the disease process or is it due to neuroleptic treatment or other epiphenomena? (5) What is its clinical significance? and (6) Are there treatment implications? The day was chaired by Lynn E. DeLisi and co-chaired by Stephen J. Wood. Christos Pantelis and Jeffrey A. Lieberman extensively helped with its planning. The ACNP assisted in its organization as an official satellite of its annual meeting and several pharmaceutical companies provided support with unrestricted educational grants. The following is a summary of the sessions as recounted by rapporteurs whose job was to record as closely as possible the outcome of discussions on the above outlined questions.

Progression of brain volume changes in adolescent-onset psychosis

Little is known about the changes that take place in the adolescent brain over the first few years following the onset of psychosis. The present longitudinal study builds on an earlier cross-sectional report demonstrating brain abnormalities in adolescent-onset psychosis patients with a recent-onset first episode of psychosis. Magnetic resonance imaging studies were obtained at baseline and 2 years later from 21 adolescents with psychosis and 34 healthy controls matched for age, gender, and years of education. Whole-brain volumes and gray matter (GM) and cerebrospinal fluid (CSF) volumes of the frontal, parietal, temporal, and occipital lobes were measured at baseline and at 2-year follow-up. In the frontal lobe, the rate of GM volume loss was significantly higher in male patients (2.9% and 2.0%, respectively, for left and right) than in controls (1.2% and 0.7%, respectively, for left and right). In the left frontal lobe, male patients showed a significantly higher rate of CSF volume increase than controls (8.6% vs 6.4%). These differences in rates of volume change were observed in male and female patients, although only males showed significant time x diagnosis interactions. This negative finding in females should be interpreted with caution as the study was underpowered to detect change in women due to limited sample size. An exploratory analysis revealed that schizophrenia and nonschizophrenia psychotic disorders showed similar volume change patterns relative to controls. Change in clinical status was not correlated with longitudinal brain changes. Our results support progression of frontal lobe changes in males with adolescent-onset psychosis.

Association between financial strain, social network and five-year recovery from first episode psychosis

Despite much effort to positively affect long-term outcome in psychosis and schizophrenia many patients are still facing a poor outcome with persistent psychotic symptoms and decline in social functioning. The aim of this study was to examine the relationship between financial strain and social network and five-year outcome of first episode psychosis (FEP). FEP patients were divided into recovered (n = 52) and non-recovered (n = 19). Each person was matched according to age and gender with four persons (n = 284) from a longitudinal population-based study. All persons had answered an extensive questionnaire including social network, quantitative and qualitative, financial strain and mental health. Linear regression analysis showed that both financial strain and social network were associated, and had a unique contribution, to outcome. The results indicate that FEP patients might benefit from interventions that reduce financial strain thus facilitating daily life and cultural and social activities.

Female specific anterior cingulate abnormality and its association with empathic disability in schizophrenia

Evidence suggests that impairments of empathy are present in schizophrenia and that such deficits lead to social dysfunction. However, the relationship between brain morphological abnormalities of the disorder and empathic disabilities has not been fully investigated. As the anterior cingulate cortex (ACC) is one of the critical structures for empathy processing, the pathology of this structure might be a major source of social dysfunction, including interpersonal miscommunication in schizophrenia. In addition, as recent studies suggest that different facets of empathic ability depend on different subdivisions of the ACC, pathology of each subdivision would affect the empathic disability of schizophrenia differentially. Structural MRI data were acquired at 3.0 T from 24 schizophrenic patients and 20 healthy participants, and the volumes of ventral and dorsal ACC were measured and compared between the groups. Subjects' empathic abilities were evaluated using a multidimensional questionnaire, the Interpersonal Reactivity Index (IRI). The relationships of structural abnormalities with empathic disabilities were investigated, by correlating ACC subdivisional volumes with each IRI subscale score. Female schizophrenic patients exhibited volume reductions in the ventral ACC bilaterally and in the left dorsal ACC compared with healthy subjects. Schizophrenic patients performed poorly on fantasy and personal distress subscales of the IRI. Furthermore, volumes of the left dorsal ACC were inversely correlated with personal distress subscale scores within female patients with schizophrenia. These results suggest that pathology of specific ACC subdivisions would have an impact on specific empathic disabilities in schizophrenia, with potential gender specificity.

Remission status and cortical thickness in childhood-onset schizophrenia

OBJECTIVE

Few studies have examined prediction of schizophrenia outcome in relation to brain magnetic resonance imaging measures. In this study, remission status at the time of discharge was examined in relation to admission cortical thickness for childhood-onset schizophrenia probands. We hypothesized that total, frontal, temporal, and parietal gray matter thickness would be greater in patients who subsequently remit.

METHOD

The relation between admission cortical brain thickness on magnetic resonance imaging and remission status at the time of discharge an average of 3 months later was examined for 56 individuals (32 males) ages 6 to 19 diagnosed with childhood-onset schizophrenia. Cortical thickness was measured across the cerebral hemispheres at admission. Discharge remission criteria were adapted from the 2005 Remission in Schizophrenia Working Group criteria.

RESULTS

Patients remitted at discharge (n = 16 [29%]) had thicker regional cortex in left orbitofrontal, left superior, and middle temporal gyri and bilateral postcentral and angular gyri (p < or = .008).

CONCLUSIONS

Our results provide neuroanatomic correlates of clinical remission in schizophrenia and evidence that response to treatment may be mediated by these cortical brain regions.

The concept of progressive brain change in schizophrenia: implications for understanding schizophrenia

Kraepelin originally defined dementia praecox as a progressive brain disease, although this concept has received various degrees of acceptance and rejection over the years since his famous published textbooks appeared. This article places an historical perspective on the current renewal of Kraepelin's concept in brain imaging literature that supports progressive brain change in schizophrenia from its earliest stages through its chronic course. It is concluded that a great deal of future research is needed focusing on the longitudinal course of change, the extent to the regions of change within each individual and the underlying mechanism and implications of brain change through functional and neurochemical imaging, combined with structural studies in the same individuals.

Progressive brain volume loss in schizophrenia over the course of the illness: evidence of maturational abnormalities in early adulthood

BACKGROUND

Considering the magnitude of the reported changes in brain volume over time in first-episode patients it is unlikely that these changes are constant over the life-span of the schizophrenic illness. Thus, one would expect the progression in brain volume change in schizophrenia to follow a more complex trajectory over time.

METHODS

Two magnetic resonance imaging brain scans were obtained over a 5-year interval of 96 schizophrenia patients and 113 healthy subjects between ages 16 to 56.

RESULTS

The trajectory of brain volume change differed between patients with schizophrenia and healthy individuals. Before the age of 45 years cerebral and gray matter loss and lateral ventricle increase were excessive in patients relative to controls, representing approximately the first 20 years of illness. Patients showed an excessive third ventricle volume increase over time. In addition, poor outcome patients showed more brain tissue loss during the follow-up interval than good outcome patients.

CONCLUSIONS

Cerebral (gray) matter volume loss in the patients was mainly characterized by the absence of the normal curved trajectory of volume change with age that was present in healthy subjects. Later in life, the degree of volume change in patients is similar to that observed with normal aging. Independently of age, larger brain volume changes appear clinically relevant.

Absence of regional brain volume change in schizophrenia associated with short-term atypical antipsychotic treatment

The first aim of this pilot study was to determine if longitudinal change in caudate volume could be detected in chronic schizophrenic patients after 12 weeks of atypical antipsychotic treatment. A sub-aim of the first aim was to determine if similar results could be obtained from an operator-assisted segmentation tool for volumetric imaging (ITK-SNAP) and voxel-based morphometry (VBM) methods in the caudate. The second aim was to determine if frontal and temporal lobe grey matter, white matter, ventricular and sulcal cerebrospinal fluid volume change could be detected after 12 weeks of atypical antipsychotic treatment with VBM. Ten chronic schizophrenic inpatients, with illness duration averaging 10.6 years, underwent two MRI scans. The first scan was obtained after a mean of 39.4 days of antipsychotic withdrawal. The second MRI was obtained following twelve weeks of atypical antipsychotic treatment. Caudate volume change was first measured with ITK-SNAP. Then the location of grey matter volume change in the caudate was identified with VBM. Finally, the location of frontal and temporal lobe grey matter, white matter, ventricular and sulcal cerebrospinal fluid volume changes were identified with VBM. No longitudinal change in caudate volume or grey matter volume was observed after brief periods of atypical antipsychotic treatment. ITK-SNAP and VBM methods showed very similar results in the caudate. No statistically significant change was identified in the volume of frontal or temporal lobe grey matter, white matter, and lateral, third, or fourth ventricular cerebrospinal fluid. Although the results do not directly show that brief periods of atypical antipsychotic treatment are associated with basal ganglia and cortical volume change, there is much evidence to suggest that such an association exists.

Very poor outcome schizophrenia: clinical and neuroimaging aspects

In spite of significant advances in treatment of patients with schizophrenia and continued efforts towards their deinstitutionalization, a considerable group of patients remain chronically hospitalized or otherwise dependent on others for basic necessities of life. It has been proposed that these patients belong to a distinct etiopathological subgroup, termed Kraepelinian, whose course of illness may be progressive and resistant to treatment. Indeed, longitudinal studies appear to show that elderly Kraepelinian patients follow a course of rapid cognitive and functional deterioration, commensurate with a dementing process, and that their poor functional status is closely correlated with the cognitive deterioration. Recent neuroimaging studies described a pattern of posteriorization of grey and white matter deficits with poor outcome in schizophrenia, and produced a constellation of findings implicating primary processing of visual and auditory information as central to the impaired functional status in this patient group. These studies are summarized in detail in this review and future directions for neuroimaging assessment of very poor outcome patients with schizophrenia are suggested.

A comprehensive assessment of gray and white matter volumes and their relationship to outcome and severity in schizophrenia

Preliminary data suggest an association of posterior cortical gray matter reduction with poor outcome in schizophrenia. We made a systematic MRI assessment of regional gray and white matter volumes, parcellated into 40 Brodmann's areas, in 104 patients with schizophrenia (51 with good outcomes, 53 with poor outcomes) and 41 normal comparison subjects, and investigated correlations of regional morphometry with outcome and severity of the illness. Schizophrenia patients displayed differential reductions in frontal and to a lesser degree temporal gray matter volumes in both hemispheres, most pronounced in the frontal pole and lateral temporal cortex. White matter volumes in schizophrenia patients were bilaterally increased, primarily in the frontal, parietal, and isolated temporal regions, with volume reductions confined to anterior cingulate gyrus. In patients with schizophrenia as a group, higher illness severity was associated with reduced temporal gray matter volumes and expanded frontal white matter volumes in both hemispheres. In comparison to good-outcome group, patients with poor outcomes had lower temporal, occipital, and to a lesser degree parietal gray matter volumes in both hemispheres and temporal, parietal, occipital, and posterior cingulate white matter volumes in the right hemisphere. While gray matter deficits in the granular cortex were observed in all schizophrenia patients, agranular cortical deficits in the left hemisphere were peculiar to patients with poor outcomes. These results provide support for frontotemporal gray matter reduction and frontoparietal white matter expansion in schizophrenia. Poor outcome is associated with more posterior distribution (posteriorization) of both gray and white matter changes, and with preferential impairment in the unimodal visual and paralimbic cortical regions.

Neuropsychological functioning in MRI-derived subgroups of schizophrenia

This study examined neuropsychological functioning in two subgroups of patients with familial schizophrenia. Those who showed evidence of progressive ventricular enlargement observed across serial MRI scans (n=6) were compared with subjects whose ventricular volume remained static (n=10) over an average of 28 months. No differences were found in terms of age, education, ethnicity, level of psychotic symptomatology, DSM-IV subtype, age of onset, or duration of illness. Neurocognitively, the static ventricle group was impaired across more cognitive domains and had a larger percentage of subjects falling into the impaired range on a majority of measures, with the greatest differences on measures of attention (p<0.02) and nonverbal memory (p<0.07). These results suggest that clinically meaningful differences between these two MRI-derived subgroups of patients with schizophrenia may exist, and further underscore the heterogeneity of the illness.

Regional change in brain morphometry in schizophrenia associated with antipsychotic treatment

The purpose of this pilot study was to: (1) determine if regional brain volume change occurs in schizophrenia patients during very short periods of withdrawal from, or stable treatment with, antipsychotics, and; (2) compare results of region-of-interest (ROI) to voxel-based morphometry (VBM) methods. In two small groups of schizophrenic inpatients, magnetic resonance imaging was performed before and after antipsychotic withdrawal, and at two time points during stable chronic antipsychotic treatment. Regional brain volumes were measured using ROI methods. Grey matter volume was measured with VBM. The medication withdrawal group showed no effect of treatment state or antipsychotic type on regional brain volumes with ROI analysis, but effects of both treatment state and antipsychotic type on grey matter volume were observed with VBM in right middle frontal, right medial frontal, right and left superior frontal, right cingulate, and right superior temporal gyrii as well as in the right and left hippocampal gyrii. The chronic stable treatment group showed an effect of time on right caudate, left hippocampal, and total cerebrospinal fluid volumes with ROI analysis, while effects of both time and antipsychotic type were observed with VBM on grey matter volume in the left superior temporal lobe. No findings survived correction for multiple comparisons. A positive correlation between regional volume change and emerging psychopathology was demonstrated using ROI methods in the medication withdrawal group. Treatment state and emergent symptoms in schizophrenia patients were associated with regional volume change over very short time periods. Longitudinal regional brain volume change in schizophrenia patients is likely physiologic and therefore potentially reversible.

A volumetric MRI and magnetization transfer imaging follow-up study of patients with first-episode schizophrenia

Conventional MRI studies have not provided definitive evidence of progressive loss of brain volume in the early stages of schizophrenia, although more subtle changes may have gone undetected. We have looked for such subtle changes using volumetric MRI and magnetization transfer imaging (MTI), an advanced MRI technique sensitive to subtle neuropathological abnormalities. Magnetization transfer images and high-resolution volumetric T1-weighted images were acquired from 16 patients with first-episode schizophrenia at the start of the study and 3.7 years later. A group of 12 healthy controls were also scanned on two occasions. Images were processed using a voxel-based approach that allows whole-brain analysis. There was a group difference with a significant volume loss in the patients' white matter adjacent to the lateral ventricles in the right and left temporal lobes, in medial temporal gyrus, and in the white matter in and around the right middle frontal gyrus. No cortical differences were detected between the groups using MTI or volumetric MRI. The absence of any time-by-group interaction suggests that these abnormalities do not progress in the early stages of the disease. The results of the study need to be interpreted in the light of the small sample size and of the limitations of current image analysis methods.

Stress, the hippocampus and the hypothalamic-pituitary-adrenal axis: implications for the development of psychotic disorders

OBJECTIVE

The experience of stress is commonly implicated in models of the onset of psychotic disorders. However, prospective studies investigating associations between biological markers of stress and the emergence of psychotic disorders are limited and inconclusive. One biological system proposed as the link between the psychological experience of stress and the development of psychosis is the Hypothalamic-Pituitary-Adrenal (HPA) axis. This paper summarizes and discusses evidence supporting a role for HPA-axis dysfunction in the early phase of schizophrenia and related disorders.

METHOD

A selective review of psychiatric and psychological research on stress, coping, HPA-axis, the hippocampus and psychotic disorders was performed, with a particular focus on the relationship between HPA-axis dysfunction and the onset of psychotic disorders.

RESULTS

Individual strands of past research have suggested that the HPA-axis is dysfunctional in at least some individuals with established psychotic disorders; that the hippocampus is an area of the brain that appears to be implicated in the onset and maintenance of psychotic disorders; and that an increase in the experience of stress precedes the onset of a psychotic episode in some individuals. Models of the onset and maintenance of psychotic disorders that link these individual strands of research and strategies for examining these models are proposed in this paper.

CONCLUSIONS

The current literature provides some evidence that the onset of psychotic disorders may be associated with a higher rate of stress and changes to the hippocampus. It is suggested that future research should investigate whether a relationship exists between psychological stress, HPA-axis functioning and the hippocampus in the onset of these disorders. Longitudinal assessment of these factors in young people at 'ultra' high risk of psychosis and first-episode psychosis cohorts may enhance understanding of the possible interaction between them in the early phases of illness.

Understanding structural brain changes in schizophrenia

Schizophrenia is a chronic progressive disorder that has at its origin structural brain changes in both white and gray matter. It is likely that these changes begin prior to the onset of clinical symptoms in cortical regions, particularly those concerned with language processing. Later, they can be detected by progressive ventricular enlargement. Current magnetic resonance imaging (MRI) technology can provide a valuable tool for detecting early changes in cortical atrophy and anomalous language processing, which may be predictive of who will develop schizophrenia.

Brain volume in first-episode schizophrenia: systematic review and meta-analysis of magnetic resonance imaging studies

BACKGROUND

Studies of people with schizophrenia assessed using magnetic resonance imaging (MRI) usually include patients with first-episode and chronic disease, yet brain abnormalities may be limited to those with chronic schizophrenia.

AIMS

To determine whether patients with a first episode of schizophrenia have characteristic brain abnormalities.

METHOD

Systematic review and meta-analysis of 66 papers comparing brain volume in patients with a first psychotic episode with volume in healthy controls.

RESULTS

A total of 52 cross-sectional studies included 1424 patients with a first psychotic episode; 16 longitudinal studies included 465 such patients. Meta-analysis suggests that whole brain and hippocampal volume are reduced (both P<0.0001) and that ventricular volume is increased (P<0.0001) in these patients relative to healthy controls.

CONCLUSIONS

Average volumetric changes are close to the limit of detection by MRI methods. It remains to be determined whether schizophrenia is a neurodegenerative process that begins at about the time of symptom onset, or whether it is better characterised as a neurodevelopmental process that produces abnormal brain volumes at an early age.

Progressive grey matter atrophy over the first 2-3 years of illness in first-episode schizophrenia: a tensor-based morphometry study

Little is known about the structural brain changes that occur over the first few years of schizophrenia, or how these changes differ from those associated with healthy brain development in adolescence and early adulthood. In this study, we aimed to identify regional differences in grey matter (GM) volume between patients with first-episode schizophrenia (FES) and matched healthy controls, both at the time of the patients' first psychotic episode (baseline condition) and 2-3 years subsequently (follow-up condition). Forty-one patients with FES and 47 matched healthy controls underwent a T1-weighted structural MRI scan. Of these participants, 25 FES patients and 26 controls returned 2-3 years later for a follow-up scan. Voxel-based morphometry in SPM2 was used to identify the regions of GM difference between the groups in the baseline condition, while tensor-based morphometry was used to identify the longitudinal change within subject over the follow-up interval. The FES patients exhibited widespread GM reductions in the frontal, parietal, and temporal cortices and cerebellum in the baseline condition, as well as more circumscribed regions of GM increase, particularly in the occipital lobe. Furthermore, the FES subjects were observed to lose considerably more GM over the follow-up interval than the controls, especially in the parietal and temporal cortices. We argue that the progressive GM atrophy we have found to be associated with the onset of schizophrenia arises from a dysfunction in the dramatic period of healthy brain development typically associated with adolescence.

Brain morphology in first-episode schizophrenia: a meta-analysis of quantitative magnetic resonance imaging studies

BACKGROUND

A number of meta-analytic reviews of structural brain imaging studies have shown that multiple subtle brain abnormalities are consistently found in schizophrenia. However, quantitative reviews till now published have included mainly studies performed on chronic schizophrenic patients but have failed to provide clear information on specific, possibly different, findings in first-episode schizophrenia.

METHODS

We performed a systematic search for MRI studies that reported quantitative measurements of volumes of brain regions in first-episode schizophrenic patients and in healthy controls. Twelve meta-analyses were performed for 6 cerebral regions.

RESULTS

Twenty-one studies were identified as suitable for analysis. Significant overall effect sizes were demonstrated for lateral and third ventricular volume increase, and for volume reduction of whole brain and hippocampus, but not for temporal lobe, amygdala and total intracranial volumes.

CONCLUSIONS

The available literature data strongly indicate that some brain abnormalities are already present in first-episode schizophrenic patients. However, unlike the results of published meta-analyses conducted primarily on samples of chronic schizophrenic patients, the present study did not confirm a significant reduction of temporal lobe or amygdala volumes in first-episode schizophrenia. These findings support the hypothesis of different patterns of involvement of various cerebral areas over the time course of schizophrenia.

Longitudinal volumetric MRI study in first- and multiple-episode male schizophrenia patients

In this longitudinal study we compared brain volume changes in first- and multiple-episode patients with schizophrenia to normal aging changes observed in healthy control subjects scanned at comparable times. Two to four years after an initial examination including MRI volumetry, we followed up 21 first episode patients, 17 patients after multiple episodes of schizophrenia, and 20 healthy controls. Volumetric measurements of left and right hemispheres, total brain volume, lateral ventricles, hippocampus and amygdala as well as a clinical evaluation were performed. Patients with schizophrenia showed significant ventricular enlargement and volume reduction of the hippocampus-amygdala complex compared with healthy control subjects both at baseline and follow-up. While there were no differences between patients and controls with respect to mean annual volume changes in the measured regions, patients with schizophrenia showed higher between-subject variability in ventricular volume change. These data are consistent with cross-sectional studies demonstrating ventricular enlargement and hippocampal volume deficits in schizophrenia. However, we were not able to demonstrate a difference in the rate of volume changes over time that distinguished patients with schizophrenia from healthy controls for any of the brain structures measured. Drawbacks of the study are that the follow-up was done after a relatively short interval and that there was a difference in time to follow-up and age between patients and controls. Our results do not support the hypothesis that schizophrenia leads to progressive volume reduction in these areas, although there may be a subset of patients with morphologically visible disease progression.

Failure to find progressive temporal lobe volume decreases 10 years subsequent to a first episode of schizophrenia

The present study used magnetic resonance imaging to examine the volumes of the temporal lobe and the superior temporal gyrus in a 10-year follow-up study of 27 patients with schizophrenia and 10 controls. No change over time was observed in these structures when patients were compared with controls. These results do not support the notion that progressive temporal lobe deterioration occurs in schizophrenia.

Characterization of brain plasticity in schizophrenia using template deformation

RATIONALE AND OBJECTIVE

Abnormal neurodevelopment may play a role in the pathophysiology of schizophrenia. We used deformation-based morphometry to examine voxel-wise age-related changes in patients with schizophrenia compared with healthy brains.

MATERIALS AND METHODS

We used a set of skull-stripped brains from an image database of cranial magnetic resonance images. We then deformed a template brain to the rest of the brains creating a set of deformation fields. Using the Jacobian values of these deformation fields, we calculated the voxel-wise t-score for comparison of controls with patients. We also calculated the voxel-wise Pearson correlation of Jacobian with age for both controls and patients.

RESULTS

By examining the volume renderings of these statistical fields, we found that healthy people undergo age-related expansion of the ventricles, the surrounding periventricular white matter, and a corresponding decline in the frontal lobes and cingulate gyrus. In contrast, patients show much less of this age-related expansion of the ventricles and less atrophy in the cerebral cortex. In addition, patients have larger ventricles and reduced volume in the frontal/parietal lobes.

CONCLUSION

These constellations of findings suggest that otherwise normal age-related ventricular enlargement and cortical loss occurs in schizophrenia patients, albeit at an earlier age.

Dynamic mapping of human cortical development during childhood through early adulthood

We report the dynamic anatomical sequence of human cortical gray matter development between the age of 4-21 years using quantitative four-dimensional maps and time-lapse sequences. Thirteen healthy children for whom anatomic brain MRI scans were obtained every 2 years, for 8-10 years, were studied. By using models of the cortical surface and sulcal landmarks and a statistical model for gray matter density, human cortical development could be visualized across the age range in a spatiotemporally detailed time-lapse sequence. The resulting time-lapse "movies" reveal that (i) higher-order association cortices mature only after lower-order somatosensory and visual cortices, the functions of which they integrate, are developed, and (ii) phylogenetically older brain areas mature earlier than newer ones. Direct comparison with normal cortical development may help understanding of some neurodevelopmental disorders such as childhood-onset schizophrenia or autism.

TNXB locus may be a candidate gene predisposing to schizophrenia

We report here on the detection of nine single nucleotide polymorphisms (SNPs) near to the NOTCH4 locus in the search for schizophrenia susceptibility genes in the class III region of the human major histocompatibility complex (MHC). We totally analyzed 122 family trios recruited in the UK. The TDT analysis demonstrated that of the nine SNPs, three were associated with schizophrenia, including rs1009382 (P = 0.00047), rs204887 (P = 0.007), and rs8283 (P = 0.015). Both rs1009382 and rs204887 are present in the TNXB locus. The rs1009382 is a non-synonymous SNP located in exon 23 of the gene and its A to G base change causes a Glu2578Gly substitution. The goodness-of-fit test showed that genotypic distribution of rs1009382 was deviated from Hardy-Weinberg equilibrium due to homozygote excess in the patient group (P = 0.01), suggesting that a double dose of a genetic risk may be involved. Possibly, rs1009382 is a candidate SNP predisposing to a schizophrenic illness. Moreover, the test for linkage disequilibrium (LD) between paired SNPs showed that the nine SNPs studied may be in the same LD block with an unexpected pattern as the strength of LD was not correlated with the distance between paired SNPs. The haplotype analysis suggested that there might be more than one disease-related allele located in the class III region of the MHC, and that these alleles possibly confer either susceptibility or resistance to schizophrenia.

Brain volumes as predictor of outcome in recent-onset schizophrenia: a multi-center MRI study

Gray matter brain volume decreases have been found in patients with schizophrenia as compared to healthy control subjects measured by using Magnetic Resonance Imaging (MRI). An association has been suggested between decreased gray matter volume and poor outcome in chronically ill patients with schizophrenia. The present longitudinal multi-center study investigated whether gray matter volume at illness onset can predict poor outcome in recent-onset schizophrenia after a follow-up of approximately 2 years. An MRI calibration study was performed since scans of patients with recent-onset psychosis were conducted at three sites with 1.5 T MR scanners from two different manufacturers. Applying a linear scaling procedure on the histogram improved comparability between volume measurements acquired from images from the different scanners. Brain scans were obtained from 109 patients with recent-onset schizophrenia. Volumes of intracranium, total brain, cerebral gray and white matter, third and lateral ventricles, and cerebellum were measured. After a mean follow-up period of approximately 2 years, measurements of symptoms, functioning, need for care, and illness history variables were assessed. No significant correlations were found between the brain volume measures and any of these measures. Gray matter volume at illness onset does not predict outcome after 2 years in recent-onset schizophrenia.

Brain morphological abnormality in schizophrenia is independent of country of origin

OBJECTIVE

The disorder schizophrenia has a worldwide prevalence of 1% and is generally associated with lateral cerebral ventricular enlargement. Whether there is a relationship between these two findings is unclear but has aetiological relevance.

METHOD

Consecutively admitted Chinese patients (n = 19) with first episode of schizophrenia and healthy community volunteers (n = 29) underwent magnetic resonance imaging brain scan. The groups were balanced for age, sex, best social class and handedness. These patients were similar on clinical and socio-demographic indices to those who declined participation (n = 15). Semi-automated volumetric analysis of whole brain volume, cortical grey matter, cerebrospinal fluid, sulci and lateral ventricles was performed.

RESULTS

Chinese patients in their first episode of schizophrenia have significant enlargement of lateral ventricles.

CONCLUSION

Brain morphological abnormality in schizophrenia is present regardless of the country of origin. The importance of genes in driving normal brain development and stable prevalence suggests that aetiology may favour genes over environment.

Initial magnetic resonance imaging volumetric brain measurements and outcome in schizophrenia: a prospective longitudinal study with 5-year follow-up

BACKGROUND

Several demographic and phenomenological variables have been identified as predictors of outcome in schizophrenia. Far fewer studies have examined the relationships between brain morphology assessed at illness onset and subsequent outcome, and their results have been contradictory.

METHODS

The relationships between magnetic resonance imaging (MRI) regional brain volumes at illness onset and outcome five years later were studied in 123 schizophrenia patients using regression and correlation analysis. Outcome measures included psychosocial functioning, weeks per year receiving inpatient treatment, and persistence of severe psychotic, disorganized and negative symptoms.

RESULTS

Temporal lobe tissue volume at onset was predictive of outcome. Smaller temporal lobe gray matter volume (both left and right) was associated with persistence of hallucinations during follow-up. There were no significant associations between hallucinations and temporal white matter, or between delusions and temporal white or gray matter volumes. None of the other volumetric brain measures were predictive of outcome.

CONCLUSIONS

The association between initial temporal lobe gray matter volume and subsequent persistent hallucinations may help identify individuals who are at higher risk for poor outcome and help guide their treatment planning. However, regional brain volumes assessed near illness onset, in general, do not appear to be indicative of subsequent outcome in schizophrenia.

Outcome of schizophreniform disorder

The aim of this review is to find data about the outcome of schizophreniform disorder. As different definitions of schizophreniform disorder were found in the literature, it was not surprising that data on its outcome, and on the relationship of schizophreniform disorder to schizophrenia and to mood disorders (as this relationship is linked to outcome), were often different and opposite. Its classic description of an acute onset psychotic episode with mood instability and a relatively brief duration should be the focus of future studies. Current studies, apart from a small number, lump together different (and probably distinct) subtypes of schizophreniform disorder (one with good prognostic features, and one without good prognostic features, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Studies of mixed samples led to different results, probably depending on the relative prevalence of one subtype over the other one. The few studies on schizophreniform disorder with good prognostic features found more often an episodic, recurrent course, and a family history of mood disorders. These features link this schizophreniform disorder subtype more to mood disorders than to schizophrenia. If confirmed by future studies, these preliminary findings can have very important treatment implications, given the very different treatment strategies in mood disorders compared with schizophrenia.

Dysregulated brain development in adult men with schizophrenia: a magnetic resonance imaging study

BACKGROUND

Recent imaging evidence suggests that normal brain development/maturation of the frontal lobes and association areas is a well-regulated process consisting of continued myelination and expansion of white matter volumes into the late 40s accompanied by complementary reductions in gray matter volumes. The possibility that a dysregulation of this process may contribute to the syndrome of schizophrenia was investigated using magnetic resonance imaging.

METHODS

Fifty-two normal adult males and 35 males with schizophrenia underwent magnetic resonance imaging. Coronal images were acquired using pulse sequences that maximized myelin signal. The age-related change in the gray to white matter ratio was used as a measure of developmental dysregulation in the schizophrenic subjects and contrasted to the age-related changes of the normal control group.

RESULTS

Regression analyses on frontal and temporal gray to white matter ratio yielded highly significant interactions of diagnosis and age for both regions (p =.0003 and p =.01, respectively). In the normal group, both frontal and temporal gray to white matter ratios decreased significantly and linearly across the age range. In contrast, neither ratio showed meaningful age-related change in the schizophrenia group. Thus, differences in gray to white matter ratio between the groups increased markedly with age, driven primarily by the absence of a white matter volume expansion in the patient group.

CONCLUSIONS

The absence of the normal complementary volume changes in the gray and white matter with age in the schizophrenic sample suggests that this dynamic developmental process is dysregulated in adult schizophrenic subjects. The importance of myelination to the continued maturation and normal functioning of the brain has implications for the diagnosis, treatment, and prognosis of schizophrenia.