Evidence for unaltered brain electrical topography during prefrontal response control in cycloid psychoses

Mood Disorder or Psychotic Disorder? Yes: A Case Report on Cycloid Psychosis

Cycloid psychosis is a disorder defined by episodic, acute psychoses involving thought, affect, and motor disturbances with polymorphous symptomatology followed by periods of full remission. Antipsychotics, benzodiazepines, and electroconvulsive therapy have been used empirically in acute treatment. This disorder has faced nosologic challenges and is not yet identified as a diagnostic entity by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Questions remain as to whether cycloid psychosis is a primary psychotic or primary affective disorder, given that its course and episodicity are like that of affective disorders, while its clinical manifestations include prominent psychotic symptoms. This report describes the case of a 38-year-old male with classic features of cycloid psychosis and highlights the unique characteristics that distinguish cycloid psychosis from other similar diagnoses.

Does a Lack of Awareness of Cycloid Psychosis Hamper Adequate Treatment for Patients Suffering From This Disorder? A Case Report

Categorial systems of nosology are based on a cross-sectional enumeration of symptoms with a predefined cut-off, but hardly capture rapid fluctuations of manifestation nor longitudinal characteristics, e.g., cyclicity. Especially with disorders presenting with an admixture or frequent change of psychotic and affective symptoms, diagnostic specifity of the DSM and ICD diminishes. In those instances, alternative concepts as cycloid psychosis might display more accurately the very characteristics and course of a mental disorder and help to tailor individualized treatments. Karl Leonhard described three major subtypes of cycloid psychosis: anxiety-happiness psychosis, confusion psychosis, and motility psychosis, all showing a pleiomorphic symptom profile resembling intraphasic switching of poles. Here we present the case of a 59-year-old woman suffering from cycloid psychosis as defined by the criteria of Perris. Between 2013 and June 2019, the patient was admitted 35 times for compulsory treatment. A frequent change of diagnoses, ranging from adjustment disorder to complex PTSD, and from unipolar depression to "pseudoneurotic schizophrenia," resembles the puzzling manifestations. Most of the time the patient was labeled as schizoaffective disorder despite never displaying clear psychotic core symptoms. Despite treatment with different antipsychotics including LAI the cumulative length of hospitalization increased steadily from 74 days in 2014 to 292 days in 2017. When reviewing the case in 2017 the longitudinal pattern of her disorder and the diverse acute manifestations were finally conceptualized as a cyclic on-off of an atypical psychosis. After starting lithium to pre-existing LAI antipsychotics and valproic acid, the number of days per year spent in inpatient care sharply dropped to 136 in 2018. We propose to reconsider cycloid psychosis as a useful clinical concept whose descriptive value, validity and utility for treatment decisions should be further evaluated. Lithium alone or in addition to valproic acid may act on cyclicity as a core symptom of cycloid psychosis as well as of bipolar disorder, even in the absence of major affective symptoms.

Deficits in Go and NoGo P3 potentials in patients with schizophrenia

Cognitive control processes elicited during a cued continuous performance test were evaluated using event-related potentials in 46 patients who were within the first 5 years of diagnosis of schizophrenia, and 29 healthy controls. Patients had longer reaction times, lower hit rates, and higher false alarm rates compared with controls. Patients had an overall P3 amplitude reduction that was more prominent on NoGo compared with Go trials. This greater P3 reduction on NoGo trials was present in central and parietal regions, but was absent in the frontal region, where the P3 reduction was comparable on NoGo and Go trials. Our findings suggest that the neural activity contributing to Go and NoGo P3s are both deteriorated in schizophrenia, but those contributing to central and parietal NoGo P3s are the most severely affected ones. We conclude that the cognitive control processes engaged during execution, and particularly during inhibition of a prepared motor response were disturbed in the early course of schizophrenia. Our findings might be related to our sample being in relatively early stages of schizophrenia and/or related to the use of atypical antipsychotics by most of our patients.

Hypofrontality in schizophrenic patients and its relevance for the choice of antipsychotic medication: an event-related potential study

OBJECTIVES

One of the neurobiological core features of schizophrenic illnesses is a hypo-functionality of the frontal cortex ("cerebral hypofrontality"). The two major classes of antipsychotic medication differ regarding their impact on frontal lobe function and metabolism, with a presumably more positive effect of "atypical" compared to "typical" agents. To date, neurobiological markers reliably predicting the treatment response to different antipsychotics are lacking. The present study, therefore, aimed at establishing a neurophysiological marker of frontal lobe function (NoGo-Anteriorization, NGA) as a predictor of the treatment response to first- and second-generation antipsychotics.

METHODS

Seventy-six schizophrenic patients were examined three times over a 6-week study period. Patients were treated with first- or second-generation antipsychotics, and NGA, neurocognitive performance, and symptomatology were assessed on admission as well as during two follow-up measurements.

RESULTS

Baseline NGA values significantly predicted the treatment response to typical and atypical antipsychotics; however, the direction of this prediction was dependent on the antipsychotic drug regimen. Moreover, atypical antipsychotics had a superior impact on neurocognitive performance and self-reported quality of life.

CONCLUSIONS

The NGA might be a useful tool in developing individualized treatment strategies based on pathophysiological aspects of schizophrenic illnesses that can be easily determined in clinical routine settings.

Increased NoGo-anteriorisation in first-episode schizophrenia patients during Continuous Performance Test

OBJECTIVE

NoGo-stimuli during a Continuous Performance Test (CPT) activate prefrontal brain structures such as the anterior cingulate gyrus and lead to an anteriorisation of the positive electrical field of the NoGo-P300 relative to the Go-P300, so-called NoGo-anteriorisation (NGA). NGA during CPT is regarded as a neurophysiological standard index for cognitive response control. While it is known that patients with chronic schizophrenia exhibit a significant reduction in NGA, it is unclear whether this also occurs in patients undergoing their first-episode. Thus, the aim of the present study was to determine NGA in a group of patients with first-episode schizophrenia by utilizing a CPT paradigm.

METHODS

Eighteen patients with first-episode schizophrenia and 18 matched healthy subjects were investigated electrophysiologically during a cued CPT, and the parameters of the Go- and NoGo-P300 were determined using microstate analysis. Low resolution tomography analysis (LORETA) was used for source determination.

RESULTS

Due to a more posterior Go- and a more anterior NoGo-centroid, NGA was greater in patients than in healthy controls. LORETA indicated the same sources for both groups after Go-stimuli, but a more anterior source in patients after NoGo-stimuli. In patients P300-amplitude responses to both Go- and NoGo-stimuli were decreased, and P300-latency to NoGo-stimuli was increased. After the Go-stimuli false reactions and reaction times were increased in patients.

CONCLUSIONS

Attention was reduced in patients with first-episode schizophrenia, as indicated by more false reactions, prolongation of reaction time, P300-latencies and by a decrease in P300-amplitude. Significantly however, the NGA and prefrontal LORETA-sources indicate intact prefrontal brain structures in first-episode schizophrenia patients. Previously described changes in this indicator of prefrontal function may be related to a progressive decay in chronic schizophrenia.

SIGNIFICANCE

The results support the idea of a possible new biological marker of first episode psychosis, which may be a useful parameter for the longitudinal measurement of changing prefrontal brain function in a single schizophrenia patient.

Cortical activation during two verbal fluency tasks in schizophrenic patients and healthy controls as assessed by multi-channel near-infrared spectroscopy

Near-infrared spectroscopy (NIRS) is an optical imaging method that allows non-invasive in-vivo measurements of changes in the concentration of oxygenated (O(2)Hb) and deoxygenated (HHb) hemoglobin in brain tissue. For the present study, we examined 12 schizophrenic patients and 12 age- and gender-matched healthy controls by means of multi-channel NIRS (Optical Topography; ETG-100, Hitachi Medical Co., Japan) during performance of two versions of the Verbal Fluency Test (VFT; letter and category version). The results indicate that the verbal fluency tasks generally led to clear frontal activation in healthy controls, which was significantly reduced in schizophrenic patients. The letter version of the VFT induced overall stronger activation than the category version, the group difference being particularly pronounced for phonological fluency. Moreover, significant positive correlations between task-related activation effects in prefrontal and temporal NIRS channels were found in both schizophrenic patients and healthy controls. The results confirm functional deficits within the frontal lobe in patients suffering from schizophrenic illnesses, but do not confirm previous findings on abnormal fronto-temporal correlations or increased temporal activation in this group of patients. The data furthermore underline the usefulness of functional NIRS in monitoring hemodynamic responses associated with cognitive processes in healthy controls and patients with neuro-psychiatric disorders.

Beneficial effect of atypical antipsychotics on prefrontal brain function in acute psychotic disorders

Disturbance of prefrontal brain functions is assumed to be responsible for prominent psychopathological symptoms in psychotic disorders. Treatment with atypical, in contrast to typical antipsychotics is considered as a possible strategy for an improvement of prefrontal brain function. In the present study, response control as a specific prefrontal brain function was assessed by means of the Nogo-anteriorization (NGA) derived from the event-related potentials elicited during a Go-NoGo task in a consecutive sample of 39 patients suffering from acute psychotic disorders (brief psychotic disorders, 298.8, n = 34 and schizoaffective disorders, 295.70, n = 5; cycloid psychoses according to the Leonhard classification). A highly significant positive correlation between the amount of antipsychotic medication in terms of chlorpromazine equivalents per day and the NGA as a measure of prefrontal response control was only found in the subgroup of patients treated exclusively or predominantly with atypical antipsychotics but not for those treated with typical antipsychotics. These results are in line with the notion that atypical antipsychotics may exert a beneficial effect on prefrontal brain function.