1
|
Chen Y, Wang S, Zhang X, Yang Q, Hua M, Li Y, Qin W, Liu F, Liang M. Functional Connectivity-Based Searchlight Multivariate Pattern Analysis for Discriminating Schizophrenia Patients and Predicting Clinical Variables. Schizophr Bull 2024:sbae084. [PMID: 38819252 DOI: 10.1093/schbul/sbae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Schizophrenia, a multifaceted psychiatric disorder characterized by functional dysconnectivity, poses significant challenges in clinical practice. This study explores the potential of functional connectivity (FC)-based searchlight multivariate pattern analysis (CBS-MVPA) to discriminate between schizophrenia patients and healthy controls while also predicting clinical variables. STUDY DESIGN We enrolled 112 schizophrenia patients and 119 demographically matched healthy controls. Resting-state functional magnetic resonance imaging data were collected, and whole-brain FC subnetworks were constructed. Additionally, clinical assessments and cognitive evaluations yielded a dataset comprising 36 clinical variables. Finally, CBS-MVPA was utilized to identify subnetworks capable of effectively distinguishing between the patient and control groups and predicting clinical scores. STUDY RESULTS The CBS-MVPA approach identified 63 brain subnetworks exhibiting significantly high classification accuracies, ranging from 62.2% to 75.6%, in distinguishing individuals with schizophrenia from healthy controls. Among them, 5 specific subnetworks centered on the dorsolateral superior frontal gyrus, orbital part of inferior frontal gyrus, superior occipital gyrus, hippocampus, and parahippocampal gyrus showed predictive capabilities for clinical variables within the schizophrenia cohort. CONCLUSION This study highlights the potential of CBS-MVPA as a valuable tool for localizing the information related to schizophrenia in terms of brain network abnormalities and capturing the relationship between these abnormalities and clinical variables, and thus, deepens our understanding of the neurological mechanisms of schizophrenia.
Collapse
Affiliation(s)
- Yayuan Chen
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging and Tianjin Institute of Radiology, Tianjin Medical University General Hospital, Tianjin, China
- School of Medical Imaging, Tianjin Key Laboratory of Functional Imaging and The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Tianjin Medical University, Tianjin, China
| | - Sijia Wang
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging and Tianjin Institute of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xi Zhang
- School of Medical Imaging, Tianjin Key Laboratory of Functional Imaging and The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Tianjin Medical University, Tianjin, China
| | - Qingqing Yang
- Department of Radiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Minghui Hua
- Department of Radiology, Chest Hospital, Tianjin University, Tianjin, China
| | - Yifan Li
- School of Medical Imaging, Tianjin Key Laboratory of Functional Imaging and The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Tianjin Medical University, Tianjin, China
| | - Wen Qin
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging and Tianjin Institute of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Feng Liu
- Department of Radiology, Tianjin Key Laboratory of Functional Imaging and Tianjin Institute of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Meng Liang
- School of Medical Imaging, Tianjin Key Laboratory of Functional Imaging and The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Tianjin Medical University, Tianjin, China
| |
Collapse
|
2
|
Guan M, Xie Y, Li C, Zhang T, Ma C, Wang Z, Ma Z, Wang H, Fang P. Rich-club reorganization of white matter structural network in schizophrenia patients with auditory verbal hallucinations following 1 Hz rTMS treatment. Neuroimage Clin 2023; 40:103546. [PMID: 37988997 PMCID: PMC10701084 DOI: 10.1016/j.nicl.2023.103546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 11/23/2023]
Abstract
The human brain comprises a large-scale structural network of regions and interregional pathways, including a selectively defined set of highly central and interconnected hub regions, often referred to as the "rich club", which may play a pivotal role in the integrative processes of the brain. A quintessential symptom of schizophrenia, auditory verbal hallucinations (AVH) have shown a decrease in severity following low-frequency repetitive transcranial magnetic stimulation (rTMS). However, the underlying mechanism of rTMS in treating AVH remains elusive. This study investigated the effect of low-frequency rTMS on the rich-club organization within the brain in patients diagnosed with schizophrenia who experience AVH using diffusion tensor imaging data. Through by constructing structural connectivity networks, we identified several critical rich hub nodes, which constituted a rich-club subnetwork, predominantly located in the prefrontal cortices. Notably, our findings revealed enhanced connection strength and density within the rich-club subnetwork following rTMS treatment. Furthermore, we found that the decreased connectivity within the subnetwork components, including the rich-club subnetwork, was notably enhanced in patients following rTMS treatment. In particular, the increased connectivity strength of the right median superior frontal gyrus, which functions as a critical local bridge, with the right postcentral gyrus exhibited a significant correlation with improvements in both positive symptoms and AVH. These findings provide valuable insights into the role of rTMS in inducing reorganizational changes within the rich-club structural network in schizophrenia and shed light on potential mechanisms through which rTMS may alleviate AVH.
Collapse
Affiliation(s)
- Muzhen Guan
- Department of Mental Health, Xi'an Medical College, Xi'an, China.
| | - Yuanjun Xie
- Military Medical Psychology School, Fourth Military Medical University, Xi'an, China; Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Chenxi Li
- Military Medical Psychology School, Fourth Military Medical University, Xi'an, China
| | - Tian Zhang
- Military Medical Psychology School, Fourth Military Medical University, Xi'an, China
| | - Chaozong Ma
- Military Medical Psychology School, Fourth Military Medical University, Xi'an, China
| | - Zhongheng Wang
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhujing Ma
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Huaning Wang
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Peng Fang
- Military Medical Psychology School, Fourth Military Medical University, Xi'an, China.
| |
Collapse
|
3
|
Zhu T, Wang Z, Wu W, Ling Y, Wang Z, Zhou C, Fang X, Huang C, Xie C, Chen J, Zhang X. Altered brain functional networks in schizophrenia with persistent negative symptoms: an activation likelihood estimation meta-analysis. Front Hum Neurosci 2023; 17:1204632. [PMID: 37954938 PMCID: PMC10637389 DOI: 10.3389/fnhum.2023.1204632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Objective To investigate brain structural and functional characteristics of three brain functional networks including default mode network (DMN), central executive network (CEN), and salience network (SN) in persistent negative symptoms (PNS) patients. Methods We performed an activation likelihood estimation (ALE) meta-analysis of functional connectivity (FC) studies and voxel-based morphometry (VBM) studies to detect specific structural and functional alterations of brain networks between PNS patients and healthy controls. Results Seventeen VBM studies and twenty FC studies were included. In the DMN, PNS patients showed decreased gray matter in the bilateral medial frontal gyrus and left anterior cingulate gyrus and a significant reduction of FC in the right precuneus. Also, PNS patients had a decrease of gray matter in the left inferior parietal lobules and medial frontal gyrus, and a significant reduction of FC in the bilateral superior frontal gyrus in the CEN. In comparison with healthy controls, PNS patients exhibited reduced gray matter in the bilateral insula, anterior cingulate gyrus, left precentral gyrus and right claustrum and lower FC in these brain areas in the SN, including the left insula, claustrum, inferior frontal gyrus and extra-nuclear. Conclusion This meta-analysis reveals brain structural and functional imaging alterations in the three networks and the interaction among these networks in PNS patients, which provides neuroscientific evidence for more personalized treatment.Systematic Review RegistrationThe PROSPERO (https://www.crd.york.ac.uk/PROSPERO/, registration number: CRD42022335962).
Collapse
Affiliation(s)
- Tingting Zhu
- Department of Psychiatry, The Third People’s Hospital of Huai’an, Huaian, Jiangsu, China
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zengxiu Wang
- Department of Hepatology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Weifeng Wu
- Department of Hepatology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yuru Ling
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zixu Wang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chao Zhou
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyu Fang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chengbing Huang
- Department of Psychiatry, The Third People’s Hospital of Huai’an, Huaian, Jiangsu, China
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chunming Xie
- Department of Neurology, Affiliated Zhongda Hospital, School of Medicine Southeast University, Nanjing, China
| | - Jiu Chen
- Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangrong Zhang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- The Affiliated Xuzhou Oriental Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| |
Collapse
|
4
|
Huang Y, Wang W, Hei G, Yang Y, Long Y, Wang X, Xiao J, Xu X, Song X, Gao S, Shao T, Huang J, Wang Y, Zhao J, Wu R. Altered regional homogeneity and cognitive impairments in first-episode schizophrenia: A resting-state fMRI study. Asian J Psychiatr 2022; 71:103055. [PMID: 35303593 DOI: 10.1016/j.ajp.2022.103055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/11/2022] [Accepted: 02/27/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with schizophrenia consistently present pervasive cognitive deficits, but the neurobiological mechanism of cognitive impairments remains unclear. By analyzing regional homogeneity (ReHo) of resting-state functional Magnetic Resonance Imaging, this study aimed to explore the association between brain functional alterations and cognitive deficits in first-episode schizophrenia (FES) with a relatively large sample. METHODS A total of 187 patients with FES and 100 healthy controls from 3 independent cohorts underwent resting-state functional magnetic resonance scans. The MATRICS Consensus Cognitive Battery (MCCB) was used to assess cognitive function. Partial correlation analysis was performed between abnormal ReHo values and the severity of symptoms and cognitive deficits. RESULTS Compared with healthy controls, ReHo values increased in right superior frontal cortex and decreased in right anterior cingulate cortex (ACC), left middle occipital gyrus (MOG), left cuneus, right posterior cingulate cortex (PCC), and right superior occipital gyrus in schizophrenia patients. ReHo values in ACC, PCC and superior occipital gyrus were correlated with PANSS scores. In addition, ReHo values in ACC and MOG were negatively correlated with working memory; left cuneus was positively correlated with multiple cognitive domains (speed of processing, attention/vigilance and social cognition); PCC was positively correlated with verbal learning; right superior occipital gyrus was positively correlated with speed of processing and social cognition. CONCLUSION In conclusion, we found widespread ReHo alterations and cognitive dysfunction in FES. And the pathophysiology mechanism of a wide range of cognitive deficits may be related to abnormal spontaneous brain activity.
Collapse
Affiliation(s)
- Yuyan Huang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Weiyan Wang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Gangrui Hei
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Ye Yang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Yujun Long
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Xiaoyi Wang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Jingmei Xiao
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Xijia Xu
- Department of Psychiatry, Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing 210000, Jiangsu, China
| | - Xueqin Song
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Shuzhan Gao
- Department of Psychiatry, Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing 210000, Jiangsu, China
| | - Tiannan Shao
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Jing Huang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Ying Wang
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Jingping Zhao
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Renrong Wu
- Department of Psychiatry, and National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China.
| |
Collapse
|
5
|
Rootes-Murdy K, Goldsmith DR, Turner JA. Clinical and Structural Differences in Delusions Across Diagnoses: A Systematic Review. Front Integr Neurosci 2022; 15:726321. [PMID: 35140591 PMCID: PMC8818879 DOI: 10.3389/fnint.2021.726321] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/16/2021] [Indexed: 12/18/2022] Open
Abstract
Delusions are marked, fixed beliefs that are incongruent with reality. Delusions, with comorbid hallucinations, are a hallmark of certain psychotic disorders (e.g., schizophrenia). Delusions can present transdiagnostically, in neurodegenerative (e.g., Alzheimer's disease and fronto-temporal dementia), nervous system disorders (e.g., Parkinson's disease) and across other psychiatric disorders (e.g., bipolar disorder). The burden of delusions is severe and understanding the heterogeneity of delusions may delineate a more valid nosology of not only psychiatric disorders but also neurodegenerative and nervous system disorders. We systematically reviewed structural neuroimaging studies reporting on delusions in four disorder types [schizophrenia (SZ), bipolar disorder (BP), Alzheimer's disease (AD), and Parkinson's disease (PD)] to provide a comprehensive overview of neural changes and clinical presentations associated with delusions. Twenty-eight eligible studies were identified. This review found delusions were most associated with gray matter reductions in the dorsolateral prefrontal cortex (SZ, BP, and AD), left claustrum (SZ and AD), hippocampus (SZ and AD), insula (SZ, BP, and AD), amygdala (SZ and BP), thalamus (SZ and AD), superior temporal gyrus (SZ, BP, and AD), and middle frontal gyrus (SZ, BP, AD, and PD). However, there was a great deal of variability in the findings of each disorder. There is some support for the current dopaminergic hypothesis of psychosis, but we also propose new hypotheses related to the belief formation network and cognitive biases. We also propose a standardization of assessments to aid future transdiagnostic study approaches. Future studies should explore the neural and biological underpinnings of delusions to hopefully, inform future treatment.
Collapse
Affiliation(s)
- Kelly Rootes-Murdy
- Department of Psychology, Georgia State University, Atlanta, GA, United States
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
- *Correspondence: Kelly Rootes-Murdy
| | - David R. Goldsmith
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Jessica A. Turner
- Department of Psychology, Georgia State University, Atlanta, GA, United States
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| |
Collapse
|
6
|
Zhu T, Wang Z, Zhou C, Fang X, Huang C, Xie C, Ge H, Yan Z, Zhang X, Chen J. Meta-analysis of structural and functional brain abnormalities in schizophrenia with persistent negative symptoms using activation likelihood estimation. Front Psychiatry 2022; 13:957685. [PMID: 36238945 PMCID: PMC9552970 DOI: 10.3389/fpsyt.2022.957685] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Persistent negative symptoms (PNS) include both primary and secondary negative symptoms that persist after adequate treatment, and represent an unmet therapeutic need. Published magnetic resonance imaging (MRI) evidence of structural and resting-state functional brain abnormalities in schizophrenia with PNS has been inconsistent. Thus, the purpose of this meta-analysis is to identify abnormalities in structural and functional brain regions in patients with PNS compared to healthy controls. METHODS We systematically searched PubMed, Web of Science, and Embase for structural and functional imaging studies based on five research methods, including voxel-based morphometry (VBM), diffusion tensor imaging (DTI), functional connectivity (FC), the amplitude of low-frequency fluctuation or fractional amplitude of low-frequency fluctuation (ALFF/fALFF), and regional homogeneity (ReHo). Afterward, we conducted a coordinate-based meta-analysis by using the activation likelihood estimation algorithm. RESULTS Twenty-five structural MRI studies and thirty-two functional MRI studies were included in the meta-analyses. Our analysis revealed the presence of structural alterations in patients with PNS in some brain regions including the bilateral insula, medial frontal gyrus, anterior cingulate gyrus, left amygdala, superior temporal gyrus, inferior frontal gyrus, cingulate gyrus and middle temporal gyrus, as well as functional differences in some brain regions including the bilateral precuneus, thalamus, left lentiform nucleus, posterior cingulate gyrus, medial frontal gyrus, and superior frontal gyrus. CONCLUSION Our study suggests that structural brain abnormalities are consistently located in the prefrontal, temporal, limbic and subcortical regions, and functional alterations are concentrated in the thalamo-cortical circuits and the default mode network (DMN). This study provides new insights for targeted treatment and intervention to delay further progression of negative symptoms. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022338669].
Collapse
Affiliation(s)
- Tingting Zhu
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zixu Wang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chao Zhou
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xinyu Fang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chengbing Huang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China.,Department of Psychiatry, The Third People's Hospital of Huai'an, Huaian, China
| | - Chunming Xie
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine Southeast University, Nanjing, China
| | - Honglin Ge
- Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Yan
- Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangrong Zhang
- Department of Geriatric Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China.,The Affiliated Xuzhou Oriental Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiu Chen
- Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
7
|
Huang X, Pu W, Li X, Greenshaw AJ, Dursun SM, Xue Z, Liu H, Liu Z. Decreased Left Putamen and Thalamus Volume Correlates with Delusions in First-Episode Schizophrenia Patients. Front Psychiatry 2017; 8:245. [PMID: 29209237 PMCID: PMC5702009 DOI: 10.3389/fpsyt.2017.00245] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/06/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delusional thinking is one of the hallmark symptoms of schizophrenia. However, the underlying neural substrate for delusions in schizophrenia remains unknown. In an attempt to further our understanding of the neural basis of delusions, we explored gray matter deficits and their clinical associations in first-episode schizophrenia patients with and without delusions. METHODS Twenty-four first-episode schizophrenia patients with delusions and 18 without delusions as well as 26 healthy controls (HC) underwent clinical assessment and whole-brain structural imaging which were acquired a 3.0 T scanner. Voxel-based morphometry was used to explore inter-group differences in gray matter volume using analysis of covariance, and Spearman correlation coefficients (rho) between the Scale for the Assessment of Positive Symptoms (SAPS)-delusion scores and mean regional brain volumes was obtained. RESULTS Patients with delusions showed decreased brain gray matter volumes in the left putamen, thalamus, and caudate regions compared with HC. Patients with delusions also showed decreased regional volume in the left putamen and thalamus compared with patients without delusions. SAPS-delusion scores were negatively correlated with the gray matter volumes of the left putamen and thalamus. DISCUSSION Left putamen and thalamus volume loss may be biological correlates of delusions in schizophrenia.
Collapse
Affiliation(s)
- Xiaojun Huang
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,The China National Clinical Research Center for Mental Health Disorders, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Changsha, China
| | - Weidan Pu
- Medical Psychological Institute, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xinmin Li
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | | | - Serdar M Dursun
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Zhimin Xue
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,The China National Clinical Research Center for Mental Health Disorders, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Changsha, China
| | - Haihong Liu
- Mental Health Center of Xiangya Hospital, Central South University, Changsha, China
| | - Zhening Liu
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,The China National Clinical Research Center for Mental Health Disorders, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, Changsha, China
| |
Collapse
|
8
|
Neural substrates underlying delusions in schizophrenia. Sci Rep 2016; 6:33857. [PMID: 27651212 PMCID: PMC5030611 DOI: 10.1038/srep33857] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 09/05/2016] [Indexed: 11/30/2022] Open
Abstract
Delusions are cardinal positive symptoms in schizophrenia; however, the neural substrates of delusions remain unknown. In the present study, we investigated the neural correlates of delusions in schizophrenia using multi-modal magnetic resonance imaging (MRI) techniques. Diffusion, structural and perfusion MRIs were performed in 19 schizophrenia patients with severe delusions, 30 patients without delusions and 30 healthy controls. Fractional anisotropy (FA), gray matter volume (GMV) and cerebral blood flow (CBF) were voxel-wisely compared among the three groups. Although patients without delusions exhibited decreased FA in white matter regions and decreased GMV in gray matter regions relative to controls, patients with severe delusions demonstrated comparable FA in all of these white matter regions and similar GMV in most of these gray matter regions. Both patient subgroups had less GMV in the amygdala and anterior cingulate cortex than controls. Although two patient subgroups showed consistent CBF changes relative to controls, only CBF in the anterior cingulate cortex was lower in patients with severe delusions than in patients without delusions. These findings suggest that schizophrenia patients with severe delusions have relatively normal structural integrity. Importantly, the excessively reduced perfusion in the anterior cingulate cortex may be associated with the development of delusions in schizophrenia.
Collapse
|
9
|
Looijestijn J, Blom JD, Aleman A, Hoek HW, Goekoop R. An integrated network model of psychotic symptoms. Neurosci Biobehav Rev 2015; 59:238-50. [PMID: 26432501 DOI: 10.1016/j.neubiorev.2015.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 09/27/2015] [Indexed: 12/29/2022]
Abstract
The full body of research on the nature of psychosis and its determinants indicates that a considerable number of factors are relevant to the development of hallucinations, delusions, and other positive symptoms, ranging from neurodevelopmental parameters and altered connectivity of brain regions to impaired cognitive functioning and social factors. We aimed to integrate these factors in a single mathematical model based on network theory. At the microscopic level this model explains positive symptoms of psychosis in terms of experiential equivalents of robust, high-frequency attractor states of neural networks. At the mesoscopic level it explains them in relation to global brain states, and at the macroscopic level in relation to social-network structures and dynamics. Due to the scale-free nature of biological networks, all three levels are governed by the same general laws, thereby allowing for an integrated model of biological, psychological, and social phenomena involved in the mediation of positive symptoms of psychosis. This integrated network model of psychotic symptoms (INMOPS) is described together with various possibilities for application in clinical practice.
Collapse
Affiliation(s)
- Jasper Looijestijn
- Parnassia Psychiatric Institute, Kiwistraat 43, The Hague 2552 DH, The Netherlands
| | - Jan Dirk Blom
- Parnassia Psychiatric Institute, Kiwistraat 43, The Hague 2552 DH, The Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
| | - André Aleman
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, Groningen 9713 AV, The Netherlands
| | - Hans W Hoek
- Parnassia Psychiatric Institute, Kiwistraat 43, The Hague 2552 DH, The Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands; Department of Epidemiology, Columbia University, 722 West 168th St., New York, NY, USA
| | - Rutger Goekoop
- Parnassia Psychiatric Institute, Kiwistraat 43, The Hague 2552 DH, The Netherlands.
| |
Collapse
|
10
|
Gao B, Wang Y, Liu W, Chen Z, Zhou H, Yang J, Cohen Z, Zhu Y, Zang Y. Spontaneous Activity Associated with Delusions of Schizophrenia in the Left Medial Superior Frontal Gyrus: A Resting-State fMRI Study. PLoS One 2015. [PMID: 26204264 PMCID: PMC4512714 DOI: 10.1371/journal.pone.0133766] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Delusions of schizophrenia have been found to be associated with alterations of some brain regions in structure and task-induced activation. However, the relationship between spontaneously occurring symptoms and spontaneous brain activity remains unclear. In the current study, 14 schizophrenic patients with delusions and 14 healthy controls underwent a resting-state functional magnetic resonance imaging (RS-fMRI) scan. Patients with delusions of schizophrenia patients were rated with Positive and Negative Syndrome Scale (PANSS) and Characteristics of Delusional Rating Scale (CDRS). Regional homogeneity (ReHo) was calculated to measure the local synchronization of the spontaneous activity in a voxel-wise way. A two-sample t-test showed that ReHo of the right anterior cingulate gyrus and left medial superior frontal gyrus were higher in patients, and ReHo of the left superior occipital gyrus was lower, compared to healthy controls. Further, among patients, correlation analysis showed a significant difference between delusion scores of CRDS and ReHo of brain regions. ReHo of the left medial superior frontal gyrus was negatively correlated with patients’ CDRS scores but not with delusional PANSS scores. These results suggested that altered local synchronization of spontaneous brain activity may be related to the pathophysiology of delusion in schizophrenia.
Collapse
Affiliation(s)
- Bin Gao
- Department of Psychiatry, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Yiquan Wang
- Hangzhou Seventh People's Hospital, Hangzhou, Zhejiang, PR China; Mental Health Center, School of Medicine, Zhe Jiang University, Hangzhou, Zhejiang, PR China
| | - Weibo Liu
- Department of Psychiatry, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Zhiyu Chen
- Hangzhou Seventh People's Hospital, Hangzhou, Zhejiang, PR China
| | - Heshan Zhou
- Hangzhou First People's Hospital, Hangzhou, Zhejiang, PR China
| | - Jinyu Yang
- Department of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Zachary Cohen
- Alpert Medical School of Brown University, Richmond St., Providence, RI, United States of America
| | - Yihong Zhu
- Department of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China; Mental Health Education and Counseling Center, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Yufeng Zang
- Center for Cognition and Brain Disorders, Hangzhou Normal University, Hangzhou, Zhejiang, PR China; Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, Zhejiang, PR China
| |
Collapse
|
11
|
Poletti M, Sambataro F. The development of delusion revisited: a transdiagnostic framework. Psychiatry Res 2013; 210:1245-59. [PMID: 23978732 DOI: 10.1016/j.psychres.2013.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 07/15/2013] [Accepted: 07/20/2013] [Indexed: 01/07/2023]
Abstract
This study proposes a transdiagnostic framework for delusion development, analysing psychiatric (schizophrenia, bipolar disorder, major depressive disorder) and neurological disorders (stroke, and neurodegenerative diseases) in which delusions are predominant. Our aim is to identify a transdiagnostic core of neural and cognitive alterations associated with delusions across distinct clinical disorders. Reviewed empirical evidence suggests delusions are associated: on the neural level with changes in the ventromedial prefrontal cortex (vmPFC) networks, and on the neuropsychological level with dysfunction in the processes (generation of affective value, the construction of internal models of the world, and the reflection about Self and/or Other's mental states) that these network mediate. The concurrent aberration of all these processes could be critical for the clinical transition to a psychotic delusional state. In particular, delusions could become clinically manifest when (1) stimuli are attributed an aberrant affective salience, that (2) is explained by the patient within distorted explanatory internal models that (3) are poorly inhibited by cognitive control systems. This framework extends the two-factor account of delusion model and suggests that common neural mechanisms for the delusions in psychiatric and in neurological disorders.
Collapse
Affiliation(s)
- Michele Poletti
- Department of Mental Health and Pathological Addiction, AUSL of Reggio Emilia, Reggio Emilia, Italy.
| | | |
Collapse
|
12
|
Pankow A, Knobel A, Voss M, Heinz A. Neurobiological correlates of delusion: beyond the salience attribution hypothesis. Neuropsychobiology 2012; 66:33-43. [PMID: 22797275 DOI: 10.1159/000337132] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 01/30/2012] [Indexed: 11/19/2022]
Abstract
Dopamine dysfunction is a mainstay of theories aimed to explain the neurobiological correlates of schizophrenia symptoms, particularly positive symptoms such as delusions and passivity phenomena. Based on studies revealing dopamine dysfunction in addiction research, it has been suggested that phasic or chaotic firing of dopaminergic neurons projecting to the (ventral) striatum attribute salience to otherwise irrelevant stimuli and thus contribute to delusional mood and delusion formation. Indeed, several neuroimaging studies revealed that neuronal encoding of usually irrelevant versus relevant stimuli is blunted in unmedicated schizophrenia patients, suggesting that some stimuli that are irrelevant for healthy controls acquire increased salience for psychotic patients. However, salience attribution per se may not suffice to explain anxieties and feelings of threat that often accompany paranoid ideation. Here, we suggest that beyond ventral striatal dysfunction, dopaminergic dysregulation in limbic areas such as the amygdala in interaction with prefrontal and temporal cortex may contribute to the formation of delusions and negative symptoms. Neuroleptic medication, on the other hand, appears to interfere with anticipation of reward in the ventral striatum and can thus contribute to secondary negative symptoms such as apathy and avolition.
Collapse
Affiliation(s)
- Anne Pankow
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte,Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | | | | | | |
Collapse
|
13
|
Ruef A, Curtis L, Moy G, Bessero S, Bâ MB, Lazeyras F, Lövblad KO, Haller S, Malafosse A, Giannakopoulos P, Merlo M. Magnetic resonance imaging correlates of first-episode psychosis in young adult male patients: combined analysis of grey and white matter. J Psychiatry Neurosci 2012; 37:305-12. [PMID: 22748698 PMCID: PMC3447129 DOI: 10.1503/jpn.110057] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Several patterns of grey and white matter changes have been separately described in young adults with first-episode psychosis. Concomitant investigation of grey and white matter densities in patients with first-episode psychosis without other psychiatric comorbidities that include all relevant imaging markers could provide clues to the neurodevelopmental hypothesis in schizophrenia. METHODS We recruited patients with first-episode psychosis diagnosed according to the DSM-IV-TR and matched controls. All participants underwent magnetic resonance imaging (MRI). Voxel-based morphometry (VBM) analysis and mean diffusivity voxel-based analysis (VBA) were used for grey matter data. Fractional anisotropy and axial, radial and mean diffusivity were analyzed using tract-based spatial statistics (TBSS) for white matter data. RESULTS We included 15 patients and 16 controls. The mean diffusivity VBA showed significantly greater mean diffusivity in the first-episode psychosis than in the control group in the lingual gyrus bilaterally, the occipital fusiform gyrus bilaterally, the right lateral occipital gyrus and the right inferior temporal gyrus. Moreover, the TBSS analysis revealed a lower fractional anisotropy in the first-episode psychosis than in the control group in the genu of the corpus callosum, minor forceps, corticospinal tract, right superior longitudinal fasciculus, left middle cerebellar peduncle, left inferior longitudinal fasciculus and the posterior part of the fronto-occipital fasciculus. This analysis also revealed greater radial diffusivity in the first-episode psychosis than in the control group in the right corticospinal tract, right superior longitudinal fasciculus and left middle cerebellar peduncle. LIMITATIONS The modest sample size and the absence of women in our series could limit the impact of our results. CONCLUSION Our results highlight the structural vulnerability of grey matter in posterior areas of the brain among young adult male patients with first-episode psychosis. Moreover, the concomitant greater radial diffusivity within several regions already revealed by the fractional anisotropy analysis supports the idea of a late myelination in patients with first-episode psychosis.
Collapse
Affiliation(s)
| | - Logos Curtis
- Correspondence to: L. Curtis, Service de Psychiatrie Générale — Hôpitaux Universitaires de Genève, 2 Chemin du Petit-Bel-Air, 1225 Chêne-Bourg, Switzerland;
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Buchy L, Ad-Dab'bagh Y, Lepage C, Malla A, Joober R, Evans A, Lepage M. Symptom attribution in first episode psychosis: a cortical thickness study. Psychiatry Res 2012; 203:6-13. [PMID: 22917501 DOI: 10.1016/j.pscychresns.2011.09.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/31/2011] [Accepted: 09/20/2011] [Indexed: 01/08/2023]
Abstract
One dimension of insight in psychosis is the ability to attribute correctly one's symptoms to a mental disorder. Recent work suggests that gray matter volumes of the orbitofrontal cortex (OFC) are correlated with aggregate symptom attribution scores in first-episode schizophrenia. Whether regions beyond the OFC are important for symptom attribution remains to be established. Further, whether common or separable neural systems underlie attribution of specific symptoms (e.g., delusions, asociality) has not been studied. In the current magnetic resonance imaging study, 52 people with a first-episode psychosis (FEP) were rated with the Scale for Assessment of Unawareness of Mental Disorder on attribution of hallucinations, delusions, flat affect and asociality. Attribution ratings were regressed on cortical thickness at 81,924 vertices. Mapping statistics revealed that delusion misattribution was associated with thickness in the OFC [Brodmann's area (BA) 11/47]. Delusion, flat affect and asociality misattribution were associated with cortical thinness in the dorsolateral prefrontal cortex (BA 9/46). Differential associations emerged between each attribution item and cortical thickness/thinness in a variety of frontal, temporal, parietal and occipital areas. The results imply a selective role for the OFC in delusion misattribution in FEP. Evidence for cortical thickness covariation in a variety of regions suggests partial independence in the neural architecture underlying attribution for different symptoms in FEP.
Collapse
Affiliation(s)
- Lisa Buchy
- Brain Imaging Group, Douglas Mental Health University Institute, Verdun, Canada
| | | | | | | | | | | | | |
Collapse
|
15
|
Structural abnormalities in the cuneus associated with Herpes Simplex Virus (type 1) infection in people at ultra high risk of developing psychosis. Schizophr Res 2012; 135:175-80. [PMID: 22244184 PMCID: PMC3405258 DOI: 10.1016/j.schres.2011.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 10/20/2011] [Accepted: 11/05/2011] [Indexed: 11/21/2022]
Abstract
It has been suggested that some cases of schizophrenia may be caused by an interaction between physiological risk factors and exposure to certain neurotropic infectious agents such as Herpes Simplex Virus type 1 (HSV1). This study investigated whether HSV1 exposure was associated with structural brain abnormalities in individuals who, because of genetic or other factors, were deemed at ultra high risk (UHR) of developing psychosis. Twenty-five UHR individuals with a history of HSV1 exposure (HSV1+), 33 UHR participants without a history of HSV1 exposure (HSV1-) and 19 healthy controls participated in the study. All participants underwent a T1-weighted structural MRI scan, and HSV1 exposure was determined based on the presence of IgG class antibodies in the blood serum. Voxel based morphometry revealed that the HSV1+ participants exhibited volumetric gray matter reductions in the cuneus, relative to both the HSV1--and healthy control participants (p<0.05, small volume corrected for familywise error). The results of the study suggest that a history of HSV1 infection is associated with volumetric gray matter reductions in individuals at ultra-high risk for developing psychosis, and are consistent with previous studies that have identified structural gray matter abnormalities in HSV1-infected patients with established schizophrenia.
Collapse
|
16
|
Waters-Metenier S, Toulopoulou T. Putative structural neuroimaging endophenotypes in schizophrenia: a comprehensive review of the current evidence. FUTURE NEUROLOGY 2011. [DOI: 10.2217/fnl.11.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The genetic contribution to schizophrenia etiopathogenesis is underscored by the fact that the best predictor of developing schizophrenia is having an affected first-degree relative, which increases lifetime risk by tenfold, as well as the observation that when both parents are affected, the risk of schizophrenia increases to approximately 50%, compared with 1% in the general population. The search to elucidate the complex genetic architecture of schizophrenia has employed various approaches, including twin and family studies to examine co-aggregation of brain abnormalities, studies on genetic linkage and studies using genome-wide association to identify genetic variations associated with schizophrenia. ‘Endophenotypes’, or ‘intermediate phenotypes’, are potentially narrower constructs of genetic risk. Hypothetically, they are intermediate in the pathway between genetic variation and clinical phenotypes and can supposedly be implemented to assist in the identification of genetic diathesis for schizophrenia and, possibly, in redefining clinical phenomenology.
Collapse
Affiliation(s)
- Sheena Waters-Metenier
- Department of Psychosis Studies, King’s College London, King’s Health Partners, Institute of Psychiatry, London, UK
| | | |
Collapse
|
17
|
Bhojraj TS, Sweeney JA, Prasad KM, Eack SM, Francis AN, Miewald JM, Montrose DM, Keshavan MS. Gray matter loss in young relatives at risk for schizophrenia: relation with prodromal psychopathology. Neuroimage 2010; 54 Suppl 1:S272-9. [PMID: 20441795 DOI: 10.1016/j.neuroimage.2010.04.257] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 03/26/2010] [Accepted: 04/28/2010] [Indexed: 11/18/2022] Open
Abstract
The maturation of neocortical regions mediating social cognition during adolescence and young adulthood in relatives of schizophrenia patients may be vulnerable to heritable alterations of neurodevelopment. Prodromal psychotic symptoms, commonly emerging during this period in relatives, have been hypothesized to result from alterations in brain regions mediating social cognition. We hypothesized these regions to show longitudinal alterations and these alterations to predict prodromal symptoms in adolescent and young adult relatives of schizophrenia patients. 27 Healthy controls and 23 relatives were assessed at baseline and one-year follow-up using scale of prodromal symptoms and gray matter volumes of hypothesized regions from T1-MRI images. Regional volumes showing deficits on ANCOVA and repeated-measures ANCOVAs (controlling intra cranial volume, age and gender) were correlated with prodromal symptoms. At baseline, bilateral amygdalae, bilateral pars triangulares, left lateral orbitofrontal, right frontal pole, angular and supramarginal gyrii were smaller in relatives compared to controls. Relatives declined but controls increased or remained stable on bilateral lateral orbitofrontal, left rostral anterior cingulate, left medial prefrontal, right inferior frontal gyrus and left temporal pole volumes at follow-up relative to baseline. Smaller volumes predicted greater severity of prodromal symptoms at both cross-sectional assessments. Longitudinally, smaller baseline volumes predicted greater prodromal symptoms at follow-up; greater longitudinal decreases in volumes predicted worsening (increase) of prodromal symptoms over time. These preliminary findings suggest that abnormal longitudinal gray matter loss may occur in regions mediating social cognition and may convey risk for prodromal symptoms during adolescence and early adulthood in individuals with a familial diathesis for schizophrenia.
Collapse
Affiliation(s)
- Tejas S Bhojraj
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Nenadic I, Sauer H, Gaser C. Distinct pattern of brain structural deficits in subsyndromes of schizophrenia delineated by psychopathology. Neuroimage 2010; 49:1153-60. [PMID: 19833216 DOI: 10.1016/j.neuroimage.2009.10.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 09/08/2009] [Accepted: 10/06/2009] [Indexed: 12/17/2022] Open
Affiliation(s)
- Igor Nenadic
- Department of Psychiatry, Friedrich-Schiller-University of Jena, Philosophenweg 3, D-07743 Jena, Germany.
| | | | | |
Collapse
|