CT scans in schizophrenia

Does schizophrenia result from developmental or degenerative processes?

The debate as to whether schizophrenia is a neurodevelopmental or a neurodegenerative disorder has its roots in the latter part of the 19th century when authorities such as Clouston (1891) posited that at least some insanities were "developmental" in origin. These views were soon eclipsed by Kraepelin's (1896) concept of dementia praecox as a degenerative disease, and the latter view carried not only the day but also much of the 20th century. Then, in the 1980s several research groups again began to speculate that schizophrenia might have a significant developmental component (Feinberg, 1982-1983; Schulsinger et al., 1984; Murray et al., 1985; Murray and Lewis, 1987; Weinberger et al., 1987). What became known as the "neurodevelopmental hypothesis" received support from neuropathological studies implicating anomalies in early brain development such as aberrant migration of neurons. Unfortunately, these studies proved difficult, if not impossible, to replicate (Harrison, 1999). The pendulum, therefore, began to swing again, and in the latter part of the 1990s came renewed claims that the clinical progression of the illness was accompanied by continued cerebral ventricular enlargement and reduction in the volumes of certain brain structures. Nevertheless, since few doubt that there is a developmental component to schizophrenia, the question which we will address in this paper is whether schizophrenia is a) simply the final consequence of a cascade of increasing developmental deviance (Bramon et al., 2001), or b) whether there is an additional brain degeneration following onset of psychosis which is superimposed on the developmental impairment (Lieberman, 1999).

VBR in schizophrenia: relationship to family history of psychosis and season of birth

Ventricular enlargement has been consistently demonstrated in schizophrenia using both CT and MRI. Despite this, the structural changes that underlie increased ventricle-brain ratio (VBR) and its relationship to environmental factors (intrauterine viral exposure, obstetric complications, etc.) and family history of schizophrenia remain poorly defined. Increased VBR has been shown in some studies to correlate with an absence of family history of schizophrenia and with Winter-Spring birth. In an attempt to obtain a clearer picture of the contribution of environmental and genetic factors to VBR, we studied 54 patients with DSM III-R schizophrenia. VBR was determined from head CT scans via computerized planimetry. Family history of psychosis and non-psychotic mood disorder was determined with the family informant method. Season of birth was encoded in several ways, including season, trimester and dichotomously. Patients without a family history of psychosis had significantly larger VBR than patients with such a history; family history of mood disorder was not related to VBR. Season of birth was not predictive of VBR. Family history of psychosis and season of birth were not related to each other. These results are in line with prior work demonstrating an association between increased VBR and sporadic (non-familial) schizophrenia. We did not find a relationship between VBR and season of birth, which suggests that risk of perinatal viral exposure and other seasonal environmental factors may not account for the ventricular enlargement in non-familial schizophrenia observed in our sample.

Neuropsychological and P300 abnormalities in schizophrenics and their relatives

Schizophrenic subjects (N = 30) performed less well than controls (N = 30) on neuropsychological tests sensitive to frontal and temporal lobe impairment and showed prolonged latency of the P300 event-related potential. Relatives of schizophrenic probands were also tested. Relatives with an abnormal P300 had a similar range of neuropsychological deficits as were found in the schizophrenic group and relatives with a normal P300 response performed as well as the normal control group. The results suggest that neurophysiological and neuropsychological testing of relatives may help to clarify the mode of inheritance of schizophrenia in some families.

Neuroradiological findings in post partum psychiatric disorder

CT findings in 17 patients and MRI in one patient with post partum psychiatric disorder (PPPD; psychosis: n = 17, depressive neurosis: n = 1) were compared with randomly selected CT scans in non-PPPD patients matched for age and sex. In the PPPD group, 13 examinations (controls: 8) revealed one or several abnormal findings such as sulcal widening, ventricular enlargement and asymmetry. There was a higher prevalence of abnormal CT/MRI findings in the PPPD group (trend, P < 0.1).

Pilot study of computerised differentiation of Huntington's disease, schizophrenic, and Parkinson's disease patients using the contingent negative variation

In this study a potential known as the contingent negative variation was used to differentiate between schizophrenic, Parkinson's disease (PD), Huntington's disease (HD) patients and normal control subjects. The aim was to assist diagnosis and the avoidance of false diagnosis. 20 schizophrenic, 16 PD, 11 HD and 43 normal control subjects were enrolled for this study. The discriminatory variables were generated by applying spectral analysis to pre- and post-stimulus sections of the CNV responses. The patient differentiation was achieved by using the measured variables in a discriminant analysis program. It was possible to accurately differentiate between HD, schizophrenic, PD patients and normal control subjects. It was also attempted to differentiate between HD and schizophrenic patients, HD and PD patients, and schizophrenic and PD patients. The test results indicated that the method is useful in differentiating between these patients. This study had a number of limitations. It was based on a limited number of individuals, and an analysis of medication effects on the test results and the test-retest reliability assessment could not be carried out.

Multivariate analyses of CT findings in typical schizophrenia and atypical psychosis

In order to investigate the brain morphological differences between typical schizophrenia and atypical psychosis, the brain CTs of 41 patients with typical schizophrenia, 27 patients with atypical psychosis (ATP), and 20 controls were examined. The schizophrenics had larger values for 9 CT indices, i.e., interhemispheric fissure (IHF) index, VBR, 2 lateral ventricles (L-V) and 3rd ventricle (III-V) indices, and 4 sylvian fissure (SF) indices, while the values of ATP patients for 3 SF indices were greater than for the controls. Moreover, the schizophrenics had greater III-V and L-V indices than the ATP patients. The correlation matrix of CT indices indicates that the III-V index correlated well with the other CT indices, whereas the VBR, IHF and right SF indices did not. Therefore, it was speculated that there might be 3 subgroups, each of which has a main focus of alteration in the above-mentioned regions. Therefore, all the cases were divided by means of a cluster analysis into 5 groups. Group I, which contained mainly normal controls, and Group II, which consisted mainly of atypical psychosis patients, had no abnormal CT findings. Group III, which comprised mainly ATP patients and paranoid type schizophrenics, had right SF enlargement. Group IV, which showed significant IHF enlargement, and the residue group, which had larger VBR and significant left SF enlargement, consisted mostly of schizophrenics. Thus, our results suggest that the classification by CT data corresponds on the whole to our clinical diagnosis, according to which schizophrenic psychosis is divided into typical schizophrenia and atypical psychosis, and that each of the two psychosis groups may be further classified into distinct subgroups.

Ventricular enlargement in schizophrenia. A meta-analysis of studies of the ventricle:brain ratio (VBR)

Multivariate meta-analysis was performed on 39 studies of ventricular size in schizophrenia which used the ventricle:brain ratio (VBR). The size of the VBR was dependent both upon the date when studies were carried out (more recent studies showing a reduction in the difference between schizophrenics and controls), and upon the diagnostic criterion used in the studies. Methodological factors in study design seemed more important than the characteristics of the schizophrenic subjects, in determining the VBR. Our analysis suggests that there is a difference in VBR between schizophrenics and controls which would seem to be an indisputable characteristic of schizophrenia. However, the difference is smaller than has previously been thought, so that, although of undoubted theoretical interest in accounting for the aetiology of schizophrenia, it is probably too small to be of practical significance in diagnosis, or in the differentiation of subtypes.

The brain damage hypothesis of the seasonality of births in schizophrenia and major affective disorders: evidence from computerised tomography

Although the excess of schizophrenic births in the winter and early spring has been replicated and some non-conclusive work supports the same seasonal birth trend in patients with major affective disorders, the aetiopathogenetic foundations of this phenomenon remain uncertain. The primary role of perinatal seasonal factors that predispose to the development of schizophrenia via induction of brain damage has been invoked, as has a tendency for patients to conceive during the spring and early summer. In order to test these two hypotheses, cerebral ventricular size and cortical atrophy in 206 schizophrenics and 107 patients with major affective disorders were assessed by CT and analysed in relation to month of birth. Compared with schizophrenics born during the remainder of the year, those born between December and April, particularly in cases lacking a family history of schizophrenia, showed increased chances for ventricular enlargement, but not for cortical atrophy. No association between season of birth and central or cortical atrophy was found for patients with major affective disorders. This suggests that the brain-damaging effect played by perinatal seasonal factors has both a disease and an anatomical specificity.

Prefrontal sulcal prominence is inversely related to response to clozapine in schizophrenia

The object of this study was to determine if brain computed tomography (CT) scan measures are related to treatment response to clozapine, an atypical antipsychotic drug that is effective in some therapy-resistant schizophrenic patients. Thirty-four therapy-resistant patients were evaluated with the Brief Psychiatric Rating Scale (BPRS) before and after 6 weeks of treatment with clozapine. The patients were classified into Nonresponders, Moderate Responders, and Good Responders based on the percent change in BPRS. Comparison of these groups on prefrontal sulcal prominence (PSP) indicated a statistically significant linear trend, with nonresponders having the highest, moderate responders an intermediate degree, and good responders the least PSP. There were no linear trends for the ventricular-brain ratio (VBR), and no quadratic trends for either brain measure. A similar linear trend relating PSP to four of five BPRS subscales, including both positive and negative symptoms, was observed. The relationship between PSP and treatment response was also assessed with multiple linear regression, and PSP significantly contributed to prediction of BPRS at 6 weeks. The results are discussed with regards to the hypothesis that the effect of clozapine on psychopathology depends on prefrontal cortical function.

A magnetic resonance imaging study of schizophrenia: brain structure and clinical symptoms

Thirty-one patients with schizophrenia and 33 normal control subjects underwent MRI. The BPRS was used to rate clinical symptoms and the NART to estimate pre-morbid IQ. All were right handed. The temporal lobe was significantly smaller on the left than the right in both the control and schizophrenic groups. The amygdala was smaller on the left than the right in controls but not in schizophrenics. The parahippocampal gyrus was smaller on the left side in the schizophrenic group but not in controls. In the schizophrenic group, ventricular enlargement and cerebral atrophy were significantly related to severity of symptoms. Patients with marked negative symptoms had a bilateral reduction in the size of the head of caudate and the two measures were significantly correlated. Patients with marked positive symptoms had larger VBRs and again the clinical and morphometric changes were significantly correlated. There were no morphometric differences between patients with short duration (two years or less) and chronic symptoms.

Smooth pursuit eye tracking dysfunction and negative symptoms in schizophrenia

This study examined the hypothesis that negative symptoms are associated with abnormalities of smooth pursuit in schizophrenic patients. The pursuit eye movements of 25 subjects with schizophrenia and 25 matched normal control subjects were recorded using an infrared eye tracking system and quantified using the log of signal-to-noise ratio (1n S/N). The severity of negative symptoms within the schizophrenic group was rated using the Scale for the Assessment of Negative Symptoms. Previous findings of pursuit abnormalities among schizophrenic patients as a group were replicated. There was, however, no significant association between the eye tracking dysfunction and the severity of negative symptoms.

Psychiatry and the frontal lobes

The frontal lobes of the brain have long been regarded as enigmatic in their function and perhaps should be considered even more so in states of dysfunction. Observed associations between structural lesions and psychiatric symptoms and the demonstration of disturbed function and morphology in the frontal lobes of individuals suffering from major psychiatric disorders have led to increased interest in this brain area. Psychiatrists have been particularly concerned with seeking the aetiogenesis of common diagnostic entities and this article attempts to synthesize the available facts. A brief overview of relevant biological data precedes a description of methods of neuropsychological testing and the clinical features arising from frontal lobe damage. A discussion of the role of the frontal lobes in some aspects of personality function follows. Neuropsychiatric features associated with known frontal lobe pathology are described, prefacing a discussion of those psychiatric conditions where an aetiological role for frontal lobe dysfunction has been proposed.

Family history and cerebral ventricular enlargement in schizophrenia. A case control study

Ventricular size was measured from CT scans in 48 patients meeting RDC for schizophrenia who had a first-degree relative with a history of treatment for major psychiatric disorder, in 48 age- and sex-matched schizophrenic patients with no such history in first- or second-degree relatives, and in 48 matched, healthy controls. There was no difference in ventricular size between those with and without a positive family history, although both groups showed ventricular enlargement with respect to normal controls. Ventricular enlargement was demonstrated in the subgroup of 23 patients with a family history of schizophrenia, but not in the subgroup of 18 patients with a family history of affective disorder. These observations provide further evidence that schizophrenics with a family history of affective disorder may constitute an aetiologically distinct subgroup.

Schizophrenia and mental handicap: an historical review, with implications for further research

The relationship between schizophrenia and 'mental handicap' has been obscured by historical changes and varying diagnostic criteria. It has been generally accepted that there is an increased incidence of psychotic illness among people with intellectual retardation, but detailed community surveys are limited. Catatonia, severity of illness and research potential are all to be found in this 'dual diagnosis' group. The value of an historical analysis is underlined.

The Scottish First Episode Schizophrenia Study. VI. Computerised tomography brain scans in patients and controls

This is the initial report of a prospective study by computerised tomography brain scan of first episode schizophrenia. Twenty-seven patients who met Research Diagnostic Criteria for schizophrenia were compared with volunteer controls on ventricular:brain ratio, sulcal:brain volume ratio, and the widths of third ventricle and Sylvian and interhemispheric fissures. The results provide evidence that sulcal enlargement, but not ventricular abnormalities, may be detected at first admission for schizophrenic illness, and are discussed in relation to findings from other studies.

Tomografia cerebral computadorizada e esquizofrenia: revisão crítica da literatura

Vários estudos sobre tomografia cerebral computadorizada (CT) relatam alteração da estrutura cerebral em esquizofrenia. A grande variação da prevalência e da localização das anomalias pode estar relacionada à heterogenidade da amostra estudada, à escolha das medidas de CT ou ao uso de diferentes critérios diagnósticos. Apesar de alguns achados contraditórios, parece estabelecido que um subgrupo de pacientes esquizofrênicos apresenta atrofia cerebral discreta ou moderada; esse subgrupo se caracterizaria por apresentar cronicidade da doença, pior resposta ao tratamento neuroléptico e pela presença de outros sinais de disfunção cerebral difusa, como distúrbios neuropsicológicos, anormalidades no EEG e «soft signs» neurológicos. Sinais de atrofia na CT foram observados em pacientes esquizofrênicos jovens, no primeiro surto psicótico, indicando que o desenvolvimento das anomalias estruturais não é conseqüência do tratamento ou da cronicidade da doença. Nos diferentes estudos, pacientes com atrofia apresentaram menor carga genética (história familiar para a esquizofrenia) e se observou com maior freqüência história de complicações na gestação, no parto e trauma craniano nos primeiros anos do desenvolvimento. Em face da possibilidade de que doentes esquizofrênicos com atrofia cerebral formem um subgrupo homogêneo quanto à clínica e à etiopatologia da doença, é importante identificar e estudar as alterações da CT e caracterizar esse subgrupo de pacientes.

The gravely inadequate definition of a "mentally ill person" in the Mental Health Act (New South Wales) 1983

The definition, given in Section 5 of the new Act, of a "mentally ill person" is examined. It is argued that this "definition" is cumbersome, logically incoherent, and impractical. It is predicted that if given effect it will have very unwelcome consequences. Various sources of inherent misunderstanding and uncertainty are noted. Arguments are presented for allowing severe mental illness itself rather than its consequences to be the ground for involuntary hospitalization in certain circumstances. Various suggestions are proposed for the Section's amendment. These fall into two categories, depending upon alternative assumptions: (1) minor improvements, upon the pessimistic assumption that the main structure and content of the definition will be retained; (2) more radical amendment, involving the abandonment of the entire present structure of the section, and the adoption of a working definition of "mental illness" with clear safeguards against error and abuse. The nature and requirements of such a definition are discussed.

The familial/sporadic distinction as a strategy in schizophrenia research

The rationale and limitations of discriminating between cases of schizophrenia with and without a family history are reviewed. It is concluded from the evidence available that, by identifying subgroups of greater aetiological homogeneity, the strategy can be a useful starting point for research into likely causes.

Age and duration of illness as predictors of ventricular brain ratio (VBR) size in chronic schizophrenic patients. A stepwise regression analysis study

The CT scans of 18 chronic schizophrenic patients and 17 controls were evaluated for Ventricular Brain Ratio (VBR) size. A trend for the patient group to have larger VBR than controls was present but did not reach statistical significance at the 5% level. Age was found to be an important correlate of VBR within the patient group but not among controls. In a stepwise multiple-regression model age, among other independent variables, can account for 47% of VBR variance in schizophrenic patients. Linear regression analysis did not reveal significant association between VBR and age in control subjects.

Combined measure of smooth pursuit eye movements and ventricle-brain ratio in schizophrenic disorders

Smooth pursuit eye movements (SPEM) were examined in 67 schizophrenic patients and 101 control subjects. Our study confirms that eye tracking in schizophrenic patients is impaired compared to that in controls. The similar pattern of distribution of SPEM abnormalities in Italian patients as in ethnically different populations strengthens the hypothesis that these abnormalities may be a biological marker for schizophrenia. We also examined the relationship between SPEM abnormalities and the ventricle-brain ratio (VBR), which is also considered useful for differentiating schizophrenic subgroups. Our preliminary results indicate that there is an inverse correlation between abnormal SPEM performance and ventricular enlargement, suggesting that these abnormalities mark distinct subgroups of patients.

Is there really a split in schizophrenia? The genetic evidence

Although the clinical presentation and course of schizophrenia is highly variable, it is unclear whether this reflects heterogeneity at an aetiological level. The genetic evidence is reviewed concerning 'traditional' clinical subtypes as more novel categories derived from multivariate statistical methods and Crow's type I-type II classification. Recent data based on a twin series and re-analysis of older published family material suggest that attempts to divide up schizophrenia have resulted in splits between two or more categories of disorder which occupy different positions on the same continuum of liability. Thus, apparent heterogeneity is more likely to be due to quantitative difference in familial-genetic loading rather than qualitative differences. Similarly, the hypothesis that schizophrenia can be broadly divided into two groups, one genetic and the other non-genetic has little to support it. It seems improbable that any further useful and genetically relevant subdivision of schizophrenia can be effected on purely clinical grounds. Further progress awaits developments in the discovery of endophenotypes and the application of molecular genetic marker strategies.

Treatment resistant chronic psychopathology and CT scans in schizophrenia

In order to examine the relationship between the neuroleptic resistant chronic psychopathology and CT findings in schizophrenia, 25 schizophrenics who had been treated well and were in a stable condition were assessed for positive and negative symptoms, CT findings, medication, and the clinical course of illness. Correlational analysis showed that there was a group of patients who had comparatively small ventricles and presented treatment resistant positive symptoms, and another group of patients who had larger ventricles and lacked positive symptoms. Negative symptoms showed a tendency toward positive correlation with atrophic CT changes of cortices. Literature on CT findings and symptomatology was critically reviewed. The importance of the more chronic positive symptoms correlating to CT findings in schizophrenia were discussed.

Increased CSF amino acids and ventricular enlargement in schizophrenia: a preliminary study

We found significantly higher levels of cerebrospinal fluid alanine, glycine, leucine, and phenylalanine in schizophrenic patients compared to healthy controls. Ventricular enlargement was present in 4 of 11 schizophrenics, and elevated CSF alanine was highly correlated with ventricular enlargement. The implications of these findings are discussed.

Cerebral ventricular enlargement in chronic schizophrenia: consistencies and contradictions

A study of cerebral ventricular size measured as ventricle to brain ratio (VBR) using computerised tomographic brain scan in chronic schizophrenics provided no support for suggestions that there are significant differences between patients who fall into different clinical subtypes. We found no significant difference in VBR between patients with and without a family history of schizophrenia or between those with or without paranoid symptoms. Applying Crow's classification, contrary to expectations, Type 1 patients had significantly larger ventricles than those with 'mixed' symptomatology (both Type 1 and Type 2 features). We also applied a variety of operational criteria which attempt to define schizophrenia as a whole: of these only Schneider's first-rank symptoms (FRS) yielded conclusive results--FRS-positive patients had significantly larger mean VBR than those without such symptoms. Previously, it has been suggested that ventricular enlargement is more closely associated with 'negative' than with 'positive' symptoms.

Obstetric complications, neurodevelopmental deviance, and risk of schizophrenia

It is concluded from a review of the literature and a pilot survey that schizophrenic patients more frequently have a history of obstetric complications (OCs) than do other psychiatric patients and normal subjects. OCs are associated with increased cerebral ventricular size in both infancy and adulthood, and are more common among non-familial schizophrenic patients. Neonatal cerebrovascular events consequent upon OCs provide a mechanism to explain the increased risk of neurodevelopmental deviance and later schizophrenia.

Neuropsychological test performance, brain morphological measures and CSF monoamine metabolites in schizophrenic patients

Twenty-three drug-free patients with an acute schizophrenic psychosis were studied by clinical rating scales, neuropsychological tests, computed tomography (CT) of the brain and analysis of monoamine metabolites in the cerebrospinal fluid (CSF). The psychological tests used were the Swedish version of the Wechsler-Bellevue Intelligence scale (WBI) and the Block Design test. The patients' performance in the Block Design test was negatively correlated to the width of the third and lateral ventricles. Test profiles indicative of schizophrenic cognitive impairment and left hemisphere dysfunction correlated significantly with a wide third ventricle, but not with the size of the lateral ventricles. Patients with a test profile indicative of left hemisphere dysfunction also had wider Sylvian fissures than the remaining patients. Neuropsychological test scores did not correlate with the CSF levels of the monoamine metabolites HVA, MHPG and 5-HIAA. Positive psychotic and autistic symptoms did not correlate with psychological test results, monoamine metabolites or with CT measures. The association between neuropsychological impairment and enlargement of the brain ventricles is in line with previous findings indicating that a subgroup of schizophrenic patients may be identified by neuropsychological and morphological methods.

Images of the brain in psychiatry

In psychiatry, the use of computer-based techniques for constructing images of the brain is relatively recent. Nevertheless, findings that have resulted from their use thus far might provide us with a new perspective in the understanding of mental illness. They raise the possibility that many of the disorders, previously understood primarily in terms of psychosocial factors, are associated with specific abnormalities of brain structure and/or function. Although terms such as NMR, BEAM, RCBF, SPECT and PET are increasingly found in medical and psychiatric journals, few people understand in simple terms the principles on which these techniques are based. In this article the techniques used for constructing images of brain structure and function are explained, and an overview of the findings in psychiatric disorders is presented.

Computed tomography and pattern reversal visual evoked potentials in chronic schizophrenic patients

Eighteen chronic schizophrenic subjects treated with a uniform dosage (4-6 mg/day p.o.) of haloperidol were submitted to computed tomography (CT) and to pattern reversal visual evoked potentials (VEPs). Compared to age-matched controls, schizophrenic patients showed lateral and third ventricular enlargement, greatly delayed VEP latencies and reduced amplitudes. These abnormalities were not related to diagnostic subgroups. Schizophrenic patients with a positive family history for major psychiatric disorders showed normal CT scan measures and greatly abnormal VEP measures, whereas patients with a negative family history showed CT scan signs of atrophy and less pronounced VEP abnormalities.

Mindlessness and brainlessness in psychiatry

The theme of this address—that brain and mind are as warp and woof in the fabric of psychiatry—may seem so much a truism as to be a banal choice. I think not. Despite the lip service paid to brain-mind integration, its implications are daily contravened in both theory and practice. At least, this is so in the country where I reside. If the problem is more extreme in the States, as most everything seems to be, recall the words Sir Aubrey Lewis (1953) wrote in commenting on Anglo-American contrasts, some 30 years ago: “the chief differences between your psychiatric scene and ours are differences only of quantity and tempo.” Think of me, then, as an anthropologist describing an exotic foreign culture and reporting on the strange customs of the natives, in hope of shedding light on your own.