Monitoring of self-generated speech in adolescents with 22q11.2 deletion syndrome

Confabulations in a teenager with a right frontal hemispherotomy: Possible underlying mechanisms

Objective: Confabulations, i.e. false memories without intention to deceive, can be observed in adults with frontal brain damage. Confabulations are typically associated with episodic memory and/or executive disorders although the severity of these impairments is highly variable. Confabulations may also be associated with emotional/motivational particularities, as a positive bias seems to prevail in such situations. Several distinct cognitive and socio-affective processes may account for the various types of confabulations and these issues remain open. Method: We present the case of a teenager with an early acquired frontal damage, referred for "strange lies." Besides a standard neuropsychological assessment, we explored (1) source memory, using a reality-monitoring task, (2) episodic autobiographical memory, including both the recollection of the past memories and the ability to imagine future personal events, with an episodic future thinking task (EFT), (3) the sense of self, with questionnaires targeting self-representations, self-esteem and self-competence. Results: The results showed the expected source memory deficits and poor episodic future thinking, whereas episodic autobiographical memory was preserved, contrary to the episodic memory dysfunction usually evidenced in adult confabulators. The confabulations produced by this teenager displayed a clear positive bias, seemed to fit to personal/social goals and to wishful ideations, and were associated with an above average self-esteem and self-representation. Conclusions: These results support the hypothesis of self-identity and emotional regulatory roles of the confabulations. Although the literature on confabulating children/teenagers is nearly non-existent, a more systematic screening of confabulations should be conducted in order to avoid false interpretation to strange discourse or behavior.

Agency Deficits in a Human Genetic Model of Schizophrenia: Insights From 22q11DS Patients

Schizophrenia is a chronic and disabling mental illness characterized by a disordered sense of self. Current theories suggest that deficiencies in the sense of control over one's actions (Sense of Agency, SoA) may underlie some of the symptoms of schizophrenia. However, it is not clear if agency deficits are a precursor or a result of psychosis. Here, we investigated full body agency using virtual reality in a cohort of 22q11 deletion syndrome participants with a genetic propensity for schizophrenia. In two experiments employing virtual reality, full body motion tracking, and online feedback, we investigated SoA in two separate domains. Our results show that participants with 22q11DS had a considerable deficit in monitoring their actions, compared to age-matched controls in both the temporal and spatial domain. This was coupled with a bias toward erroneous attribution of actions to the self. These results indicate that nonpsychotic 22q11DS participants have a domain general deficit in the conscious sensorimotor mechanisms underlying the bodily self. Our data reveal an abnormality in the SoA in a cohort with a genetic predisposition for schizophrenia, but without psychosis, providing evidence that deficits in delineation of the self may be a precursor rather than a result of the psychotic state.

Self-Monitoring for speech and its links to age, cognitive effort, schizotypal trait expression and impulsivity during adolescence

Introduction: Disruptions in self-monitoring processes represent key cognitive factors associated with schizophrenia spectrum disorders. In the current study, we assessed the effects of age and cognitive effort on self-monitoring for speech in adolescence, as well as its associations with personality dimensions pertaining to schizotypy and impulsivity.Methods: 121 community adolescents undertook a self-monitoring task that assesses the capacity to discriminate between self-generated overt and silent speech, for items requiring different levels of cognitive effort. Self-report measures were used to assess trait dimensions of schizotypy and impulsivity.Results: Cognitive effort, but not age, contributed to the overall rate of self-monitoring errors. Contrary to clinical psychosis and high risk samples, increased cognitive effort in healthy adolescents led to more internalising than externalising self-monitoring errors. Higher scores on the interpersonal dimension of schizotypy were associated with increases in the total rate of self-monitoring errors. No associations were found between positive schizotypy and externalising self-monitoring misattributions. Finally, trait impulsivity dimensions were not associated with self-monitoring performance.Conclusions: The present findings suggest that self-monitoring confusions may be linked to trait-risk for psychosis in adolescence. Future studies can prospectively assess whether the association between negative schizotypal traits and self-monitoring represents a distal marker of psychosis vulnerability.

Patterns of source monitoring bias in incarcerated youths with and without conduct problems

INTRODUCTION

Antisocial individuals present behaviours that violate the social norms and the rights of others. In the present study, we examine whether biases in monitoring the self-generated cognitive material might be linked to antisocial manifestations during adolescence. We further examine the association with psychopathic traits and conduct problems (CPs).

METHODS

Sixty-five incarcerated adolescents (IAs; M age = 15.85, SD = 1.30) and 88 community adolescents (CAs; M age = 15.78, SD = 1.60) participated in our study. In the IA group, 28 adolescents presented CPs (M age = 16.06, SD = 1.41) and 19 did not meet the diagnostic criteria for CPs (M age = 15.97, SD = 1.20). Source monitoring was assessed through a speech-monitoring task, using items requiring different levels of cognitive effort; recognition and source-monitoring bias scores (internalising and externalising biases) were calculated.

RESULTS

Between-group comparisons indicate greater overall biases and different patterns of biases in the source monitoring. IA participants manifest a greater externalising bias, whereas CA participants present a greater internalising bias. In addition, IA with CPs present different patterns of item recognition.

CONCLUSIONS

These results indicate that the two groups of adolescents present different types of source-monitoring bias for self-generated speech. In addition, the IAs with CPs present impairments in item recognition. Future studies may examine the developmental implications of self-monitoring biases in the perseverance of antisocial behaviours from adolescence to adulthood.

Genomic and Imaging Biomarkers in Schizophrenia

Recent large-scale genomic studies have confirmed that schizophrenia is a polygenic syndrome and have implicated a number of biological pathways in its aetiology. Both common variants individually of small effect and rarer but more penetrant genetic variants have been shown to play a role in the pathogenesis of the disorder. No simple Mendelian forms of the condition have been identified, but progress has been made in stratifying risk on the basis of the polygenic burden of common variants individually of small effect, and the contribution of rarer variants of larger effect such as Copy Number Variants (CNVs). Pathway analysis of risk-associated variants has begun to identify specific biological processes implicated in risk for the disorder, including elements of the glutamatergic NMDA receptor complex and post synaptic density, voltage-gated calcium channels, targets of the Fragile X Mental Retardation Protein (FMRP targets) and immune pathways. Genetic studies have also been used to drive genomic imaging approaches to the investigation of brain markers associated with risk for the disorder. Genomic imaging approaches have been applied both to investigate the effect of polygenic risk and to study the impact of individual higher-penetrance variants such as CNVs. Both genomic and genomic imaging approaches offer potential for the stratification of patients and at-risk groups and the development of better biomarkers of risk and treatment response; however, further research is needed to integrate this work and realise the full potential of these approaches.

No age effect in the prevalence and clinical significance of ultra-high risk symptoms and criteria for psychosis in 22q11 deletion syndrome: Confirmation of the genetically driven risk for psychosis?

BACKGROUND

The 22q11.2 deletion syndrome (22q11DS) is one of the highest known risk factors for schizophrenia. Thus, the detection of 22q11DS patients at particularly high risk of psychosis is important, yet studies on the clinical significance of the widely used ultra-high risk (UHR) criteria in 22q11DS are inconclusive. Since age was reported to moderate clinical significance of UHR symptoms in community samples, we explored whether age at presentation of UHR symptoms and criteria may explain part of this heterogeneity.

METHODS

111 patients with 22q11DS (8-30 years; 15.7±4.7) were assessed for UHR symptoms/criteria. Information on diagnoses, psychosocial functioning, and IQ were collected.

RESULTS

Any UHR symptom was reported by 38.7%, any UHR criterion by 27%. No significant influence of age on the prevalence of UHR symptoms or criteria was detected. Moreover, age did not significantly modulate the association between UHR symptoms and functioning. However, significant interaction terms suggested that younger age groups were more likely to meet UHR criteria in the presence of UHR symptoms compared to the adult group.

DISCUSSION

Compared to the general population, prevalence of UHR symptoms and criteria was 3.8-fold and 20.8-fold in our 22q11DS sample. Contrary to the general population, age only modulated the prevalence of UHR criteria among those with UHR symptoms, but not their prevalence per se or their clinical significance. This suggests that UHR symptoms might develop as a trait factor in terms of a genetically driven schizotypal disposition in 22q11DS, thus necessitating future studies on psychosis-risk indicators in this genetic high-risk group.

Cognitive behavioral therapy in 22q11.2 microdeletion with psychotic symptoms: What do we learn from schizophrenia?

The 22q11.2 deletion syndrome (22q11.2DS) is one of the most common microdeletion syndromes, with a widely underestimated prevalence between 1 per 2000 and 1 per 6000. Since childhood, patients with 22q11.2DS are described as having difficulties to initiate and maintain peer relationships. This lack of social skills has been linked to attention deficits/hyperactivity disorder, anxiety and depression. A high incidence of psychosis and positive symptoms is observed in patients with 22q11.2DS and remains correlated with poor social functioning, anxiety and depressive symptoms. Because 22q11.2DS and schizophrenia share several major clinical features, 22q11.2DS is sometimes considered as a genetic model for schizophrenia. Surprisingly, almost no study suggests the use of cognitive and behavioral therapy (CBT) in this indication. We reviewed what should be learned from schizophrenia to develop specific intervention for 22q11.2DS. In our opinion, the first step of CBT approach in 22q11.2DS with psychotic symptoms is to identify precisely which tools can be used among the already available ones. Cognitive behavioral therapy (CBT) targets integrated disorders, i.e. reasoning biases and behavior disorders. In 22q11.2DS, CBT-targeted behavior disorders may take the form of social avoidance and withdrawal or, in the contrary, a more unusual disinhibition and aggressiveness. In our experience, other negative symptoms observed in 22q11.2DS, such as motivation deficit or anhedonia, may also be reduced by CBT. Controlled trials have been studying the benefits of CBT in schizophrenia and several meta-analyses proved its effectiveness. Therefore, it is legitimate to propose this tool in 22q11.2DS, considering symptoms similarities. Overall, CBT is the most effective psychosocial intervention on psychotic symptoms and remains a relevant complement to pharmacological treatments such as antipsychotics.

Cognitive phenotype and psychiatric disorder in 22q11.2 deletion syndrome: A review

The behavioural phenotype of 22q11.2 deletion syndrome syndrome (22q11DS), one of the most common human multiple anomaly syndromes, frequently includes intellectual disability (ID) together with high risk of diagnosis of psychotic disorders including schizophrenia. Candidate cognitive endophenotypes include problems with retrieval of contextual information from memory and in executive control and focussing of attention. 22q11DS may offer a model of the relationship between ID and risk of psychiatric disorder. This paper reviews research on the relationship between the cognitive phenotype and the development of psychiatric disorders in 22q11DS. Aspects of cognitive function including verbal I.Q., visual memory, and executive function, are associated with mental health outcome in people with 22q11DS. This relationship may result from a common neurobiological basis for the cognitive difficulties and psychiatric disorders. Some of the cognitive difficulties experienced by people with 22q11DS, especially in attention, memory retrieval, and face processing, may, however, in themselves constitute risk factors for development of hallucinations and paranoid delusions. Future research into factors leading to psychiatric disorder in people with 22q11DS should include assessment of social and psychological factors including life events, symptoms associated with trauma, attachment, and self-esteem, which together with cognitive risk factors may mediate mental health outcome.

Long-range dysconnectivity in frontal and midline structures is associated to psychosis in 22q11.2 deletion syndrome

Patients affected by 22q11.2 deletion syndrome (22q11DS) present a characteristic cognitive and psychiatric profile and have a genetic predisposition to develop schizophrenia. Although brain morphological alterations have been shown in the syndrome, they do not entirely account for the complex clinical picture of the patients with 22q11DS and for their high risk of psychotic symptoms. Since Friston proposed the "disconnection hypothesis" in 1998, schizophrenia is commonly considered as a disorder of brain connectivity. In this study, we review existing evidence pointing to altered brain structural and functional connectivity in 22q11DS, with a specific focus on the role of dysconnectivity in the emergence of psychotic symptoms. We show that widespread alterations of structural and functional connectivity have been described in association with 22q11DS. Moreover, alterations involving long-range association tracts as well as midline structures, such as the corpus callosum and the cingulate gyrus, have been associated with psychotic symptoms in this population. These results suggest common mechanisms for schizophrenia in syndromic and non-syndromic populations. Future directions for investigations are also discussed.

Mother-Child Interaction as a Window to a Unique Social Phenotype in 22q11.2 Deletion Syndrome and in Williams Syndrome

Mother-child interactions in 22q11.2 Deletion syndrome (22q11.2DS) and Williams syndrome (WS) were coded for maternal sensitivity/intrusiveness, child's expression of affect, levels of engagement, and dyadic reciprocity. WS children were found to express more positive emotions towards their mothers compared to 22q11.2DS children and those with developmental delay in a conflict interaction. During the same interaction, dyads of 22q11.2DS children were characterized by higher levels of maternal intrusiveness, lower levels of child's engagement and reduced reciprocity compared to dyads of typically developing children. Finally, 22q11.2DS children with the COMT Met allele showed less adaptive behaviors than children with the Val allele. Dyadic behaviors partially coincided with the distinct social phenotypes in these syndromes and are potential behavioral markers of psychopathological trajectory.

Action simulation in hallucination-prone adolescents

Theoretical and empirical accounts suggest that impairments in self-other discrimination processes are likely to promote the expression of hallucinations. Studies using a variety of paradigms involving self-performed actions argue in favor of perspective taking confusion in hallucination-prone subjects. However, our understanding of such processes during adolescence is still at an early stage. The present study thus aims (1) to delineate the neural correlates sustaining mental simulation of actions involving self-performed actions (first-person perspective; 1PP) and other-performed actions (third-person perspective; 3PP) during adolescence (2) to identify atypical activation patterns during 1PP/3PP mental simulation of actions in hallucination-prone adolescents (3) to examine whether differential risk for schizophrenia (clinical vs. genetic) is also associated with differential impairments in the 1PP/3PP mental simulation of actions during adolescence. Twenty-two typically developing controls (Control group; 6 females), 12 hallucination-prone adolescents [auditory hallucination (AH) group; 7 females] and 13 adolescents with 22q11.2 Deletion Syndrome (22q11.2DS group; 4 females) were included in the study. During the fMRI task, subjects were presented with a cue (self-other priming cues) indicating to perform the task using either a first person perspective (“you”-1PP) or a third person perspective (“best friend”-3PP) and then they were asked to mentally simulate actions based on the type of cue. Hallucination-proneness was assessed using a self-report questionnaire [Cardiff Anomalous Perception Scale (CAPS)]. Our results indicated that atypical patterns of cerebral activation, particularly in the key areas of self-other distinction, were found in both groups at risk for auditory hallucinations (AHs and 22q11.2DS). More precisely, adolescents in the AH group presented decreased activations in the right middle occipital gyrus BA19, left cingulate gyrus BA31, and right precuneus BA31 for the 3PP > 1PP contrast. Adolescents in the 22q11.2DS group presented decreased activations in the right superior occipital gyrus BA19, left caudate tail and left precuneus BA7 for the 3PP > 1PP contrast. In comparison to the Control group, only the 22q11.2DS adolescents showed a decreased activation for other-related cues (prime other > prime self contrast) in areas of visual imagery, episodic memory and social cognition. This study characterizes the neural correlates of mental imagery for actions during adolescence, and suggests that a differential risk for hallucination-proneness (clinical vs. genetic) is associated to similar patterns of atypical activations in key areas sustaining self-other discrimination processes. These observations may provide relevant information for future research and prevention strategies with regards to hallucination-proneness during adolescence.

Resting-state networks in adolescents with 22q11.2 deletion syndrome: associations with prodromal symptoms and executive functions

Atypical functional connectivity in the maturing brains of 22q11.2 deletion syndrome (22q11DS) may contribute to the expression of early psychotic symptoms commonly reported by these youths. This study's objective was to examine functional connectivity in cerebral networks at rest (Resting-State Networks; RSNs) and their relationship to symptomatic and neuropsychological characteristics putting them at very high risk factor for developing psychosis. Twenty-seven adolescents with 22q11DS and 33 typically developing control adolescents matched for age, gender and handedness underwent an 8-minute resting state functional MRI session. RSNs identification procedure employed Independent Component Analysis (ICA). We tested for potential group differences in functional connectivity within-networks. Then, we examined relationships between network connectivity and symptomatic/neuropsychological characteristics in the 22q11DS group. A total of nine resting-state networks were identified. Between-group differences suggested both increased and decreased functional connectivity in the 22q11DS group, involving the default-mode, sensorimotor, visuo-spatial, and high level visual networks. Finally, atypical connectivity in the default-mode network, specifically within the left superior frontal gyrus region, correlated with prodromal symptom intensity and neuropsychological performances in the 22q11DS group. The results suggest that atypical functional connectivity may sustain both increased vulnerability to psychosis and characteristic cognitive impairments in 22q11DS.

Is there a core neuropsychiatric phenotype in 22q11.2 deletion syndrome?

PURPOSE OF REVIEW

The aim is to discuss the clinical features of psychiatric illness in 22q11.2 deletion syndrome (22q11DS), and to review current evidence that a core neuropsychiatric phenotype could underlie the full spectrum of different presentations.

RECENT FINDINGS

Individuals carrying the 22q11.2 microdeletion are at risk for diverse psychiatric diagnoses across the lifespan, including schizophrenia in a significant minority, and anxiety or mood disorder in the majority. Symptoms and cognitive disruptions can be grouped into domains: attention-executive deficits, social-cognitive deficits, anxiety-affective dysregulation, and psychotic phenomena. These domains do not respect the boundaries of traditional diagnostic categories, and can be consistently recognized in children, adolescents and adults. There is early evidence that some symptom-domain disruptions may predict adult psychiatric morbidity.

SUMMARY

If a core neuropsychiatric phenotype does exist in 22q11DS, its detection is likely to require dimensional assessment of subtle aspects of cognitive and emotional processing, not encompassed by current diagnostic systems. A core phenotype would account for disruptions across multiple symptom domains, directly reflecting genetic and neurobiological mechanisms. Relative severity of a core phenotype would predict risk for multiple psychiatric disorders, and could, therefore, be an important target for therapeutic and preventive interventions. A core phenotype meeting these criteria has not yet been defined for 22q11DS.

Velopharyngeal Dysfunction and 22q11.2 Deletion Syndrome: A Longitudinal Study of Functional Outcome and Preoperative Prognostic Factors

Objective

To describe the effect of time after velopharyngoplasty on outcome and to search for preoperative prognostic factors for residual hypernasality in patients with 22q11.2 deletion syndrome.

Design

Retrospective chart review.

Setting

Tertiary hospital.

Patients

Patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction who underwent a primary (modified) Honig velopharyngoplasty between 1989 and 2009.

Main Outcome Measures

Clinically obtained perceptual and instrumental measurements of resonance, nasalance, and understandability before and after velopharyngoplasty.

Results

Data were available for 44 of 54 patients (81% follow-up), with a mean follow-up time of 7.0 years (range, 1.0 to 19.4 years). During follow-up, 24 (55%) patients attained normal resonance and 20 (45%) had residual hypernasality or underwent revision surgery. Mean postoperative nasalance and understandability scores were closer to the norm than mean preoperative scores were (2.0 versus 5.5 standard deviations for the normal passage, 1.3 versus 8.1 standard deviations for the nonnasal passage, and score 2.3 versus 4.1 understandability). Serial measurements revealed that hypernasality only resolved an average of 5 years after surgery, and three patients whose resonance initially normalized later relapsed to hypernasality. Gender, age at surgery, lateral pharyngeal wall adduction, velar elevation, presence of a palatal defect, previous intravelar veloplasty, nasalance, understandability, adenoidectomy, hearing loss, and IQ were not able to predict poor outcome following primary velopharyngoplasty (all p > .05).

Conclusions

In this chart review of patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction, residual hypernasality persisted in many patients after velopharyngoplasty. None of the preoperative factors that were studied had prognostic value for the outcome.

Comparing the neural bases of self-referential processing in typically developing and 22q11.2 adolescents

The investigation of self-reflective processing during adolescence is relevant, as this period is characterized by deep reorganization of the self-concept. It may be the case that an atypical development of brain regions underlying self-reflective processing increases the risk for psychological disorders and impaired social functioning. In this study, we investigated the neural bases of self- and other-related processing in typically developing adolescents and youths with 22q11.2 deletion syndrome (22q11DS), a rare neurogenetic condition associated with difficulties in social interactions and increased risk for schizophrenia. The fMRI paradigm consisted in judging if a series of adjectives applied to the participant himself/herself (self), to his/her best friend or to a fictional character (Harry Potter). In control adolescents, we observed that self- and other-related processing elicited strong activation in cortical midline structures (CMS) when contrasted with a semantic baseline condition. 22q11DS exhibited hypoactivation in the CMS and the striatum during the processing of self-related information when compared to the control group. Finally, the hypoactivation in the anterior cingulate cortex was associated with the severity of prodromal positive symptoms of schizophrenia. The findings are discussed in a developmental framework and in light of their implication for the development of schizophrenia in this at-risk population.

Neural correlates of reality monitoring during adolescence

BACKGROUND

Reality monitoring processes serve the critical function of discriminating between externally derived information and self-generated information. Several reality monitoring studies with healthy adult participants have identified the anterior prefrontal cortex (PFC) as consistently engaged during the recollection of self-generated contextual cues. Furthermore, reduced activity of medial PFC has been linked with schizotypal trait expression of delusion and hallucination-like symptoms in healthy adults undergoing fMRI reality-monitoring tasks. The present study seeks to examine the cerebral underpinnings of reality monitoring during adolescence, a developmental stage where the expression of schizotypal traits may increase risk for psychosis.

METHOD

A group of 33 adolescents, assessed using the Schizotypal Personality Scale (SPQ), underwent fMRI while performing a reality monitoring task. After an encoding session where the subject or the experimenter read out a series of complete or incomplete word pairs, subjects were presented with the first word of studied word pairs and asked whether the corresponding word had been: (1) perceived or produced (context monitoring), or (2) read by the subject or by the experimenter (origin monitoring).

RESULTS

Analyses revealed a common set of activated brain areas during both context and origin monitoring conditions. When compared to context monitoring, origin monitoring was associated with greater activation in anterior PFC within Brodmann area 10 (BA 10). Correlation analyses revealed that reduced signal change in BA 10 during origin monitoring was associated with greater schizotypal trait expression.

CONCLUSION

Much like adults performing a similar reality monitoring task, adolescents exhibit a common pattern of brain activity during origin and context monitoring, with functional specialization within the prefrontal cortex involving preferential activation of BA 10 during origin monitoring. Greater schizotypal trait expression appears to be significantly associated to reduced BA 10 activity during origin monitoring trials. Results are discussed in relation to cortical specialization within the PFC and trait expression during adolescence.