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Peterson BS, Kaur T, Sawardekar S, Colibazzi T, Hao X, Wexler BE, Bansal R. Aberrant hippocampus and amygdala morphology associated with cognitive deficits in schizophrenia. Front Cell Neurosci 2023; 17:1126577. [PMID: 36909281 PMCID: PMC9996667 DOI: 10.3389/fncel.2023.1126577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background Working memory deficits are thought to be a primary disturbance in schizophrenia. We aimed to identify differences in morphology of the hippocampus and amygdala in patients with schizophrenia compared with healthy controls (HCs), and in patients who were either neuropsychologically near normal (NPNN) or neuropsychologically impaired (NPI). Morphological disturbances in the same subfields of the hippocampus and amygdala, but of greater magnitude in those with NPI, would strengthen evidence for the centrality of these limbic regions and working memory deficits in the pathogenesis of schizophrenia. Methods We acquired anatomical MRIs in 69 patients with schizophrenia (18 NPNN, 46 NPI) and 63 age-matched HC participants. We compared groups in hippocampus and amygdala surface morphologies and correlated morphological measures with clinical symptoms and working memory scores. Results Schizophrenia was associated with inward deformations of the head and tail of the hippocampus, protrusion of the hippocampal body, and widespread inward deformations of the amygdala. In the same regions where we detected the effects of schizophrenia, morphological measures correlated positively with the severity of symptoms and inversely with working memory performance. Patients with NPI displayed a similar pattern of anatomical abnormality compared to patients with NPNN. Conclusion Our findings indicate that anatomical abnormalities of the hippocampus relate to working memory performance and clinical symptoms in persons with schizophrenia. Moreover, NPNN and NPI patients may lie on a continuum of severity, both in terms of working memory abilities and altered brain structure, with NPI patients being more severe than NPNN patients in both domains.
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Affiliation(s)
- Bradley S. Peterson
- Children’s Hospital Los Angeles, Department of Psychiatry at the Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Bradley S. Peterson,
| | - Tejal Kaur
- Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, United States
| | - Siddhant Sawardekar
- Children’s Hospital Los Angeles, Department of Psychiatry at the Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Tiziano Colibazzi
- Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, United States
| | - Xuejun Hao
- Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, United States
| | - Bruce E. Wexler
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Ravi Bansal
- Children’s Hospital Los Angeles, Department of Psychiatry at the Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Ferrari M, Godio M, Martini S, Callegari C, Cosentino M, Marino F. Effect of quetiapine on inflammation and immunity: a systematic review. Int J Psychiatry Clin Pract 2022:1-12. [PMID: 35913757 DOI: 10.1080/13651501.2022.2101928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Knowledge about the neurobiology of psychiatric disorders is increasing in the last decades and evidence from literature suggests a central role for immuno-inflammatory mechanisms in these illnesses. The antipsychotic quetiapine acts on dopamine and serotonin signalling and well-established evidence demonstrates that these neurotransmitters can modulate immune functions in healthy and diseased conditions. Starting from this perspective, in the last few decades, a number of studies attempted to identify quetiapine effects on immune functions in order to highlight a possible additional effect of this drug in psychotic diseases, although no conclusive results were obtained. METHODS We critically reviewed preclinical and clinical studies evaluating quetiapine effects on immune systems, suggesting strategies for future work in this field. RESULTS Computerised search, in PubMed and Embase databases, was performed in March 2020: 120 studies were identified but only 29 relevant papers were selected for detailed review. CONCLUSION Despite some interesting preliminary findings about anti-inflammatory effects of quetiapine, mainly supported by preclinical studies, it is possible to conclude further studies are needed to investigate the immunomodulatory effects of this drug and achieve a better understanding of its relevance on clinical outcomes to finally identify new therapeutic approaches in psychiatric treatment.KeypointsMounting evidence points to a role for immuno-inflammatory mechanisms in psychiatric disorders.Quetiapine (QUE) acts on catecholamine (dopamine and norepinephrine) and serotonin signalling.The immunomodulatory effects of catecholamines are well established.Treatment with QUE in psychiatric disorders could leverage immunomodulatory effects.QUE unclear role in immune function modulation suggests future work.
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Affiliation(s)
- Marco Ferrari
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
| | - Marco Godio
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy.,PhD Program in Clinical and Experimental Medicine and Medical Humanities, University of Insubria, Varese, Italy
| | - Stefano Martini
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
| | - Camilla Callegari
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Varese, Italy
| | - Marco Cosentino
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
| | - Franca Marino
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
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Blaylock RL, Faria M. New concepts in the development of schizophrenia, autism spectrum disorders, and degenerative brain diseases based on chronic inflammation: A working hypothesis from continued advances in neuroscience research. Surg Neurol Int 2021; 12:556. [PMID: 34877042 PMCID: PMC8645502 DOI: 10.25259/sni_1007_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 12/14/2022] Open
Abstract
This paper was written prompted by a poignant film about adolescent girl with schizophrenia who babysits for a younger girl in an isolated cabin. Schizophrenia is an illness that both authors are fascinated with and that they continue to study and investigate. There is now compelling evidence that schizophrenia is a very complex syndrome that involves numerous neural pathways in the brain, far more than just dopaminergic and serotonergic systems. One of the more popular theories in recent literature is that it represents a hypo glutaminergic deficiency of certain pathways, including thalamic ones. After much review of research and study in this area, we have concluded that most such theories contain a number of shortcomings. Most are based on clinical responses to certain drugs, particularly antipsychotic drugs affecting the dopaminergic neurotransmitters; thus, assuming dopamine release was the central cause of the psychotic symptoms of schizophrenia. The theory was limited in that dopamine excess could only explain the positive symptoms of the disorder. Antipsychotic medications have minimal effectiveness for the negative and cognitive symptoms associated with schizophrenia. It has been estimated that 20–30% of patients show either a partial or no response to antipsychotic medications. In addition, the dopamine hypothesis does not explain the neuroanatomic findings in schizophrenia.
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Affiliation(s)
| | - Miguel Faria
- Clinical Professor of Surgery (Neurosurgery, ret.) and Adjunct Professor of Medical History (ret.), Mercer University School of Medicine, United States
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Brain morphology does not clearly map to cognition in individuals on the bipolar-schizophrenia-spectrum: a cross-diagnostic study of cognitive subgroups. J Affect Disord 2021; 281:776-785. [PMID: 33246649 DOI: 10.1016/j.jad.2020.11.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/08/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Characterisation of brain morphological features common to cognitively similar individuals with bipolar disorder (BD) and schizophrenia spectrum disorders (SSD) may be key to understanding their shared neurobiological deficits. In the current study we examined whether three previously characterised cross-diagnostic cognitive subgroups differed among themselves and in comparison to healthy controls across measures of brain morphology. METHOD T1-weighted structural magnetic resonance imaging scans were obtained for 143 individuals; 65 healthy controls and 78 patients (SSD, n = 40; BD I, n = 38) classified into three cross-diagnostic cognitive subgroups: Globally Impaired (n = 24), Selectively Impaired (n = 32), and Superior/Near-Normal (n = 22). Cognitive subgroups were compared to each other and healthy controls on three separate analyses investigating (1) global, (2) regional, and (3) vertex-wise comparisons of brain volume, thickness, and surface area. RESULTS No significant subgroup differences were evident in global measures of brain morphology. In region of interest analyses, the Selectively Impaired subgroup had greater right accumbens volume than those Superior/Near-Normal subgroup and healthy controls, and the Superior/Near-Normal subgroup had reduced volume of the left entorhinal region compared to all other groups. In vertex-wise comparisons, the Globally Impaired subgroup had greater right precentral volume than the Selectively Impaired subgroup, and thicker cortex in the postcentral region relative to the Superior/Near-Normal subgroup. LIMITATIONS Exploration of medication effects was limited in our data. CONCLUSIONS Although some differences were evident in this sample, generally cross-diagnostic cognitive subgroups of individuals with SSD and BD did not appear to be clearly distinguished by patterns in brain morphology.
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Adamczyk P, Płonka O, Kruk D, Jáni M, Błądziński P, Kalisz A, Castelein S, Cechnicki A, Wyczesany M. On the relation of white matter brain abnormalities and the asociality symptoms in schizophrenia outpatients - a DTI study. Acta Neurobiol Exp (Wars) 2021; 81:80-95. [PMID: 33949167 DOI: 10.21307/ane-2021-009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/29/2021] [Indexed: 11/11/2022]
Abstract
Recent MRI studies have shown that abnormal functional connections in schizophrenia coexist with subtle changes in the structure of axons in the brain. However, there is a discrepancy in the literature concerning the relationship between white matter abnormalities and the occurrence of negative psychopathological symptoms. In the present study, we investigate the relationship between the altered white matter structure and specific psychopathology symptoms, i.e., subscales of Positive and Negative Syndrome Scale (PANSS) and Brief Negative Symptoms Scale (BNSS) in a sample of schizophrenia outpatients. For investigation on white matter abnormalities in schizophrenia, the diffusion tensor imaging analysis of between-group differences in main diffusion parameters by tract-based spatial statistics was conducted on schizophrenia outpatients and healthy controls. Hence, the correlation of PANSS and BNSS psychopathology subscales in the clinical group with fractional anisotropy was analyzed in the 17 selected cortical regions of interest. Presented between-group results revealed widespread loss of white matter integrity located across the brain in schizophrenia outpatients. Results on the white matter relationship with psychopathology revealed the negative correlation between fractional anisotropy in the left orbital prefrontal cortex, right Heschl's gyrus, bilateral precuneus and posterior cingulate cortex and the severity of asociality, as assessed with the BNSS. In conclusion, the presented study confirms the previous evidence on the widespread white matter abnormalities in schizophrenia outpatients and indicates the existence of the subtle but specific association between fractional anisotropy in the fronto-temporo-parietal regions with the asociality. Recent MRI studies have shown that abnormal functional connections in schizophrenia coexist with subtle changes in the structure of axons in the brain. However, there is a discrepancy in the literature concerning the relationship between white matter abnormalities and the occurrence of negative psychopathological symptoms. In the present study, we investigate the relationship between the altered white matter structure and specific psychopathology symptoms, i.e., subscales of Positive and Negative Syndrome Scale (PANSS) and Brief Negative Symptoms Scale (BNSS) in a sample of schizophrenia outpatients. For investigation on white matter abnormalities in schizophrenia, the diffusion tensor imaging analysis of between-group differences in main diffusion parameters by tract-based spatial statistics was conducted on schizophrenia outpatients and healthy controls. Hence, the correlation of PANSS and BNSS psychopathology subscales in the clinical group with fractional anisotropy was analyzed in the 17 selected cortical regions of interest. Presented between-group results revealed widespread loss of white matter integrity located across the brain in schizophrenia outpatients. Results on the white matter relationship with psychopathology revealed the negative correlation between fractional anisotropy in the left orbital prefrontal cortex, right Heschl’s gyrus, bilateral precuneus and posterior cingulate cortex and the severity of asociality, as assessed with the BNSS. In conclusion, the presented study confirms the previous evidence on the widespread white matter abnormalities in schizophrenia outpatients and indicates the existence of the subtle but specific association between fractional anisotropy in the fronto-temporo-parietal regions with the asociality.
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Affiliation(s)
| | - Olga Płonka
- Institute of Psychology , Jagiellonian University , Krakow , Poland
| | - Dawid Kruk
- Psychosis Research and Psychotherapy Unit , Association for the Development of Community Psychiatry and Care , Krakow , Poland ; Community Psychiatry and Psychosis Research Center , Chair of Psychiatry , Medical College , Jagiellonian University , Krakow , Poland
| | - Martin Jáni
- Institute of Psychology , Jagiellonian University , Krakow , Poland ; Department of Psychiatry , Faculty of Medicine , Masaryk University and University Hospital Brno , Brno , Czech Republic
| | - Piotr Błądziński
- Community Psychiatry and Psychosis Research Center , Chair of Psychiatry , Medical College , Jagiellonian University , Krakow , Poland
| | - Aneta Kalisz
- Community Psychiatry and Psychosis Research Center , Chair of Psychiatry , Medical College , Jagiellonian University , Krakow , Poland
| | - Stynke Castelein
- Lentis Research , Lentis Psychiatric Institute , Groningen , The Netherlands ; Faculty of Behavioural and Social Sciences , University of Groningen , Groningen , The Netherlands
| | - Andrzej Cechnicki
- Psychosis Research and Psychotherapy Unit , Association for the Development of Community Psychiatry and Care , Krakow , Poland ; Community Psychiatry and Psychosis Research Center , Chair of Psychiatry , Medical College , Jagiellonian University , Krakow , Poland
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Plastic Adaptation to Pathology in Psychiatry: Are Patients with Psychiatric Disorders Pathological Experts? Neuroscientist 2019; 26:208-223. [DOI: 10.1177/1073858419867083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Psychiatric disorders share the same pattern of longitudinal evolution and have courses that tend to be chronic and recurrent. These aspects of chronicity and longitudinal evolution are currently studied under the deficit-oriented neuroprogression framework. Interestingly, considering the plasticity of the brain, it is also necessary to emphasize the bidirectional nature of neuroprogression. We review evidence highlighting alterations of the brain associated with the longitudinal evolution of psychiatric disorders from the framework of neuroplastic adaptation to pathology. This new framework highlights that substantial plasticity and remodeling may occur beyond the classic deficit-oriented neuroprogressive framework, which has been associated with progressive loss of gray matter thickness, decreased brain connectivity, and chronic inflammation. We also integrate the brain economy concept in the neuroplastic adaptation to pathology framework, emphasizing that to preserve its economy, i.e. function, the brain learns how to cope with the disease by adapting its architecture. Neuroplastic adaptation to pathology is a proposition for a paradigm shift to overcome the shortcomings of traditional psychiatric diagnostic boundaries; this approach can disentangle both the specific pathophysiology of psychiatric symptoms and the adaptation to pathology, thus offering a new framework for both diagnosis and treatment.
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Bache WK, DeLisi LE. The Sex Chromosome Hypothesis of Schizophrenia: Alive, Dead, or Forgotten? A Commentary and Review. MOLECULAR NEUROPSYCHIATRY 2018; 4:83-89. [PMID: 30397596 DOI: 10.1159/000491489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/22/2018] [Indexed: 12/14/2022]
Abstract
The X chromosome has long been an intriguing site for harboring genes that have importance in brain development and function. It has received the most attention for having specific genes underlying the X-linked inherited intellectual disabilities, but has also been associated with schizophrenia in a number of early studies. An X chromosome hypothesis for a genetic predisposition for schizophrenia initially came from the X chromosome anomaly population data showing an excess of schizophrenia in Klinefelter's (XXY) males and triple X (XXX) females. Crow and colleagues later expanded the X chromosome hypothesis to include the possibility of a locus on the Y chromosome and, specifically, genes on X that escaped inactivation and are X-Y homologous loci. Some new information about possible risk loci on these chromosomes has come from the current large genetic consortia genome-wide association studies, suggesting that perhaps this hypothesis needs to be revisited for some schizophrenias. The following commentary reviews the early and more recent literature supporting or refuting this dormant hypothesis and emphasizes the possible candidate genes still of interest that could be explored in further studies.
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Affiliation(s)
- William K Bache
- VA Boston Healthcare System, Brockton, Massachusetts, USA.,Harvard South Shore Residency Program, Brockton, Massachusetts, USA
| | - Lynn E DeLisi
- VA Boston Healthcare System, Brockton, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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8
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Radoeva PD, Bansal R, Antshel KM, Fremont W, Peterson BS, Kates WR. Longitudinal study of cerebral surface morphology in youth with 22q11.2 deletion syndrome, and association with positive symptoms of psychosis. J Child Psychol Psychiatry 2017; 58:305-314. [PMID: 27786353 PMCID: PMC5340081 DOI: 10.1111/jcpp.12657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND 22q11.2 deletion syndrome (22q11DS) is a genetic disorder that greatly increases risk of developing schizophrenia. We previously characterized cerebral surface morphology trajectories from late childhood to mid adolescence in a cohort of youth with 22q11DS. Herein, we extend the study period into early adulthood, and describe further the trajectories associated with severe psychiatric symptoms in this cohort. METHODS Participants included 76 youth with 22q11DS and 30 unaffected siblings, assessed at three timepoints, during which high resolution, anatomic magnetic resonance images were acquired. High-dimensional, nonlinear warping algorithms were applied to images in order to derive characteristics of cerebral surface morphology for each participant at each timepoint. Repeated-measures, linear regressions using a mixed model were conducted, while covarying for age and sex. RESULTS Alterations in cerebral surface morphology during late adolescence/early adulthood in individuals with 22q11DS were observed in the lateral frontal, orbitofrontal, temporal, parietal, occipital, and cerebellar regions. An Age x Diagnosis interaction revealed that relative to unaffected siblings, individuals with 22q11DS showed age-related surface protrusions in the prefrontal cortex (which remained stable or increased during early adulthood), and surface indentations in posterior regions (which seemed to level off during late adolescence). Symptoms of psychosis were associated with a trajectory of surface indentations in the orbitofrontal and parietal regions. CONCLUSIONS These results advance our understanding of cerebral maturation in individuals with 22q11DS, and provide clinically relevant information about the psychiatric phenotype associated with the longitudinal trajectory of cortical surface morphology in youth with this genetic syndrome.
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Affiliation(s)
- Petya D. Radoeva
- Department of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Ravi Bansal
- Children’s Hospital Los Angeles and the Keck School of Medicine at the University of Southern California, Los Angeles, California, USA
| | - Kevin M. Antshel
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Wanda Fremont
- Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Bradley S. Peterson
- Children’s Hospital Los Angeles and the Keck School of Medicine at the University of Southern California, Los Angeles, California, USA
| | - Wendy R. Kates
- Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, New York, USA
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Mühle C, Kreczi J, Rhein C, Richter-Schmidinger T, Alexopoulos P, Doerfler A, Lenz B, Kornhuber J. Additive sex-specific influence of common non-synonymous DISC1 variants on amygdala, basal ganglia, and white cortical surface area in healthy young adults. Brain Struct Funct 2016; 222:881-894. [PMID: 27369464 DOI: 10.1007/s00429-016-1253-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 06/16/2016] [Indexed: 01/30/2023]
Abstract
The disrupted-in-schizophrenia-1 (DISC1) gene is known for its role in the development of mental disorders. It is also involved in neurodevelopment, cognition, and memory. To investigate the association between DISC1 variants and brain morphology, we analyzed the influence of the three common non-synonymous polymorphisms in DISC1 on specific brain structures in healthy young adults. The volumes of brain regions were determined in 145 subjects by magnetic resonance imaging and automated analysis using FreeSurfer. Genotyping was performed by high resolution melting of amplified products. In an additive genetic model, rs6675281 (Leu607Phe), rs3738401 (Arg264Gln), and rs821616 (Ser704Cys) significantly explained the volume variance of the amygdala (p = 0.007) and the pallidum (p = 0.004). A higher cumulative portion of minor alleles was associated with larger volumes of the amygdala (p = 0.005), the pallidum (p = 0.001), the caudate (p = 0.024), and the putamen (p = 0.007). Sex-stratified analysis revealed a strong genetic effect of rs6675281 on putamen and pallidum in females but not in males and an opposite influence of rs3738401 on the white cortical surface in females compared to males. The strongest single association was found for rs821616 and the amygdala volume in male subjects (p < 0.001). No effect was detected for the nucleus accumbens. We report-to our knowledge-for the first time a significant and sex-specific influence of common DISC1 variants on volumes of the basal ganglia, the amygdala and on the cortical surface area. Our results demonstrate that the additive model of all three polymorphisms outperforms their single analysis.
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Affiliation(s)
- Christiane Mühle
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Jakob Kreczi
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Cosima Rhein
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tanja Richter-Schmidinger
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Panagiotis Alexopoulos
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Lenz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
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Edwin Thanarajah S, Han CE, Rotarska-Jagiela A, Singer W, Deichmann R, Maurer K, Kaiser M, Uhlhaas PJ. Abnormal Connectional Fingerprint in Schizophrenia: A Novel Network Analysis of Diffusion Tensor Imaging Data. Front Psychiatry 2016; 7:114. [PMID: 27445870 PMCID: PMC4928135 DOI: 10.3389/fpsyt.2016.00114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 06/10/2016] [Indexed: 12/11/2022] Open
Abstract
The graph theoretical analysis of structural magnetic resonance imaging (MRI) data has received a great deal of interest in recent years to characterize the organizational principles of brain networks and their alterations in psychiatric disorders, such as schizophrenia. However, the characterization of networks in clinical populations can be challenging, since the comparison of connectivity between groups is influenced by several factors, such as the overall number of connections and the structural abnormalities of the seed regions. To overcome these limitations, the current study employed the whole-brain analysis of connectional fingerprints in diffusion tensor imaging data obtained at 3 T of chronic schizophrenia patients (n = 16) and healthy, age-matched control participants (n = 17). Probabilistic tractography was performed to quantify the connectivity of 110 brain areas. The connectional fingerprint of a brain area represents the set of relative connection probabilities to all its target areas and is, hence, less affected by overall white and gray matter changes than absolute connectivity measures. After detecting brain regions with abnormal connectional fingerprints through similarity measures, we tested each of its relative connection probability between groups. We found altered connectional fingerprints in schizophrenia patients consistent with a dysconnectivity syndrome. While the medial frontal gyrus showed only reduced connectivity, the connectional fingerprints of the inferior frontal gyrus and the putamen mainly contained relatively increased connection probabilities to areas in the frontal, limbic, and subcortical areas. These findings are in line with previous studies that reported abnormalities in striatal-frontal circuits in the pathophysiology of schizophrenia, highlighting the potential utility of connectional fingerprints for the analysis of anatomical networks in the disorder.
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Affiliation(s)
- Sharmili Edwin Thanarajah
- Department of Neurology, University Hospital of Cologne, Cologne, Germany; Department of Neurophysiology, Max-Planck Institute for Brain Research, Frankfurt am Main, Germany; Max-Planck Institute for Metabolism Research, Cologne, Germany
| | - Cheol E Han
- Department of Electronics and Information Engineering, Korea University, Sejong, South Korea; Department of Bio-Convergence Engineering, Korea University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Seoul National University, Seoul, South Korea
| | - Anna Rotarska-Jagiela
- Department of Neurophysiology, Max-Planck Institute for Brain Research , Frankfurt am Main , Germany
| | - Wolf Singer
- Department of Neurophysiology, Max-Planck Institute for Brain Research, Frankfurt am Main, Germany; Ernst-Strüngmann Institut, Frankfurt am Main, Germany; Frankfurt Institute of Advanced Studies, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Ralf Deichmann
- Brain Imaging Centre, Goethe University Frankfurt am Main , Frankfurt am Main , Germany
| | - Konrad Maurer
- Department of Psychiatry, Psychosomatics and Psychotherapy, Goethe University Frankfurt am Main , Frankfurt am Main , Germany
| | - Marcus Kaiser
- Department of Brain and Cognitive Sciences, Seoul National University, Seoul, South Korea; Interdisciplinary Computing and Complex BioSystems (ICOS) Research, School of Computing Science, Newcastle University, Newcastle, UK; Institute of Neuroscience, Newcastle University, Newcastle, UK
| | - Peter J Uhlhaas
- Department of Neurophysiology, Max-Planck Institute for Brain Research, Frankfurt am Main, Germany; Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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Anderson VM, Goldstein ME, Kydd RR, Russell BR. Extensive gray matter volume reduction in treatment-resistant schizophrenia. Int J Neuropsychopharmacol 2015; 18:pyv016. [PMID: 25716781 PMCID: PMC4540109 DOI: 10.1093/ijnp/pyv016] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Approximately one-third of people with schizophrenia are treatment-resistant and some do not achieve remission with clozapine, the gold-standard antipsychotic medication for treatment-resistant schizophrenia. This study compared global and regional brain volumes between treatment-respondent and treatment-resistant patients with schizophrenia, including a group of patients who were clozapine-resistant. METHODS T1-weighted brain MRIs were obtained on a 3T scanner in 20 controls and 52 people with schizophrenia who were selected based on their symptomatic responses to antipsychotic medication: 18 responded well to first-line atypical antipsychotics (FLR), 19 were treatment-resistant but responsive to clozapine monotherapy (TR), and 15 were ultra-treatment-resistant and did not respond to clozapine (UTR). Treatment groups were matched for disease duration and current psychopathology. SIENAX and FSL-VBM were used to investigate differences in the global brain, gray matter (GM), white matter, ventricular cerebrospinal fluid volumes, and regional GM volumes. RESULTS GM volume was significantly reduced in the TR and UTR groups compared with controls and the FLR group (p < 0.05). GM volume was significantly reduced in TR patients compared with FLRs in the superior, middle, and inferior temporal gyri, pre- and post-central gyri, middle and superior frontal gyri, right supramarginal gyrus, and right lateral occipital cortex. UTR patients showed reduced GM compared with FLRs in their right parietal operculum and left cerebellum. No significant volume differences were observed between TR and UTR groups. CONCLUSIONS These differences are unlikely to be solely due to medication effects, and reduced GM volume in treatment-resistant schizophrenia may represent an accelerated disease course or a different underlying pathology.
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Affiliation(s)
| | | | | | - Bruce R Russell
- School of Pharmacy, University of Auckland, Auckland, New Zealand (Drs Anderson, Goldstein, and Russell); Centre for Brain Research, University of Auckland, Auckland, New Zealand (Drs Anderson, Goldstein, Kydd, and Russell); Department of Psychological Medicine, University of Auckland, Auckland, New Zealand (Dr Kydd).
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Plitman E, Nakajima S, de la Fuente-Sandoval C, Gerretsen P, Chakravarty MM, Kobylianskii J, Chung JK, Caravaggio F, Iwata Y, Remington G, Graff-Guerrero A. Glutamate-mediated excitotoxicity in schizophrenia: a review. Eur Neuropsychopharmacol 2014; 24:1591-605. [PMID: 25159198 PMCID: PMC4470624 DOI: 10.1016/j.euroneuro.2014.07.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/22/2014] [Accepted: 07/26/2014] [Indexed: 12/16/2022]
Abstract
Findings from neuroimaging studies in patients with schizophrenia suggest widespread structural changes although the mechanisms through which these changes occur are currently unknown. Glutamatergic activity appears to be increased in the early phases of schizophrenia and may contribute to these structural alterations through an excitotoxic effect. The primary aim of this review was to describe the possible role of glutamate-mediated excitotoxicity in explaining the presence of neuroanatomical changes within schizophrenia. A Medline(®) literature search was conducted, identifying English language studies on the topic of glutamate-mediated excitotoxicity in schizophrenia, using the terms "schizophreni" and "glutam" and (("MRS" or "MRI" or "magnetic resonance") or ("computed tomography" or "CT")). Studies concomitantly investigating glutamatergic activity and brain structure in patients with schizophrenia were included. Results are discussed in the context of findings from preclinical studies. Seven studies were identified that met the inclusion criteria. These studies provide inconclusive support for the role of glutamate-mediated excitotoxicity in the occurrence of structural changes within schizophrenia, with the caveat that there is a paucity of human studies investigating this topic. Preclinical data suggest that an excitotoxic effect may occur as a result of a paradoxical increase in glutamatergic activity following N-methyl-D-aspartate receptor hypofunction. Based on animal literature, glutamate-mediated excitotoxicity may account for certain structural changes present in schizophrenia, but additional human studies are required to substantiate these findings. Future studies should adopt a longitudinal design and employ magnetic resonance imaging techniques to investigate whether an association between glutamatergic activity and structural changes exists in patients with schizophrenia.
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Affiliation(s)
- Eric Plitman
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Geriatric Mental Health Division, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Camilo de la Fuente-Sandoval
- Experimental Psychiatry Laboratory, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico; Neuropsychiatry Department, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - M Mallar Chakravarty
- Cerebral Imaging Centre, Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada; Departments of Psychiatry and Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Jane Kobylianskii
- Department of Medicine, Queen׳s University, Kingston, Ontario, Canada
| | - Jun Ku Chung
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Yusuke Iwata
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Gary Remington
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Campbell Institute Research Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Schizophrenia Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Campbell Institute Research Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada.
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Wong EH, So HC, Li M, Wang Q, Butler AW, Paul B, Wu HM, Hui TC, Choi SC, So MT, Garcia-Barcelo MM, McAlonan GM, Chen EY, Cheung EF, Chan RC, Purcell SM, Cherny SS, Chen RR, Li T, Sham PC. Common variants on Xq28 conferring risk of schizophrenia in Han Chinese. Schizophr Bull 2014; 40:777-86. [PMID: 24043878 PMCID: PMC4059435 DOI: 10.1093/schbul/sbt104] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Schizophrenia is a highly heritable, severe psychiatric disorder affecting approximately 1% of the world population. A substantial portion of heritability is still unexplained and the pathophysiology of schizophrenia remains to be elucidated. To identify more schizophrenia susceptibility loci, we performed a genome-wide association study (GWAS) on 498 patients with schizophrenia and 2025 controls from the Han Chinese population, and a follow-up study on 1027 cases and 1005 controls. In the follow-up study, we included 384 single nucleotide polymorphisms (SNPs) which were selected from the top hits in our GWAS (130 SNPs) and from previously implicated loci for schizophrenia based on the SZGene database, NHGRI GWAS Catalog, copy number variation studies, GWAS meta-analysis results from the international Psychiatric Genomics Consortium (PGC) and candidate genes from plausible biological pathways (254 SNPs). Within the chromosomal region Xq28, SNP rs2269372 in RENBP achieved genome-wide significance with a combined P value of 3.98 × 10(-8) (OR of allele A = 1.31). SNPs with suggestive P values were identified within 2 genes that have been previously implicated in schizophrenia, MECP2 (rs2734647, P combined = 8.78 × 10(-7), OR = 1.28; rs2239464, P combined = 6.71 × 10(-6), OR = 1.26) and ARHGAP4 (rs2269368, P combined = 4.74 × 10(-7), OR = 1.25). In addition, the patient sample in our follow-up study showed a significantly greater burden for pre-defined risk alleles based on the SNPs selected than the controls. This indicates the existence of schizophrenia susceptibility loci among the SNPs we selected. This also further supports multigenic inheritance in schizophrenia. Our findings identified a new schizophrenia susceptibility locus on Xq28, which harbor the genes RENBP, MECP2, and ARHGAP4.
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Affiliation(s)
- Emily H.M. Wong
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China;,
Co-first authors
| | - Hon-Cheong So
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China;,
Co-first authors
| | - Miaoxin Li
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China;,Centre for Genomic Sciences, The University of Hong Kong, Hong Kong, China
| | - Quang Wang
- The Mental Health Centre and Psychiatric Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Amy W. Butler
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China;,MRC Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
| | - Basil Paul
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Hei-Man Wu
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Tomy C.K. Hui
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Siu-Chung Choi
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Man-Ting So
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Maria-Mercè Garcia-Barcelo
- Centre for Genomic Sciences, The University of Hong Kong, Hong Kong, China;,Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Grainne M. McAlonan
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College London, UK
| | - Eric Y.H. Chen
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | | | - Raymond C.K. Chan
- Institute of Psychology, Chinese Academy of Sciences, Beijing, China
| | - Shaun M. Purcell
- Division of Psychiatric Genomics, Mount Sinai School of Medicine, New York
| | - Stacey S. Cherny
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China;,Centre for Genomic Sciences, The University of Hong Kong, Hong Kong, China;,State Key Laboratory in Brain and Cognitive Sciences, The University of Hong Kong, Hong King, China
| | - Ronald R.L. Chen
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Tao Li
- The Mental Health Centre and Psychiatric Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Pak-Chung Sham
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China; Centre for Genomic Sciences, The University of Hong Kong, Hong Kong, China; State Key Laboratory in Brain and Cognitive Sciences, The University of Hong Kong, Hong King, China;
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Davis J, Moylan S, Harvey BH, Maes M, Berk M. Neuroprogression in schizophrenia: Pathways underpinning clinical staging and therapeutic corollaries. Aust N Z J Psychiatry 2014; 48:512-29. [PMID: 24803587 DOI: 10.1177/0004867414533012] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Whilst dopaminergic dysfunction remains a necessary component involved in the pathogenesis of schizophrenia, our current pharmacological armoury of dopamine antagonists does little to control the negative symptoms of schizophrenia. This suggests other pathological processes must be implicated. This paper aims to elaborate on such theories. METHODS Data for this review were sourced from the electronic database PUBMED, and was not limited by language or date of publication. RESULTS It has been suggested that multiple 'hits' may be required to unveil the clinical syndrome in susceptible individuals. Such hits potentially first occur in utero, leading to neuronal disruption, epigenetic changes and the establishment of an abnormal inflammatory response. The development of schizophrenia may therefore potentially be viewed as a neuroprogressive response to these early stressors, driven on by changes in tryptophan catabolite (TRYCAT) metabolism, reactive oxygen species handling and N-methyl d-aspartate (NMDA) circuitry. Given the potential for such progression over time, it is prudent to explore the new treatment strategies which may be implemented before such changes become established. CONCLUSIONS Outside of the dopaminergic model, the potential pathogenesis of schizophrenia has yet to be fully elucidated, but common themes include neuropil shrinkage, the development of abnormal neuronal circuitry, and a chronic inflammatory state which further disrupts neuronal function. Whilst some early non-dopaminergic treatments show promise, none have yet to be fully studied in appropriately structured randomized controlled trials and they remain little more than potential attractive targets.
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Affiliation(s)
- Justin Davis
- IMPACT Strategic Research Centre, Deakin University, School of Medicine, Barwon Health, Geelong, Australia
| | - Steven Moylan
- IMPACT Strategic Research Centre, Deakin University, School of Medicine, Barwon Health, Geelong, Australia
| | - Brian H Harvey
- Division of Pharmacology, and Center of Excellence for Pharmaceutical Sciences, School of Pharmacy, North West University, Potchefstroom, South Africa
| | - Michael Maes
- IMPACT Strategic Research Centre, Deakin University, School of Medicine, Barwon Health, Geelong, Australia Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
| | - Michael Berk
- IMPACT Strategic Research Centre, Deakin University, School of Medicine, Barwon Health, Geelong, Australia Orygen Youth Health Research Centre, Parkville, Australia Centre of Youth Mental Health, University of Melbourne, Parkville, Australia Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia
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Rizos E, Papathanasiou MA, Michalopoulou PG, Laskos E, Mazioti A, Kastania A, Vasilopoulou K, Nikolaidou P, Margaritis D, Papageorgiou C, Liappas I. A longitudinal study of alterations of hippocampal volumes and serum BDNF levels in association to atypical antipsychotics in a sample of first-episode patients with schizophrenia. PLoS One 2014; 9:e87997. [PMID: 24551075 PMCID: PMC3923760 DOI: 10.1371/journal.pone.0087997] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 01/03/2014] [Indexed: 02/07/2023] Open
Abstract
Background Schizophrenia is associated with structural and functional abnormalities of the hippocampus, which have been suggested to play an important role in the formation and emergence of schizophrenia syndrome. Patients with schizophrenia exhibit significant bilateral hippocampal volume reduction and progressive hippocampal volume decrease in first-episode patients with schizophrenia has been shown in many neuroimaging studies. Dysfunction of the neurotrophic system has been implicated in the pathophysiology of schizophrenia. The initiation of antipsychotic medication alters the levels of serum Brain Derived Neurotrophic Factor (BDNF) levels. However it is unclear whether treatment with antipsychotics is associated with alterations of hippocampal volume and BDNF levels. Methods In the present longitudinal study we investigated the association between serum BDNF levels and hippocampal volumes in a sample of fourteen first-episode drug-naïve patients with schizophrenia (FEP). MRI scans, BDNF and clinical measurements were performed twice: at baseline before the initiation of antipsychotic treatment and 8 months later, while the patients were receiving monotherapy with second generation antipsychotics (SGAs). Results We found that left hippocampal volume was decreased (corrected left HV [t = 2.977, df = 13, p = .011] at follow-up; We also found that the higher the BDNF levels change the higher were the differences of corrected left hippocampus after 8 months of treatment with atypical antipsychotics (Pearson r = 0.597, p = 0.024). Conclusions The association of BDNF with hippocampal volume alterations in schizophrenia merits further investigation and replication in larger longitudinal studies.
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Affiliation(s)
- Emmanouil Rizos
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- * E-mail:
| | - Matilda A. Papathanasiou
- 2nd Department of Radiology, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiota G. Michalopoulou
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Psychosis Studies, Section on Schizophrenia, Imaging and Therapeutics, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Efstathios Laskos
- Biochemistry and Microbiology Department, Athens Psychiatric Hospital “Dromokaition”, Athens, Greece
| | - Aggeliki Mazioti
- 2nd Department of Radiology, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kastania
- Department of Informatics, Athens University of Economics and Business, Athens, Greece
| | - Konstantina Vasilopoulou
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Nikolaidou
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Margaritis
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalabos Papageorgiou
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Liappas
- 2 Department of Psychiatry, “ATTIKON” General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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