Large-scale analysis of structural brain asymmetries in schizophrenia via the ENIGMA consortium

Left-right asymmetry is an important organizing feature of the healthy brain that may be altered in schizophrenia, but most studies have used relatively small samples and heterogeneous approaches, resulting in equivocal findings. We carried out the largest case-control study of structural brain asymmetries in schizophrenia, with MRI data from 5,080 affected individuals and 6,015 controls across 46 datasets, using a single image analysis protocol. Asymmetry indexes were calculated for global and regional cortical thickness, surface area, and subcortical volume measures. Differences of asymmetry were calculated between affected individuals and controls per dataset, and effect sizes were meta-analyzed across datasets. Small average case-control differences were observed for thickness asymmetries of the rostral anterior cingulate and the middle temporal gyrus, both driven by thinner left-hemispheric cortices in schizophrenia. Analyses of these asymmetries with respect to the use of antipsychotic medication and other clinical variables did not show any significant associations. Assessment of age- and sex-specific effects revealed a stronger average leftward asymmetry of pallidum volume between older cases and controls. Case-control differences in a multivariate context were assessed in a subset of the data (N = 2,029), which revealed that 7% of the variance across all structural asymmetries was explained by case-control status. Subtle case-control differences of brain macrostructural asymmetry may reflect differences at the molecular, cytoarchitectonic, or circuit levels that have functional relevance for the disorder. Reduced left middle temporal cortical thickness is consistent with altered left-hemisphere language network organization in schizophrenia.

Mega-analysis of association between obesity and cortical morphology in bipolar disorders: ENIGMA study in 2832 participants

BACKGROUND

Obesity is highly prevalent and disabling, especially in individuals with severe mental illness including bipolar disorders (BD). The brain is a target organ for both obesity and BD. Yet, we do not understand how cortical brain alterations in BD and obesity interact.

METHODS

We obtained body mass index (BMI) and MRI-derived regional cortical thickness, surface area from 1231 BD and 1601 control individuals from 13 countries within the ENIGMA-BD Working Group. We jointly modeled the statistical effects of BD and BMI on brain structure using mixed effects and tested for interaction and mediation. We also investigated the impact of medications on the BMI-related associations.

RESULTS

BMI and BD additively impacted the structure of many of the same brain regions. Both BMI and BD were negatively associated with cortical thickness, but not surface area. In most regions the number of jointly used psychiatric medication classes remained associated with lower cortical thickness when controlling for BMI. In a single region, fusiform gyrus, about a third of the negative association between number of jointly used psychiatric medications and cortical thickness was mediated by association between the number of medications and higher BMI.

CONCLUSIONS

We confirmed consistent associations between higher BMI and lower cortical thickness, but not surface area, across the cerebral mantle, in regions which were also associated with BD. Higher BMI in people with BD indicated more pronounced brain alterations. BMI is important for understanding the neuroanatomical changes in BD and the effects of psychiatric medications on the brain.

Obesity and brain structure in schizophrenia - ENIGMA study in 3021 individuals

Schizophrenia is frequently associated with obesity, which is linked with neurostructural alterations. Yet, we do not understand how the brain correlates of obesity map onto the brain changes in schizophrenia. We obtained MRI-derived brain cortical and subcortical measures and body mass index (BMI) from 1260 individuals with schizophrenia and 1761 controls from 12 independent research sites within the ENIGMA-Schizophrenia Working Group. We jointly modeled the statistical effects of schizophrenia and BMI using mixed effects. BMI was additively associated with structure of many of the same brain regions as schizophrenia, but the cortical and subcortical alterations in schizophrenia were more widespread and pronounced. Both BMI and schizophrenia were primarily associated with changes in cortical thickness, with fewer correlates in surface area. While, BMI was negatively associated with cortical thickness, the significant associations between BMI and surface area or subcortical volumes were positive. Lastly, the brain correlates of obesity were replicated among large studies and closely resembled neurostructural changes in major depressive disorders. We confirmed widespread associations between BMI and brain structure in individuals with schizophrenia. People with both obesity and schizophrenia showed more pronounced brain alterations than people with only one of these conditions. Obesity appears to be a relevant factor which could account for heterogeneity of brain imaging findings and for differences in brain imaging outcomes among people with schizophrenia.

Diagnosis of bipolar disorders and body mass index predict clustering based on similarities in cortical thickness-ENIGMA study in 2436 individuals

AIMS

Rates of obesity have reached epidemic proportions, especially among people with psychiatric disorders. While the effects of obesity on the brain are of major interest in medicine, they remain markedly under-researched in psychiatry.

METHODS

We obtained body mass index (BMI) and magnetic resonance imaging-derived regional cortical thickness, surface area from 836 bipolar disorders (BD) and 1600 control individuals from 14 sites within the ENIGMA-BD Working Group. We identified regionally specific profiles of cortical thickness using K-means clustering and studied clinical characteristics associated with individual cortical profiles.

RESULTS

We detected two clusters based on similarities among participants in cortical thickness. The lower thickness cluster (46.8% of the sample) showed thinner cortex, especially in the frontal and temporal lobes and was associated with diagnosis of BD, higher BMI, and older age. BD individuals in the low thickness cluster were more likely to have the diagnosis of bipolar disorder I and less likely to be treated with lithium. In contrast, clustering based on similarities in the cortical surface area was unrelated to BD or BMI and only tracked age and sex.

CONCLUSIONS

We provide evidence that both BD and obesity are associated with similar alterations in cortical thickness, but not surface area. The fact that obesity increased the chance of having low cortical thickness could explain differences in cortical measures among people with BD. The thinner cortex in individuals with higher BMI, which was additive and similar to the BD-associated alterations, may suggest that treating obesity could lower the extent of cortical thinning in BD.

Longitudinal Structural Brain Changes in Bipolar Disorder: A Multicenter Neuroimaging Study of 1232 Individuals by the ENIGMA Bipolar Disorder Working Group

BACKGROUND

Bipolar disorder (BD) is associated with cortical and subcortical structural brain abnormalities. It is unclear whether such alterations progressively change over time, and how this is related to the number of mood episodes. To address this question, we analyzed a large and diverse international sample with longitudinal magnetic resonance imaging (MRI) and clinical data to examine structural brain changes over time in BD.

METHODS

Longitudinal structural MRI and clinical data from the ENIGMA (Enhancing Neuro Imaging Genetics through Meta Analysis) BD Working Group, including 307 patients with BD and 925 healthy control subjects, were collected from 14 sites worldwide. Male and female participants, aged 40 ± 17 years, underwent MRI at 2 time points. Cortical thickness, surface area, and subcortical volumes were estimated using FreeSurfer. Annualized change rates for each imaging phenotype were compared between patients with BD and healthy control subjects. Within patients, we related brain change rates to the number of mood episodes between time points and tested for effects of demographic and clinical variables.

RESULTS

Compared with healthy control subjects, patients with BD showed faster enlargement of ventricular volumes and slower thinning of the fusiform and parahippocampal cortex (0.18 <d < 0.22). More (hypo)manic episodes were associated with faster cortical thinning, primarily in the prefrontal cortex.

CONCLUSIONS

In the hitherto largest longitudinal MRI study on BD, we did not detect accelerated cortical thinning but noted faster ventricular enlargements in BD. However, abnormal frontocortical thinning was observed in association with frequent manic episodes. Our study yields insights into disease progression in BD and highlights the importance of mania prevention in BD treatment.

What we learn about bipolar disorder from large-scale neuroimaging: Findings and future directions from the ENIGMA Bipolar Disorder Working Group

MRI-derived brain measures offer a link between genes, the environment and behavior and have been widely studied in bipolar disorder (BD). However, many neuroimaging studies of BD have been underpowered, leading to varied results and uncertainty regarding effects. The Enhancing Neuro Imaging Genetics through Meta-Analysis (ENIGMA) Bipolar Disorder Working Group was formed in 2012 to empower discoveries, generate consensus findings and inform future hypothesis-driven studies of BD. Through this effort, over 150 researchers from 20 countries and 55 institutions pool data and resources to produce the largest neuroimaging studies of BD ever conducted. The ENIGMA Bipolar Disorder Working Group applies standardized processing and analysis techniques to empower large-scale meta- and mega-analyses of multimodal brain MRI and improve the replicability of studies relating brain variation to clinical and genetic data. Initial BD Working Group studies reveal widespread patterns of lower cortical thickness, subcortical volume and disrupted white matter integrity associated with BD. Findings also include mapping brain alterations of common medications like lithium, symptom patterns and clinical risk profiles and have provided further insights into the pathophysiological mechanisms of BD. Here we discuss key findings from the BD working group, its ongoing projects and future directions for large-scale, collaborative studies of mental illness.

Association between body mass index and subcortical brain volumes in bipolar disorders-ENIGMA study in 2735 individuals

Individuals with bipolar disorders (BD) frequently suffer from obesity, which is often associated with neurostructural alterations. Yet, the effects of obesity on brain structure in BD are under-researched. We obtained MRI-derived brain subcortical volumes and body mass index (BMI) from 1134 BD and 1601 control individuals from 17 independent research sites within the ENIGMA-BD Working Group. We jointly modeled the effects of BD and BMI on subcortical volumes using mixed-effects modeling and tested for mediation of group differences by obesity using nonparametric bootstrapping. All models controlled for age, sex, hemisphere, total intracranial volume, and data collection site. Relative to controls, individuals with BD had significantly higher BMI, larger lateral ventricular volume, and smaller volumes of amygdala, hippocampus, pallidum, caudate, and thalamus. BMI was positively associated with ventricular and amygdala and negatively with pallidal volumes. When analyzed jointly, both BD and BMI remained associated with volumes of lateral ventricles  and amygdala. Adjusting for BMI decreased the BD vs control differences in ventricular volume. Specifically, 18.41% of the association between BD and ventricular volume was mediated by BMI (Z = 2.73, p = 0.006). BMI was associated with similar regional brain volumes as BD, including lateral ventricles, amygdala, and pallidum. Higher BMI may in part account for larger ventricles, one of the most replicated findings in BD. Comorbidity with obesity could explain why neurostructural alterations are more pronounced in some individuals with BD. Future prospective brain imaging studies should investigate whether obesity could be a modifiable risk factor for neuroprogression.

The genetic architecture of the human cerebral cortex

The cerebral cortex underlies our complex cognitive capabilities, yet little is known about the specific genetic loci that influence human cortical structure. To identify genetic variants that affect cortical structure, we conducted a genome-wide association meta-analysis of brain magnetic resonance imaging data from 51,665 individuals. We analyzed the surface area and average thickness of the whole cortex and 34 regions with known functional specializations. We identified 199 significant loci and found significant enrichment for loci influencing total surface area within regulatory elements that are active during prenatal cortical development, supporting the radial unit hypothesis. Loci that affect regional surface area cluster near genes in Wnt signaling pathways, which influence progenitor expansion and areal identity. Variation in cortical structure is genetically correlated with cognitive function, Parkinson's disease, insomnia, depression, neuroticism, and attention deficit hyperactivity disorder.

White matter integrity and symptom dimensions of schizophrenia: A diffusion tensor imaging study

Impaired fiber bundle connectivity between brain regions is a key neuropathological finding in schizophrenia. Symptom dimensions in schizophrenia can be clustered into factor models. Single syndromes have been related to grey and white matter brain structure alterations. We associated all core syndromes of schizophrenia in a single patient group with changes in white matter integrity. Diffusion weighted images (3T MRI) and SAPS/SANS scores were measured in 26 male patients and 26 healthy controls. First, group differences in fractional anisotropy (FA) were calculated with TBSS. Second, core symptom dimensions of schizophrenia were correlated with FA within these altered tracts. We found differences between groups in nine white matter tracts. Hallucinations were positively correlated with FA in the left uncinate fasciculus and left corticospinal tract. Ego-disturbances (passivity phenomena) showed a positive correlation with FA in the right anterior thalamic radiation. Positive formal thought disorders (FTD) corresponded negatively with FA in the right cingulum bundle. Negative symptoms were positively associated with the right anterior thalamic radiation and negatively with the right ventral cingulum bundle. For the first time, we analyzed the whole range of psychopathological factors in one schizophrenia patient group. We could validate our novel results for positive FTD and passivity phenomena by replicating findings for hallucinations and negative symptoms. Only those brain circuits which are most vulnerable at a given time during neurodevelopment are affected by a particular pathological impact (genetic, environmental). This scenario could explain the predominance of particular psychopathological syndromes related to specific white matter anomalies.

Dysconnectivity of the inferior frontal gyrus: implications for an impaired self-other distinction in patients with schizophrenia

Ego disturbances in schizophrenia might be caused by a failure of the efference copy mechanism, which compares efferent with reafferent signals and attenuates the sensory consequences of self-produced movements. We carried out a functional magnetic resonance imaging study in which 16 patients with schizophrenia and 16 healthy matched controls were studied while performing both intentional and unintentional continuous hand movements in two consecutive experiments. We periodically varied the delay of visual feedback to create a sensory-motor discrepancy. Exclusively for intentional movements the activation pattern of the inferior frontal gyrus (IFG) in patients was opposite to that of controls: less attenuated during time-congruent feedback and less activated during time-incongruent feedback. Additionally, several functional connections within the mismatch detection network (IFG with insula, putamen, medial orbitofrontal cortex) were affected. Also, activity of the dysconnected orbitofrontal cortex was correlated with ego disturbance in patients. We discuss that in healthy individuals the IFG might enable a distinction between self and non-self using time-characteristics of feedback, whereas in patients this sensory mismatch detection appears to be altered. Moreover, due to the dysconnectivity of the IFG, the efferent and reafferent signal exchange between perceptual and motor areas seems to be affected. This might cause self-monitoring deficits in patients, phenomena that contribute to the emergence of ego disturbances.

Me, myself and I: temporal dysfunctions during self-evaluation in patients with schizophrenia

Self-concept is deeply affected in schizophrenia. Positive symptoms in particular are related to disturbed self/other distinctions. The neural networks underlying self-evaluation in schizophrenia have barely been investigated. The study reported here involved 13 patients with schizophrenia and 13 matched controls. During functional MRI, participants decided in three conditions whether the presented positive and negative personality traits characterized themselves, an intimate person, or included a certain letter. Based on the responses, each experimental condition was designed using a flexible factorial model. Controls and patients showed a similar behavioral pattern during self-evaluation, with group comparison revealing decreased activation in patients in the left inferior temporal gyrus and both temporal poles during self-ascription of traits, and in the anterior medial prefrontal cortex during evaluation of an intimate person. In patients, positive symptoms correlated positively with brain activation in the left parahippocampus during trait self-ascription. Hence, while evaluating themselves, schizophrenia patients revealed decreased activation in areas related to self-awareness overlapping with networks involved in theory of mind, empathy and social knowledge. Moreover, patients' brain activation during self-reflection was affected by the current positive symptomatology. The close interaction between self and other highlights the clinical and social relevance of self-processing deficits in schizophrenia.

Hyperintentionality during automatic perception of naturalistic cooperative behavior in patients with schizophrenia

Social cognition and the corresponding functionality of involved brain networks are essential for effortless social interaction. Patients with schizophrenia exhibit impaired social functioning. In this study, we focused on the neural networks involved in the automatic perception of cooperative behavior and their alterations in schizophrenia. We performed a functional magnetic resonance imaging study of 19 schizophrenia patients and 19 healthy matched controls. Participants watched a set of short videos with two actors manipulating objects, either with (C+) or without cooperation (C-). Additionally, we assessed delusional symptoms in patients using the Scales for the Assessment of Positive Symptoms and psychosis proneness in healthy controls using the brief schizotypal personality questionnaire. The observed group-by-condition interaction revealed a contrasting activation pattern for patients versus healthy controls in the medial and lateral prefrontal cortex, the middle cingulate cortex, and the left angular gyrus. Furthermore, increased activation of the middle prefrontal areas, left angular gyrus, and the posterior sulcus temporalis superior in response to the noncooperative condition (C-) was positively correlated with delusional symptoms in patients. Our findings suggest an overactivated "theory of mind" network in patients for the processing of noncooperative behavior. Thus, "overmentalizing" might be based on delusions and altered processing of cooperative behavior in patients with schizophrenia.

Frequency and neural correlates of pauses in patients with formal thought disorder

BACKGROUND

Pauses during speech may reflect the planning and monitoring of discourse, two processes putatively impaired in patients with schizophrenia, particularly those with formal thought disorder (FTD). We used functional MRI to examine the neural correlates of between-clause and of filled pauses, which are respectively associated with speech planning and speech monitoring.

METHODS

BOLD contrast was measured while six schizophrenia patients with FTD and six healthy subjects spoke about Rorshach inkblots. In an event-related design, we examined activity associated with pauses that occurred between clauses and with pauses that were filled.

RESULTS

There was no significant group difference in the frequency of between-clause pauses but patients with FTD made strikingly fewer filled pauses than controls. Between-clause pauses were associated with activation in the anterior part of the left superior temporal gyrus (STG) and the left insula in controls and the engagement of these regions was significantly attenuated in patients.

CONCLUSION

The anterior part of the left STG and the left insula are normally involved in both the planning and monitoring of discourse. The attenuated engagement of these regions with between-clause pauses and the striking infrequency of filled pauses in the patients are consistent with cognitive models implicating defective speech planning and speech monitoring in schizophrenia, especially in relation to FTD.

Neuromagnetic oscillations and hemodynamic correlates of P50 suppression in schizophrenia

Behavioral and electrophysiological data indicate compromised stimulus suppression in schizophrenia. The physiological basis of this effect and its contributions to the etiology of the disease are poorly understood. We examined neural and metabolic measures of P50 suppression in 12 patients with schizophrenia and controls. First, whole-head magnetoencephalography (MEG) assessed amplitudes of left- and right-hemispheric evoked responses and induced oscillations. Secondly, functional magnetic resonance imaging (fMRI) measured the hemodynamic responses to pairs of beeps with a short interval (500ms) as compared with those with a long interval (1500ms). The suppression of alpha power (8-13Hz) time-locked to the stimuli was negatively correlated with the suppression of evoked components and the hemodynamic measures. Remarkably, the suppression of alpha power was reduced in the patients already prior to stimulus onset. Conceivably, alpha oscillations play a central role in stimulus adaptation of neuronal networks and reflect an active mechanism for sensory suppression. The reduced stimulus suppression in schizophrenia seems to be in part due to impaired generation of alpha oscillations in the auditory cortex, resulting in higher metabolic demand as detected by fMRI. Delayed recovery of alpha rhythm may reflect an impaired gating function and contribute to sensory and cognitive deficits in schizophrenia.

Neural contributions to flow experience during video game playing

Video games are an exciting part of new media. Although game play has been intensively studied, the underlying neurobiology is still poorly understood. Flow theory is a well-established model developed to describe subjective game experience. In 13 healthy male subjects, we acquired fMRI data during free play of a video game and analyzed brain activity based on the game content. In accordance with flow theory, we extracted the following factors from the game content: (i) balance between ability and challenge; (ii) concentration and focus; (iii) direct feedback of action results; (iv) clear goals; and (v) control over the situation/activity. We suggest that flow is characterized by specific neural activation patterns and that the latter can be assessed-at least partially-by content factors contributing to the emergence of flow. Each of the content factors was characterized by specific and distinguishable brain activation patterns, encompassing reward-related midbrain structures, as well as cognitive and sensorimotor networks. The activation of sensory and motor networks in the conjunction analyses underpinned the central role of simulation for flow experience. Flow factors can be validated with functional brain imaging which can improve the understanding of human emotions and motivational processes during media entertainment.

[The relationship between psychiatry and neurology]

Neurology and psychiatry deal with diseases of the (central) nervous system. Historically neurological disorders are related to a proven organic basis, whereas psychiatric disorders are mainly defined by the phenomenology and course of the symptoms. Neuroscientific research methods such as molecular genetics, neurochemistry, neurophysiology, neuropathology, functional (SPECT, PET, fMRI) or structural (MRI) imaging have dramatically increased our knowledge of psychiatric and neurological disorders in the last 20 years. Accordingly diagnostic and therapeutic procedures and the long-term prognosis of numerous diseases in both disciplines have substantially improved (i.e. pharmacotherapy, psychotherapy, functional neurosurgery). For major brain disorders - such as dementia of the Alzheimer type - close collaboration between both disciplines is developing in diagnosis, therapy and care. Due to common neurobiological research topics, educational programs, medical training and the challenges of assuring appropriate care to patients with brain disorders, further cooperation between neurology and psychiatry is expected and necessary.

The influence of face similarity in the case of the perception of morphed self-face

The purpose of the study was to examine if differences in behavioral effects in terms of facial self-recognition, compared to other identity recognition (familiar, strange) exist. Morphed versions of three facial identities were used in the experiment. The subject's own face was morphed with an unknown identity. A face of a highly familar person and of a stranger were also morphed in the same manner. This morphing procedure was repeated six times for each identity, but with six different unknown faces, in which three of the unknown faces were rated as being similar and the other three as dissimilar. The reaction times and categorical boundaries were then measured. The major finding of the study was that there were significant delayed mean reaction times for the morphed images of version "self versus similarly rated unknown faces" in contrast to the images of "self versus dissimilarly rated unknown faces" only. No significant differences were found in any of the other morphed versions. The authors interpret this result as being uniquely associated to the facial self-recognition and suggest that this association might be related to the "self effect."

The neural basis of disturbed efference copy mechanism in patients with schizophrenia

Core psychopathological symptoms in patients with schizophrenia suggest that their sense of self may be disturbed. A disturbance in predictive motor mechanisms may be the cause of such symptoms. Ten patients with schizophrenia and ten healthy right-handed control subjects opened and closed their hand. This movement was filmed with an MRI compatible video camera and projected online onto a monitor. BOLD contrast was measured with fMRI. The temporal delay between movement and feedback was parametrically varied. Participants judged whether or not there was a delay. Patients were less sensitive to these delays than a matched control group. Comparing neural activation between the two groups showed a reduced attenuation of movement-sensitive perceptual areas in patients with increasing delay and a higher activation in the putamen in controls. The results provide further evidence that impaired efference copy mechanisms may contribute to the pathogenesis of schizophrenia and its first rank symptoms.

The influence of multiple primes on bottom-up and top-down regulation during meaning retrieval: evidence for 2 distinct neural networks

Meaning retrieval of a word can proceed fast and effortlessly or can be characterized by a controlled search for candidate lexical items and a subsequent selection process. In the current study, we facilitated meaning retrieval by increasing the number of words that were related to the final target word in a triplet (e.g., lion-stripes-tiger). To induce higher search and selection demands, we presented ambiguous words as targets (i.e., homonyms like ball) in half of the trials. Hereby, the dominant (game), low-frequent (dance), or both meanings of the homonym were primed. Participants performed a relatedness judgment during functional magnetic resonance imaging. Activation in a bilateral network (angular gyrus, rostromedial prefrontal cortex) increased linearly with multiple related primes, whereas the posterior left inferior prefrontal cortex (pLIPC) showed the reverse activation pattern for unambiguous trials. When homonyms served as targets, pLIPC responded strongest when both meanings or low-frequent concepts were addressed. Additional anterior left inferior prefrontal cortex activation was observed for the latter trials only. The data support an interaction between 2 distinct cerebral networks that can be linked to automatic bottom-up support and top-down control during meaning retrieval. They further imply a functional specialization of the LIPC along an anterior-posterior dimension.

Visualization and quantification of disease progression in multiple system atrophy

To visualize and quantify disease progression in multiple system atrophy (MSA) from cerebellar type (MSA-C), we combined two magnetic resonance imaging (MRI) techniques, voxel-based morphometry (VBM) and 3D-based volumetry. Patients suffering from MSA-C (n = 14) were imaged twice with an interval of 2.0 +/- 0.2 years. We first applied VBM to map brain morphology changes between MSA patients and controls and to identify brain areas that showed a significant amount of atrophy. Using 3D-based volumetry, we confirmed that in MSA-C patients, the brainstem including medulla and pons, vermis and cerebellar hemispheres, caudate nucleus and putamen showed significant atrophy compared with controls. Next, we used 3D-based volumetry to analyze the atrophy rates. Atrophy rates in patients with MSA were significantly different from controls for putamen (-11.4% +/- 2.6%/year), vermis (-12.3% +/- 2.9%/year), and cerebellar hemispheres (-6.6% +/- 1.1%/year). The results show that 3D-based MRI volumetry is a tool that allows the disease progression of MSA to be followed over a time period of 2 years and suggest that it may serve as a surrogate marker in clinical trials to measure disease progression.

Laterality in metaphor processing: lack of evidence from functional magnetic resonance imaging for the right hemisphere theory

We investigated processing of metaphoric sentences using event-related functional magnetic resonance imaging (fMRI). Seventeen healthy subjects (6 female, 11 male) read 60 novel short German sentence pairs with either metaphoric or literal meaning and performed two different tasks: judging the metaphoric content and judging whether the sentence has a positive or negative connotation. Laterality indices for 8 regions of interest were calculated: Inferior frontal gyrus (opercular part and triangular part), superior, middle, and inferior temporal gyrus, precuneus, temporal pole, and hippocampus. A left lateralised network was activated with no significant differences in laterality between the two tasks. The lowest degree of laterality was found in the temporal pole. Other factors than metaphoricity per se might trigger right hemisphere recruitment. Results are discussed in the context of lesion and hemifield studies.

A randomised trial of a geriatric evaluation and management consultation services in frail hospitalised patients

BACKGROUND

the usefulness of geriatric evaluation and management (GEM) approaches in the care of frail elderly patients remains uncertain. We examined whether an inpatient geriatric consultation service might be beneficial in a country with a social welfare system.

METHODS

we conducted a randomised trial with 345 patients from five centres. Ninety additional patients from four separate centres without GEM teams served as an external comparison. All patients were hospitalised, at least 65 years and frail. Patients were randomly assigned to either comprehensive geriatric assessment and management in the form of consultations and follow-up or usual care. Primary outcomes were rehospitalisation and nursing home placement 1 year after randomisation. Secondary outcomes were survival, functional, emotional and cognitive status, social situation and quality of life.

FINDINGS

at 12 months, the groups did not differ in the rate of rehospitalisation (intervention 67%, control 60%, P=0.30), nursing home placement (intervention 19%, control 14%, P=0.27), survival (intervention 81%, control 85%, P=0.56) or any of the other secondary measures. The external comparison groups were also similar in nursing home placement (16%, P=0.40), survival (80%, P=0.88) and all the secondary variables, but rehospitalisation was less (48%, P=0.04). No subgroup benefited from the intervention.

INTERPRETATION

care provided by consultation teams did not improve the rates of rehospitalisation or nursing home placement. This is not due to carry-over effects of geriatric knowledge into the control group.

Metacognition and reflexivity in patients with schizophrenia

BACKGROUND

Many patients with schizophrenia demonstrate a lack of insight into their disorder and often do not complain about their cognitive impairments. This might be due to generally reduced metacognitive abilities.

SAMPLING AND METHODS

Twenty-seven patients with a DSM IV diagnosis of schizophrenia and 19 healthy control subjects performed 2 separate tasks tapping into metacognitive functions. In the first experiment the participants encoded words. In the following recognition part they judged their level of subjective confidence in the correctness of their answer. In the second experiment reaction time was measured, whilst judgments were made about personality trait adjectives describing the subjects themselves or other familiar people.

RESULTS

Although the recognition rate in the first experiment was equal between the groups, the patients showed a significantly reduced ability to correctly judge their memory performance. There was no correlation between metamemory and psychopathology nor insight measures. The patients further needed significantly more time to characterize themselves compared to the healthy participants. The response rates for self-characterization correlated with the ability to recognize symptoms as part of a disorder but did not correlate with psychopathology.

CONCLUSIONS

Metacognitive faculties seem to be, at least in part, a separable cognitive entity. Patients with schizophrenia demonstrate impaired metacognitive capacities, independent of current symptoms or memory performance.

Neural correlates of metaphor processing in schizophrenia

OBJECTIVE

A main feature of schizophrenic thought and language disturbance is concretism, the inability to understand the figurative meaning of proverbs and metaphors. Although this is routinely tested during clinical interview, its neural basis is unknown.

METHOD

We investigated processing of metaphoric sentences with functional magnetic resonance imaging (fMRI) in 12 patients with schizophrenia and 12 control subjects. Stimuli consisted of 60 novel short sentences with either metaphoric or literal meaning presented visually, intersparsed by a low level baseline (grey background). Subjects read these sentences silently and judged by button press whether they had a positive or negative connotation.

RESULTS

Reading metaphors in contrast to literal sentences revealed signal changes in the left inferior frontal gyrus in the control subjects (BA 45/47) and an area 3 cm dorsal to that in the patients (BA 45). Only activation in this area was negatively correlated with the severity of concretism rated with the PANSS. Comparison between groups for the contrast metaphors vs. low level baseline revealed stronger signal changes in the control group in the right superior/middle temporal gyrus (BA 39) and the left inferior frontal gyrus (BA 45) in the patients.

CONCLUSIONS

The results in the control subjects are in line with studies showing an involvement of the left inferior frontal and right lateral temporal cortex during context processing. Failure to recruit these areas in the patients may underlie schizophrenic concretism.

Functional brain imaging of symptoms and cognition in schizophrenia

The advent of functional magnetic resonance imaging and positron emission tomography has provided novel insights into the neural correlates of cognitive function and psychopathological symptoms. In patients with mental disorders, cognitive and emotional processes are disrupted. In this chapter, we review the basic methodological and conceptual principles for neuroimaging studies in these patients. By taking schizophrenia as an example, we outline the cerebral processes involved in the symptoms of this disorder, such as auditory hallucinations and formal thought disorder. We also characterize the neural networks involved in their emotional and cognitive dysfunction.

Cortical activation during cholinesterase-inhibitor treatment in Alzheimer disease: preliminary findings from a pharmaco-fMRI study

OBJECTIVE

Cholinesterase inhibitors improve cognitive functioning in Alzheimer disease (AD). The authors studied, with functional magnetic resonance imaging (fMRI), the neural mechanism by which this cholinergic enhancement improves memory encoding in AD over longer time periods.

METHODS

Brain activation was measured in 10 patients with AD and 10 healthy elderly comparison subjects with fMRI while they were encoding novel faces. Patients were scanned again after a 10-week open treatment with the cholinesterase-inhibitor donepezil.

RESULTS

Neuropsychologically-tested memory performance improved during the treatment phase in the patients. During the encoding of novel faces, elderly comparison subjects showed more activation in the right fusiform gyrus than the group of AD patients. After a 10-week treatment with donepezil, the fusiform gyrus was also activated in patients, similar to the comparison group.

CONCLUSIONS

The right fusiform gyrus is associated with the processing of faces. Cholinergic enhancement augments selective attention by increased selectivity of perceptual responses in patients with AD. This mechanism may contribute to a more efficient processing of the attended stimulus and thus be a mechanism underlying clinical improvement of cognitive functioning. These promising preliminary findings need to be confirmed in a larger, controlled trial in which both fMRI and attention measures serve as outcomes.

Disorders of agency in schizophrenia correlate with an inability to compensate for the sensory consequences of actions

Psychopathological symptoms in schizophrenia patients suggest that the concept of self might be disturbed in these individuals [1]. Delusions of influence make them feel that someone else is guiding their actions, and certain kinds of their hallucinations seem to be misinterpretations of their own inner voice as an external voice, the common denominator being that self-produced information is perceived as if coming from outside. If this interpretation were correct, we might expect that schizophrenia patients might also attribute the sensory consequences of their own eye movements to the environment rather than to themselves, challenging the percept of a stable world. Indeed, this seems to be the case because we found a clear correlation between the strength of delusions of influence and the ability of schizophrenia patients to cancel out such self-induced retinal information in motion perception. This correlation reflects direct experimental evidence supporting the view that delusions of influence in schizophrenia might be due to a specific deficit in the perceptual compensation of the sensory consequences of one's own actions [1, 2, 3, 4, 5 and 6].

Neural correlates of syntax production in schizophrenia

BACKGROUND

The production of grammatically complex sentences is impaired in schizophrenia. It has been suggested that impaired syntax processing reflects a risk for the disorder.

AIMS

To examine the neural correlates of syntax production in people with schizophrenia using functional magnetic resonance imaging (fMRI).

METHOD

Six patients with schizophrenia and six healthy volunteers spoke about seven Rorschach inkblots for 3 min each while correlates of brain activation were measured with fMRI. Participants produced varying amounts of syntactically simple and complex sentences during each 3 min run. The number of simple and complex sentences was correlated separately with the BOLD contrast.

RESULTS

In the comparison between the control group and the patient group, the number of complex sentences produced was correlated with activation in the posterior portion of the right middle temporal (Brodmann area 21) and left superior frontal (BA10) gyriin the control group but not in the patients.

CONCLUSIONS

The absence of activation in the right posterior temporal and left superior frontal cortex in patients with schizophrenia might contribute to the articulation of grammatically more simple speech in people with this disorder.

Deceiving oneself about being in control: conscious detection of changes in visuomotor coupling

Previous research has demonstrated that compensatory movements for changes in visuomotor coupling often are not consciously detected. But what factors affect the conscious detection of such changes? This issue was addressed in 4 experiments. Participants carried out a drawing task in which the relative velocity between the actual movement and its visual consequences was perturbed. Unconscious compensatory movements and conscious detection rates were simultaneously recorded. There was an invariant relationship between the extent of the change and its conscious detection that was proportional to the initial drawing velocity. This suggests that conscious change detection relies on a system that integrates visual and motor information-as, for instance, suggested by the internal model theory of motor control. Figural discrepancies increased the detection rates, indicating that additional cues for the what system facilitate conscious change detection.

Neural correlates of metaphor processing

Metaphoric language is used to express meaning that is otherwise difficult to conceptualize elegantly. Beyond semantic analysis, understanding the figurative meaning of a metaphor requires mental linkage of different category domains normally not related to each other. We investigated processing of metaphoric sentences using event-related functional magnetic resonance imaging (fMRI). Stimuli consisted of 60 novel short German sentence pairs with either metaphoric or literal meaning. The pairs differed only in their last one to three words and were matched for syntax structure, word frequency, connotation and tense. Fifteen healthy subjects (six female, nine male, 19-51 years) read these sentences silently and judged by pressing one of two buttons whether they had a positive or negative connotation. Reading metaphors in contrast to literal sentences revealed signal changes in the left lateral inferior frontal (BA 45/47), inferior temporal (BA 20) and posterior middle/inferior temporal (BA 37) gyri. The activation in the left inferior frontal gyrus may reflect semantic inferencing processes during the understanding of a metaphor. This is in line with the results from other functional imaging studies showing an involvement of the left inferior frontal gyrus in integrating word and sentence meanings. Previous results of a right hemispheric involvement in metaphor processing might reflect understanding of complex sentences.

Self-consciousness, self-agency, and schizophrenia

Empirical approaches on topics such as consciousness, self-awareness, or introspective perspective, need a conceptual framework so that the emerging, still unconnected findings can be integrated and put into perspective. We introduce a model of self-consciousness derived from phenomenology, philosophy, the cognitive, and neurosciences. We will then give an overview of research data on one particular aspect of our model, self-agency, trying to link findings from cognitive psychology and neuroscience. Finally, we will expand on pathological aspects of self-agency, and in particular on psychosis in schizophrenia. We show, that a deficient self-monitoring system underlies, in part, hallucinations and formal thought (language) disorder in schizophrenia. We argue, that self-consciousness is a valid construct and can be studied with the instruments of cognitive and neuroscience.

The neural correlates of perceiving one's own movements

Feedforward mechanisms are important for movement control. They may also contribute to the identification of self-produced actions by attenuating the sensory consequences of self-produced movements. In our study, subjects opened and closed their hand slowly and continuously (0.5 Hz). This movement was filmed with an MRI compatible video camera and projected online onto a screen, viewed by the subject while BOLD contrast was measured with fMRI. The temporal delay between movement and feedback was parametrically varied (0-200 ms). In each trial, subjects judged whether there was a delay or not. There was a positive correlation between the extent of the temporal delay and activation in the right posterior superior temporal cortex (pSTS) and a negative correlation in the left putamen. A second analysis addressed the neural correlates of subjective judgement under conditions of uncertainty. This contrast showed a differential activation in the cerebellum. These results support the assumption of a forward model implying that predictions generated in motor areas attenuate sensory areas. They also suggest that efference copy mechanisms are not located within specific brain areas but are implemented as a specific form of interaction between perceptual and motor areas depending on the modalities and the type of actions involved. Further, conscious detection of small temporal deviations might be based on signals generated in the cerebellum which provide fine-grained temporal information. These results might be useful to refine theories about the role of forward mechanisms in the emergence of disorders of the self, such as in schizophrenia.

Mismatch negativity responses in schizophrenia: a combined fMRI and whole-head MEG study

OBJECTIVE

Mismatch negativity is an event-related brain response sensitive to deviations within a sequence of repetitive auditory stimuli. It is thought to reflect short-term sensory memory and is independent of higher-level cognitive processes. Mismatch negativity response is diminished in patients with schizophrenia. Little is known about the mechanisms of this decreased response, the contribution of the different hemispheres, and its locus of generation.

METHOD

Patients with schizophrenia (N=12) and matched comparison subjects (N=12) were studied. A novel design to measure mismatch negativity responses to deviant auditory stimuli was generated by using the switching noises from the functional magnetic resonance imaging (fMRI) scanner, thus avoiding any interfering background sound. Stimuli included deviants of amplitude (9 dB lower) and duration (76 msec shorter) presented in a random sequence. The scanner noise was recorded and applied to the same subjects in a whole-head magnetoencephalography (MEG) device. Neuromagnetic and hemodynamic responses to the identical stimuli were compared between the patients and comparison subjects.

RESULTS

As expected, neuromagnetic mismatch fields were smaller in the patient group. More specifically, a lateralization to the right for duration deviance was only found in comparison subjects. For the relative amplitude of the blood-oxygen-level-dependent signal (measured with fMRI), differences emerged in the secondary (planum temporale), but not primary (Heschl's gyrus), auditory cortex. Duration deviants achieved a right hemispheric advantage only in the comparison group. A significantly stronger lateralization to the left was found for the deviant amplitude stimuli in the patients.

CONCLUSIONS

The data support the view of altered hemispheric interactions in the formation of the short-term memory traces necessary for the integration of auditory stimuli. This process is predominantly mediated by the planum temporale (secondary auditory cortex). Altered interaction of regions within the superior temporal plane and across hemispheres could be in part responsible for language-mediated cognitive (e.g., verbal memory) and psychopathological (hallucinations, formal thought disorder) symptoms in schizophrenia.

Pausing for thought: engagement of left temporal cortex during pauses in speech

Pauses during continuous speech, particularly those that occur within clauses, are thought to reflect the planning of forthcoming verbal output. We used functional Magnetic Resonance Imaging (fMRI) to examine their neural correlates. Six volunteers were scanned while describing seven Rorschach inkblots, producing 3 min of speech per inkblot. In an event-related design, the level of blood oxygenation level dependent (BOLD) contrast during brief speech pauses (mean duration 1.3 s, SD 0.3 s) during overt speech was contrasted with that during intervening periods of articulation. We then examined activity associated with pauses that occurred within clauses and pauses that occurred between grammatical junctions. Relative to articulation during speech, pauses were associated with activation in the banks of the left superior temporal sulcus (BA 39/22), at the temporoparietal junction. Continuous speech was associated with greater activation bilaterally in the inferior frontal (BA 44/45), middle frontal (BA 8) and anterior cingulate (BA 24) gyri, the middle temporal sulcus (BA 21/22), the occipital cortex and the cerebellum. Left temporal activation was evident during pauses that occurred within clauses but not during pauses at grammatical junctions. In summary, articulation during continuous speech involved frontal, temporal and cerebellar areas, while pausing was associated with activity in the left temporal cortex, especially when this occurred within a clause. The latter finding is consistent with evidence that within-clause pauses are a correlate of speech planning and in particular lexical retrieval.

Observing one’s hand become anarchic: An fMRI study of action identification

The self seems to be a unitary entity remaining stable across time. Nevertheless, current theorizing conceptualizes the self as a number of interacting sub-systems involving perception, intention and action (self-model). One important function of such a self-model is to distinguish between events occurring as a result of one's own actions and events occurring as the result of somebody else's actions. We conducted an fMRI experiment that compared brain activation after an abrupt mismatch between one's own movement and its visual consequences with an abrupt mismatch between one's own movement and somebody else's visually perceived hand movement. A right fronto-parietal network was selectively active during a sudden mismatch between one's own observed and performed hand action.

Successful episodic memory retrieval of newly learned faces activates a left fronto-parietal network

It is easier to recognize a familiar face than a newly learned face. The neural basis of familiar face recognition has been elucidated in functional imaging and lesion studies. Behavioural and neuropsychological data indicate, however, that brain systems involved in episodic retrieval of familiar and newly learned faces are distinct. In our study, 12 subjects viewed 30 novel faces in an encoding session. In the study condition, event-related functional magnetic resonance imaging (fMRI) was used to compare brain activation during correct recognition of the recently learned faces to that observed during correct rejection of unknown control faces. Differences were present in the left inferior parietal (BA 40) and left medial frontal/anterior cingulate (BA 32/9) cortex. These two regions may be part of a pathway in the dorsal visual stream, responsible for a "feeling of familiarity" in contrast to the ventral pathway in the temporal lobes, which is mainly involved in the recognition of personal identity.

Brain regions sensitive to the face inversion effect: a functional magnetic resonance imaging study in humans

Perception of upright faces relies on configural processing. Therefore recognition of inverted, compared to upright faces is impaired. In a functional magnetic resonance imaging experiment we investigated the neural correlate of a face inversion task. Thirteen healthy subjects were presented with a equal number of upright and inverted faces alternating with a low level baseline with an upright and inverted picture of an abstract symbol. Brain activation was calculated for upright minus inverted faces. For this differential contrast, we found a signal change in the right superior temporal sulcus and right insula. Configural properties are processed in a network comprising right superior temporal and insular cortex.

Mismatch responses to randomized gradient switching noise as reflected by fMRI and whole-head magnetoencephalography

The central auditory system of the human brain uses a variety of mechanisms to analyze auditory scenes, among others, preattentive detection of sudden changes in the sound environment. Electroencephalography (EEG) and magnetoencephalography (MEG) provide a measure to monitor neuronal cortical currents. The mismatch negativity (MMN) or field (MMNm) reflect preattentive activation in response to deviants within a sequence of homogenous auditory stimuli. Functional magnetic resonance imaging (fMRI) allows for a higher spatial resolution as compared to the extracranial electrophysiological techniques. The image encoding gradients of echo planar imaging (EPI) sequences, however, elicit an interfering background noise. To circumvent this shortcoming, the present study applied multi-echo EPI mimicking an auditory oddball design. The gradient trains (SOA = 800 msec, 94.5 dB SPL, stimulus duration = 152 msec) comprised amplitude (-9 dB) and duration (76 msec) deviants in a randomized sequence. Moreover, the scanner noise was recorded and applied in a whole-head MEG device to validate the properties of this specific material. Robust fMRI activation patterns emerged in response to the deviant gradient switching. Changes in amplitude activated the entire auditory cortex, whereas the duration deviants elicited right-lateralized signal increase in secondary areas. The recorded scanner noise evoked reliably right-lateralized mismatch MEG responses. Source localization was in accordance with activation of secondary auditory cortex. The presented paradigm provides a robust and feasible tool to study the functional anatomy of early cognitive auditory processing in clinical populations such as schizophrenia.

Reversed lateralization of temporal activation during speech production in thought disordered patients with schizophrenia

BACKGROUND

Formal thought disorder is a core symptom of schizophrenia. It is associated with a reversed lateralization of the superior temporal cortex volume, an area that is implicated in lexical retrieval. We investigated the neural correlates of word retrieval during continuous speech in patients with formal thought disorder using functional magnetic resonance imaging (fMRI).

METHODS

Blood oxygenation level dependent (BOLD) contrast was measured with fMRI while six patients with schizophrenia and six healthy control subjects spoke about seven Rorschach inkblots for 3 min each. Subjects produced varying amounts of speech during each run. In a within subject design, the number of words produced was correlated with the BOLD contrast in the two runs in each participant who showed the highest variance of speech output.

RESULTS

In control subjects, the amount of speech produced was mainly correlated with activation in the left superior temporal gyrus. In the patient group, the main correlations were in the right superior temporal gyrus.

CONCLUSIONS

During the production of continuous speech, patients with formal thought disorder showed a reversed laterality of activation in the superior temporal cortex. This is consistent with findings of perturbed hemispheric interaction in schizophrenia, particularly in patients with formal thought disorder.

The neural correlates of intentional and incidental self processing

The neuroscientific study of the 'Self' is just beginning to emerge. We used functional Magnetic Resonance Imaging (fMRI) to investigate cerebral activation while subjects processed words describing personality traits and physical features, in two experiments with contrasting designs: incidental and intentional. In the first experiment (intentional self processing), subjects were presented with personality trait adjectives and made judgements as to their self descriptiveness (versus non self descriptiveness). In the second experiment (incidental self processing), subjects categorised words according to whether they described physical versus psychological attributes, while unaware that the words had been arranged in blocks according to self descriptiveness. The subjects had previously rated all words for self descriptiveness 6 weeks prior to the scanning session. A reaction time advantage was present in both experiments for self descriptive trait words, suggesting a facilitation effect. Common areas of activation for the two experiments included the left superior parietal lobe, with adjacent regions of the lateral prefrontal cortex also active in both experiments. Differential signal changes were present in the left precuneus for the intentional and the right middle temporal gyrus for the incidental experiment. The results suggest that self processing involves distinct processes and can occur on more than one cognitive level with corresponding functional neuroanatomic correlates in areas previously implicated in the awareness of one's own state.