Neurochemical effects of oxytocin in people at clinical high risk for psychosis

Alterations in neurochemical metabolites are thought to play a role in the pathophysiology of psychosis onset. Oxytocin, a neuropeptide with prosocial and anxiolytic properties, modulates glutamate neurotransmission in preclinical models but its neurochemical effects in people at high risk for psychosis are unknown. We used proton magnetic resonance spectroscopy (¹H-MRS) to examine the effects of intranasal oxytocin on glutamate and other metabolites in people at Clinical High Risk for Psychosis (CHR-P) in a double-blind, placebo-controlled, crossover design. 30 CHR-P males were studied on two occasions, once after 40IU intranasal oxytocin and once after placebo. The effects of oxytocin on the concentration of glutamate, glutamate+glutamine and other metabolites (choline, N-acetylaspartate, myo-inositol) scaled to creatine were examined in the left thalamus, anterior cingulate cortex (ACC) and left hippocampus, starting approximately 75, 84 and 93 min post-dosing, respectively. Relative to placebo, administration of oxytocin was associated with an increase in choline levels in the ACC (p=.008, Cohen's d = 0.54). There were no other significant effects on metabolite concentrations (all p>.05). Our findings suggest that, at ∼75-99 min post-dosing, a single dose of intranasal oxytocin does not alter levels of neurochemical metabolites in the thalamus, ACC, or hippocampus in those at CHR-P, aside from potential effects on choline in the ACC.

When trust is lost: the impact of interpersonal trauma on social interactions

BACKGROUND

Trauma due to deliberate harm by others is known to increase the likelihood of developing Post-Traumatic Stress Disorder (PTSD). This is the first study investigating basic and dynamic trust in 'interpersonal' PTSD.

METHODS

Thirty-two participants with PTSD and 22 healthy controls played a novel multi-round version of a monetary investment protocol, the so-called 'Trust Game', a task from the behavioural economics literature, which is considered to involve trust and reciprocity. We used two 'Trust Games' including cooperative and unfair partners.

RESULTS

Findings showed an effect for lower basic investment in PTSD compared to healthy controls, that trended towards significance (p = 0.09). All participants showed behavioural flexibility and modified their trust based on behavioural cues from their cooperative and unfair game partners. However, participants with PTSD made significantly lower investments towards the cooperative partner than controls. Investments towards the unfair partner did not differ between groups. Higher trauma scores were associated with lower levels of trust-related investments towards the cooperative but not the unfair game partner.

CONCLUSION

The association between reduced trust towards cooperative others in individuals who experienced interpersonal trauma could indicate acquired insensitivity to social rewards or inflexible negative beliefs about others as a sequel of the traumatic experience, which increases in a dose response relationship with the severity of the trauma. A specific focus on cooperation and trusting behaviour could provide a treatment target for future cognitive and pharmacological interventions.

Erratum: A symptom-based approach to treatment of psychosis in autism spectrum disorder in October 2017-ERRATUM

[This corrects the article DOI: 10.1192/bjo.2017.2.].

A symptom-based approach to treatment of psychosis in autism spectrum disorder [corrected]

The optimal management of autism with psychosis remains unclear. This report describes a 22-year-old man with autism and psychosis who was referred to a tertiary-level specialist psychosis service, following a 6-year history of deterioration in mental health starting around the time of sitting GCSE examinations and an episode of bullying at school. We describe the individualised symptom-based approach that was effective in his treatment. Declaration of interest The authors declare no conflict of interest.

Hope or hype in the treatment of schizophrenia - what's the role of the physician?

According to the experience of people with schizophrenia, their psychiatrists' attitude towards the outcome of their illness is lacking in hope, which directly affects mutual faith in treatment. Here we discuss the scientific basis of hope and show its instrumental role in optimising the best treatment strategies for schizophrenia. Declaration of interest R.A.B has received honoraria for educational input and non-financial support from Ache; honoraria for educational input from Lundbeck; grants, honoraria for educational input and non-financial support from Janssen; all outside the submitted work. G.E.M.G. has received honoraria for educational input and non-financial support from Janssen outside the submitted work. G.M. reports support from Janssen-Cilag, outside the submitted work, and is an employee at Janssen-Cilag. S.S. has received grants and honoraria for educational input from EnVivo Pharmaceuticals, Takeda, AbbVie and Janssen Pharmaceuticals, outside the submitted work.

Successful clozapine re-challenge in a patient with three previous episodes of clozapine-associated blood dyscrasia

A case is presented of a 30-year-old female with treatment-resistant schizoaffective disorder who was referred to a tertiary-level specialist psychosis service. We describe the history of clozapine trials and associated episodes of agranulocytosis and neutropenia, followed by the successfully tolerated third clozapine re-challenge within our service.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Clozapine in a patient with treatment-resistant schizophrenia and hypertrophic cardiomyopathy: a case report

BACKGROUND

There is currently limited experience in the initiation and maintenance of clozapine for treatment-resistant psychosis in adults with established structural heart disease. These complex patients require close supervision and liaison between colleagues. Here we present the successful experience of treating one such patient within our service and describe a monitoring plan to ensure that these treatments can be provided both safely and effectively.

CASE PRESENTATION

A 36-year-old man with treatment-resistant schizophrenia and known hypertrophic cardiomyopathy (HCM) was admitted to a specialist unit for a trial of clozapine. His psychiatric illness was characterised by multimodal hallucinations and delusions combined with low mood and poor motivation. The diagnosis of HCM was made 3 years previously following a routine electrocardiogram (ECG), and he had remained asymptomatic throughout this time; there were concerns about the risk of initiating clozapine given his pre-existing cardiac condition. Baseline investigations were performed as per local guidelines prior to commencing clozapine; these were within normal limits other than a mildly raised troponin level of 54 ng/L (normal <16 ng/L), which was attributed to the HCM. In addition, baseline transthoracic echocardiography (TTE) was performed which showed no change in the structural heart disease in comparison with previous TTEs. Clozapine was started at 12.5 mg daily and up-titrated to 150 mg twice daily over 14 days as per our institute's guidelines. The patient was monitored with regular testing of troponins, inflammatory markers and ECG. On day 18, the troponin level increased to 1371 ng/L. Creatine kinase and inflammatory markers remained stable. No changes in ECG or TTE were noted and the patient remained clinically asymptomatic. Cardiology opinion was sought and reported that the finding of an isolated elevated troponin was likely to reflect a 'troponin leak' in the context of increased cardiac muscle mass associated with HCM. In the absence of any clinical compromise, it was not felt to be of concern. Clozapine was continued with good effect on mental state. Troponin levels gradually reduced and the patient remained well.

CONCLUSIONS

While multiple cases of clozapine-induced cardiotoxicity have been reported in the literature, its implications for pre-existing structural disease are unclear. This case report suggests that clozapine can be safely introduced in pre-existing HCM, explores strategies for monitoring and highlights the importance of liaising with experienced cardiologists.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Post graduate clinical placements: evaluating benefits and challenges with a mixed methods cross sectional design

BACKGROUND

Systematic evaluations of clinical placements are rare, especially when offered alongside academic postgraduate courses. An evidence-based approach is important to allow pedagogically-driven provision, rather than that solely governed by opinion or market demand. Our evaluation assessed a voluntary clinical placement scheme allied to a mental health course.

METHODS

Data were collected over academic years 2010/11- 2013/14, from participating students (n = 20 to 58) and clinician supervisors (n = 10-12), using a mixed-methods cross-sectional design. Quantitative evaluation captured information on uptake, dropout, resource use, attitudes and experience, using standardized (the Placement Evaluation Questionnaire; the Scale To Assess the Therapeutic Relationship - Clinical version and the University of Toronto Placement Supervisor Evaluation) and bespoke questionnaires and audit data. Qualitative evaluation comprised two focus groups (5 clinicians, 5 students), to investigate attitudes, experience, perceived benefits, disadvantages and desired future developments. Data were analysed using framework analysis to identify a priori and emergent themes.

RESULTS

High uptake (around 70 placements per annum), low dropout (2-3 students per annum; 5 %) and positive focus group comments suggested placements successfully provided added value and catered sufficiently to student demand. Students' responses confirmed that placements met expectations and the perception of benefit remained after completion with 70 % (n = 14) reporting an overall positive experience, 75 % (n = 15) reporting a pleasant learning experience, 60 % (n = 12) feeling that their clinical skills were enhanced and 85 % (n = 17) believing that it would benefit other students. Placements contributed the equivalent of seven full time unskilled posts per annum to local health care services. While qualitative data revealed perceived 'mutual benefit' for both students and clinicians, this was qualified by the inherent limitations of students' time and expertise. Areas for development included fostering learning around professionalism and students' confidence on placement.

CONCLUSIONS

The addition of healthcare placements to academic postgraduate taught courses can improve their attractiveness to applicants, benefit healthcare services and enhance students' perception of their learning experiences. Well-positioned and supported placement learning opportunities could become a key differentiator for academic courses, over potential competitors. However, the actual implications for student employability and achievement remain to be established.

How can we enhance cognitive bias modification techniques? The effects of prospective cognition

BACKGROUND AND OBJECTIVES

Cognitive bias modification for interpretation, a computerized program which manipulates biased interpretations, has shown therapeutic promise, including evidence that negatively biased interpretations can be reduced, leading to corresponding improvements in symptoms. Cognitive bias modification for cognitive errors (CBM-errors) is a second generation CBM-I procedure which manipulates seven types of cognitive error and is especially relevant to depressive cognition. The aim of this study was to investigate whether the effects of the CBM-errors manipulation would be enhanced by adding a component facilitating prospective cognition to help embed and extend newly acquired interpretations.

METHODS

A sample of 80 volunteers completed a single session experiment. With a pretraining-posttraining design, we compared the effects of enhanced CBM-errors (targeting cognitive errors plus prospective cognition) with standard CBM-errors (targeting cognitive errors without prospective cognition), on interpretations of new material and mood.

RESULTS

Significant differences between enhanced and standard CBM-errors revealed that enhanced positive training was more effective at decreasing negative interpretations compared to the standard procedure.

LIMITATIONS

Extending the current investigation to a sample dysphoria or depression is needed for an appropriate next step.

CONCLUSION

The findings serve as 'a proof of principle' for the potential of prospective cognition to enhance the effects of CBM-errors and other similar CBM procedures. Further work to enhance the effectiveness of CBM procedures is needed.

Optimizing outcomes in clozapine rechallenge following neutropenia: a cohort analysis

OBJECTIVE

Certain patients with treatment-refractory schizophrenia may be rechallenged with clozapine following previous neutropenia. Evidence guiding patient selection and the effectiveness of lithium and granulocyte-colony stimulating factor (G-CSF) in rechallenge is limited, and factors associated with successful outcomes are unclear.

METHOD

Outcomes were studied in patients rechallenged with clozapine at a tertiary referral center between January 2007 and December 2013, following 1 or more previous trials terminated due to neutropenia, defined as an absolute neutrophil count (ANC) < 1.5 × 10(9)/L. Demographic characteristics, details of each clozapine trial including ANC, and coprescribed medication were extracted, and factors associated with rechallenge outcomes were examined.

RESULTS

Nineteen patients underwent clozapine rechallenge following previous neutropenia; 4 (21%) experienced further neutropenia, 2 of which developed agranulocytosis. Compared to successfully rechallenged patients, unsuccessfully rechallenged patients were significantly older (t = 2.10, P = .05), experienced onset of neutropenia sooner (W = 10.0, P = .03), and were more commonly coprescribed valproate. In addition to 5 patients with benign ethnic neutropenia (BEN), 8 patients not of an ethnicity associated with BEN also had idiopathic low neutrophil counts at baseline; lithium and G-CSF coprescription facilitated successful rechallenge in these patients.

CONCLUSIONS

In this selected population, the initial neutropenia was unlikely to be related to clozapine in a substantial proportion of cases. This group was successfully rechallenged following careful consideration of the risks and benefits, and lithium and G-CSF contributed to allowing continued clozapine therapy. In addition to black patients, other ethnic groups can have persistently low ANC unrelated to clozapine.

Predictors of healthcare professionals' attitudes towards family involvement in safety-relevant behaviours: a cross-sectional factorial survey study

OBJECTIVES

To investigate predictors of healthcare professionals' (HCPs) attitudes towards family involvement in safety-relevant behaviours.

DESIGN

A cross-sectional fractional factorial survey that assessed HCPs' attitudes towards family involvement in two error scenarios relating to hand hygiene and medication safety. Each survey comprised two randomised vignettes that described the potential error, how the family member communicated with the HCP about the error and how the HCP responded to the family member's question.

SETTING

5 teaching hospitals in London, the Midlands and York. HCPs were approached on a range of medical and surgical wards.

PARTICIPANTS

160 HCPs (73 doctors; 87 nurses) aged between 21 and 65 years (mean 37) 102 were female.

OUTCOME MEASURES

HCP approval of family member's behaviour; HCP reaction to the family member; anticipated effects on the family member-HCP relationship; HCP support for being questioned about hand hygiene/medication; affective rating responses.

RESULTS

HCPs supported family member's intervening (88%) but only 41% agreed this would have positive effects on the family member/HCP relationship. Across vignettes and error scenarios the strongest predictors of attitudes were how the HCP (in the scenario) responded to the family member and whether an error actually occurred. Doctors (vs nurses) provided systematically more positive affective ratings to the vignettes.

CONCLUSIONS

Important predictors of HCPs' attitudes towards family members' involvement in patient safety have been highlighted. In particular, a discouraging response from HCP's decreased support for family members being involved and had strong perceived negative effects on the family member/HCP relationship.

Ivabradine, a novel treatment for clozapine-induced sinus tachycardia: a case series

OBJECTIVES

Clozapine is the most efficacious treatment for treatment-resistant schizophrenia; however its use can be limited by intolerability. Sinus tachycardia is a common adverse event associated with clozapine use, which may lead to the premature discontinuation of clozapine. Traditionally, β blockers are used to treat clozapine-associated tachycardia, though problems with intolerability and ineffectiveness can limit their utility.

METHODS

In this article, we present two cases of patients with treatment-resistant schizophrenia who developed symptomatic tachycardia associated with clozapine therapy.

RESULTS

We demonstrate that the novel heart rate controlling agent ivabradine can be effectively and safely used to control the heart rate and to allow for continued treatment with clozapine.

CONCLUSION

This is the first report in the literature demonstrating that ivabradine appears to be a well tolerated agent, which should be considered as a symptomatic treatment of clozapine-induced tachycardia if the use of a β blocker fails due to a lack of response or intolerability.

When the drugs don't work: the potential of glutamatergic antipsychotics in schizophrenia

Currently available antipsychotic drugs target dopaminergic neurotransmission. Many patients do not respond fully to these treatments, and there has been considerable effort to investigate alternative targets. Here we summarise the rationale and recent evidence supporting efforts to develop glutamatergic antipsychotic drugs.

The influence of prior expectations on facial expression discrimination in schizophrenia

BACKGROUND

Belief inflexibility is a thinking style observed in patients with schizophrenia, in which patients tend to refute evidence that runs counter to their prior beliefs. This bias has been related to a dominance of prior expectations (prior beliefs) over incoming sensory evidence. In this study we investigated the reliance on prior expectations for the processing of emotional faces in schizophrenia.

METHOD

Eighteen patients with schizophrenia and 18 healthy controls were presented with sequences of emotional (happy, fearful, angry or neutral) faces. Perceptual decisions were biased towards a particular expression by a specific instruction at the start of each sequence, referred to as the context in which stimuli occurred. Participants were required to judge the emotion on each face and the effect of the context on emotion discrimination was investigated.

RESULTS

For threatening emotions (anger and fear), there was a performance cost for facial expressions that were incongruent with, and perceptually close to, the expression named in the instruction. For example, for angry faces, participants in both groups made more errors and reaction times (RTs) were longer when they were asked to look out for fearful faces compared with the other contexts. This bias against sensory evidence that runs counter to prior information was stronger in the patients, evidenced by a group by context interaction in accuracy and RTs for anger and fear respectively.

CONCLUSIONS

Overall, the present data suggest an overdependence on prior expectations for threatening stimuli, reflecting belief inflexibility, in schizophrenia.

Exploring psychotic symptoms: a comparison of motor related neuronal activation during and after acute psychosis

BACKGROUND

Delusions and hallucinations are classic positive symptoms of schizophrenia. A contemporary cognitive theory called the 'forward output model' suggests that the misattribution of self-generated actions may underlie some of these types of symptoms, such as delusions of control - the experience of self-generated action being controlled by an external agency. In order to examine the validity of this suggestion, we performed a longitudinal functional magnetic resonance imaging (fMRI) study examining neuronal activation associated with motor movement during acute psychosis.

METHODS

We studied brain activation using fMRI during a motor task in 11 patients with schizophrenia and 9 healthy controls. The patient group was tested at two time points separated by 6-8 weeks.

RESULTS

At initial testing, the patient group had a mean Positive and Negative Syndrome Scale score of 56.3, and showed significantly increased activation within the left inferior parietal lobe (IPL) compared to controls. Patients reported significantly decreased positive symptoms at 6-8 week followup and IPL activation had returned to normal. Our results demonstrate that first-rank positive symptoms are associated with hyperactivation in the secondary somatosensory cortex (IPL).

CONCLUSIONS

These findings lend further credence to the theory that a dysfunction in the sensory feedback system located in the IPL, and which is thought to underlie our sense of agency, may contribute to the aetiology of delusions of control.

Computerized cognitive remediation training for schizophrenia: an open label, multi-site, multinational methodology study

A recent single-site study (Fisher et al., 2009. Am J Psychiatry. 166 (7) 805-11) showed that repeated training with the Brain Fitness Program (BFP) improved performance on a battery of neuropsychological tasks. If replicated these data suggest an important non-pharmacological method for ameliorating cognitive impairment in schizophrenia. Our study evaluated the BFP training effects in an open-label, multi-site, multinational clinical trial. Fifty-five stable adult patients with schizophrenia on regular antipsychotic medication completed ≥ 32 BFP training sessions over 8-10 weeks. Training effects on cognitive performance and functional capacity outcome measures were measured using CogState® schizophrenia battery, UCSD Performance based Skills Assessment (UPSA-2) and Cognitive Assessment Interview (CAI). BFP training showed a large and significant treatment effect on a training exercise task (auditory processing speed), however this effect did not generalize to improved performance on independent CogState® assessment. There were no significant effects on UPSA-2 or CAI scores. Our study demonstrated the feasibility of implementing BFP training in a multi-site study. However, BFP training did not show significant treatment effects on cognitive performance or functional capacity outcome measures despite showing large and significant effects on a training exercise.

An fMRI study of prefrontal dysfunction and symptomatic recovery in schizophrenia

OBJECTIVE

Prefrontal cortical dysfunction has been implicated in the pathophysiology of schizophrenia but it is unclear to what extent these are related to changes in symptomatology as well as task demand.

METHOD

We examined the neural correlates of symptom change and task demand during a longitudinal functional magnetic resonance imaging (fMRI) study using a verbal fluency task with differential task demands in patients with schizophrenia and matched healthy control subjects. The fMRI data were acquired using clustered acquisition technique, enabling ongoing monitoring of behavioural responses, in the patient group on two occasions separated by 6-8 weeks, and the control group at baseline.

RESULTS

Positive psychotic symptoms were significantly reduced over the 6-8-week duration of the study. This change was associated with increased activation within the left middle frontal gyrus and decreased activation of the left precuneus. An interaction between symptom change and task demand was evident in the activation of the left middle frontal gyrus. The decrease in positive symptoms was associated with normalisation of activation in the dorsolateral prefrontal cortex and a decrease in parietal activation during the verbal fluency task.

CONCLUSION

The data supports the role of dysfunctional prefronto-parietal relationships in the genesis of positive psychotic symptoms.