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Fattal J, Brascamp JW, Slate RE, Lehet M, Achtyes ED, Thakkar KN. Blunted pupil light reflex is associated with negative symptoms and working memory in individuals with schizophrenia. Schizophr Res 2022; 248:254-262. [PMID: 36115190 PMCID: PMC9613610 DOI: 10.1016/j.schres.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 08/21/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
Two largely separate lines of research have documented altered pupillary dynamics in individuals diagnosed with schizophrenia. An older set of studies has demonstrated reductions in the pupillary light reflex (PLR) in individuals with schizophrenia; however, clinical and cognitive correlates of this blunted PLR have been relatively unexplored. More recently, a large body of work has demonstrated reductions in pupillary dilation in response to cognitive demands in individuals with schizophrenia, and the degree of this blunted pupil dilation has been related to more severe cognitive deficits and motivational negative symptoms. These clinically relevant alterations in the cognitive modulation of pupil size have been interpreted as reflecting insufficient information processing resources or inappropriate effort allocation. To begin to bridge these two lines of work, we investigated the PLR in 34 individuals with schizophrenia and 30 healthy controls and related the amplitude of the PLR to motivational negative symptoms and cognitive performance. Consistent with prior work, we found that the PLR was reduced in individuals with schizophrenia, and furthermore, that these measurements were highly reliable across individuals. Blunted constriction was associated with more severe motivational negative symptoms and poorer working memory among individuals with schizophrenia. These observed correlates provide a bridge between older literature documenting an altered PLR and more recent work reporting associations between negative symptoms, cognition, and blunted pupillary dilation in response to cognitive demands in individuals with schizophrenia. We provide possible mechanistic interpretations of our data and consider a parsimonious explanation for reduced cognitive- and light-related modulation of pupil size.
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Affiliation(s)
- Jessica Fattal
- Department of Psychology, Michigan State University, East Lansing, MI, United States of America
| | - Jan W Brascamp
- Department of Psychology, Michigan State University, East Lansing, MI, United States of America
| | - Rachael E Slate
- Department of Psychology, Michigan State University, East Lansing, MI, United States of America
| | - Matthew Lehet
- Department of Psychology, Michigan State University, East Lansing, MI, United States of America
| | - Eric D Achtyes
- Division of Psychiatry and Behavioral Medicine, Michigan State University, Grand Rapids, MI, United States of America; Cherry Health, Grand Rapids, MI, United States of America
| | - Katharine N Thakkar
- Department of Psychology, Michigan State University, East Lansing, MI, United States of America; Division of Psychiatry and Behavioral Medicine, Michigan State University, Grand Rapids, MI, United States of America.
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Muddle S, Jones B, Taylor G, Jacobsen P. A systematic review and meta-analysis of the association between emotional stress reactivity and psychosis. Early Interv Psychiatry 2022; 16:958-978. [PMID: 34904353 DOI: 10.1111/eip.13247] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 01/03/2023]
Abstract
AIM Emotional stress reactivity may be a mediating factor in the association between trauma and psychosis. This review aimed to (i) identify, summarise and critically evaluate the link between emotional stress reactivity and psychotic experiences (ii) examine evidence for a 'dose-response' relationship between stress reactivity and psychosis in the wider psychosis phenotype (i.e., sub-clinical symptoms). METHODS Electronic database searches (PsychINFO, MEDLINE, EMBASE) were conducted for studies which investigated the link between stress reactivity and psychosis, psychotic symptoms, or a vulnerability to developing psychosis (wider phenotype). Cross-sectional, experimental and experience sampling method study designs were eligible for inclusion. RESULTS Fourty five eligible articles were identified (N participants = 8830). Narrative synthesis showed that increased emotional stress reactivity was associated with psychosis and subclinical psychotic experiences across all study designs, however, findings were inconsistent across studies. The preliminary meta-analysis (k = 4, n = 383) showed increases in emotional stress reactivity was associated with higher negative affect in response to event-related stress, in those with psychosis compared to controls (mean difference in beta coefficients = 0.05, 95% CI 0.02-0.08, p = .004). However, this difference was small with a considerable degree of heterogeneity (p = .001, I2 = 81%) so results should be interpreted with caution. CONCLUSIONS Overall, the evidence suggests that there is a link between emotional stress reactivity and psychosis in those with psychosis, those at high risk of developing psychosis and in relation to subclinical psychotic-like experiences in the general population.
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Affiliation(s)
- Sarah Muddle
- Department of Psychology, University of Bath, Bath, UK
| | - Bradley Jones
- Department of Psychology, University of Bath, Bath, UK
| | - Gemma Taylor
- Department of Psychology, University of Bath, Bath, UK
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Beck AT, Himelstein R, Bredemeier K, Silverstein SM, Grant P. What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors. Psychol Med 2018; 48:2776-2785. [PMID: 29501072 DOI: 10.1017/s0033291718000442] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neurocognitive deficits are often seen as core features of schizophrenia, and as primary determinants of poor functioning. Yet, our clinical observations suggest that individuals who score within the impaired range on standardized tests can reliably perform better in complex real-world situations, especially when performance is embedded within a positive socio-affective context. METHODS We analyzed literature on the influence of non-neurocognitive factors on test performance in order to clarify their contributions. RESULTS We identified seven non-neurocognitive factors that significantly contribute to neurocognitive test performance: avolition, dysfunctional attitudes, effort, stress, negative emotions, asociality, and disorganized symptoms. We then proposed an alternative model based on dysfunctional (e.g. defeatist) attitudes and their consequences for motivation and sustained task engagement. We demonstrated that these factors account for substantial variance in negative symptoms, neurocognitive test performance, and functional outcomes. We then demonstrated that recovery-oriented cognitive therapy - which is derived from this alternative model and primarily targets dysfunctional beliefs - has been successful in the treatment of low functioning individuals with schizophrenia. CONCLUSION The contributions of neurocognitive impairments to poor real-world functioning in people with schizophrenia may be overstated in the literature, and may even be limited relative to non-neurocognitive factors. We offer suggestions for further research to more precisely quantify the contributions of attitudinal/motivation v. neurocognitive factors in schizophrenia.
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Affiliation(s)
- Aaron T Beck
- Department of Psychiatry,University of Pennsylvania,Philadelphia,Pennsylvania,USA
| | - Robyn Himelstein
- Department of Psychiatry,University of Pennsylvania,Philadelphia,Pennsylvania,USA
| | - Keith Bredemeier
- Center for Assessment Research and Translation,University of Delaware,Newark,Delaware,USA
| | - Steven M Silverstein
- Department of Psychiatry,Rutgers - Robert Wood Johnson Medical School,Piscataway Township,New Jersey,USA
| | - Paul Grant
- Department of Psychiatry,University of Pennsylvania,Philadelphia,Pennsylvania,USA
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Lincoln TM, Riehle M, Pillny M, Helbig-Lang S, Fladung AK, Hartmann-Riemer M, Kaiser S. Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms. Front Psychol 2017; 8:2108. [PMID: 29259567 PMCID: PMC5723417 DOI: 10.3389/fpsyg.2017.02108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/17/2017] [Indexed: 12/19/2022] Open
Abstract
Although numerous interventions are available for negative symptoms, outcomes have been unsatisfactory with pharmacological and psychological interventions producing changes of only limited clinical significance. Here, we argue that because negative symptoms occur as a complex syndrome caused and maintained by numerous factors that vary between individuals they are unlikely to be treated effectively by the present "one size fits all" approaches. Instead, a well-founded selection of those interventions relevant to each individual is needed to optimize both the efficiency and the efficacy of existing approaches. The concept of functional analysis (FA) can be used to structure existing knowledge so that it can guide individualized treatment planning. FA is based on stimulus-response learning mechanisms taking into account the characteristics of the organism that contribute to the responses, their consequences and the contingency with which consequences are tied to the response. FA can thus be flexibly applied to the level of individual patients to understand the factors causing and maintaining negative symptoms and derive suitable interventions. In this article we will briefly introduce the concept of FA and demonstrate-exemplarily-how known psychological and biological correlates of negative symptoms can be incorporated into its framework. We then outline the framework's implications for individual assessment and treatment. Following the logic of FA, we argue that a detailed assessment is needed to identify the key factors causing or maintaining negative symptoms for each individual patient. Interventions can then be selected according to their likelihood of changing these key factors and need to take interactions between different factors into account. Supplementary case vignettes exemplify the usefulness of functional analysis for individual treatment planning. Finally, we discuss and point to avenues for future research guided by this model.
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Affiliation(s)
- Tania M. Lincoln
- Clinical Psychology and Psychotherapy, Faculty of Psychology and Movement Sciences, Institute of Psychology, Universität Hamburg, Hamburg, Germany
| | - Marcel Riehle
- Clinical Psychology and Psychotherapy, Faculty of Psychology and Movement Sciences, Institute of Psychology, Universität Hamburg, Hamburg, Germany
| | - Matthias Pillny
- Clinical Psychology and Psychotherapy, Faculty of Psychology and Movement Sciences, Institute of Psychology, Universität Hamburg, Hamburg, Germany
| | - Sylvia Helbig-Lang
- Clinical Psychology and Psychotherapy, Faculty of Psychology and Movement Sciences, Institute of Psychology, Universität Hamburg, Hamburg, Germany
| | - Anne-Katharina Fladung
- Clinical Psychology and Psychotherapy, Faculty of Psychology and Movement Sciences, Institute of Psychology, Universität Hamburg, Hamburg, Germany
| | - Matthias Hartmann-Riemer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Kaiser
- Adult Psychiatry Division, Department of Mental Health and Psychiatry, Geneva University Hospital, Geneva, Switzerland
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Nilsson BM, Holm G, Hultman CM, Ekselius L. Cognition and autonomic function in schizophrenia: inferior cognitive test performance in electrodermal and niacin skin flush non-responders. Eur Psychiatry 2014; 30:8-13. [PMID: 25169443 DOI: 10.1016/j.eurpsy.2014.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 06/13/2014] [Accepted: 06/29/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients with schizophrenia suffer from a broad range of cognitive disturbances. The impact in terms of functional outcome is significant. There are also several reports of disturbed autonomic regulation in the disease. The present study examined cognitive function as well as psychophysiological parameters in patients with schizophrenia and healthy controls. METHODS Twenty-five patients and 14 controls were investigated with electrodermal activity (EDA), an oral niacin skin flush test and a comprehensive neurocognitive test program including the Wechsler battery (WAIS-R), Fingertapping Test, Trail Making Test, Verbal Fluency, Benton Visual Retention Test, Wisconsin Card Sorting Test and Rey Auditory Verbal Learning Test. RESULTS The patients generally had inferior test results compared to controls. Further analysis revealed that the EDA non-responding patient group explained this variation with significant lower test results than controls. On executive tests, EDA non-responders also performed significantly worse than EDA responding patients. The small group of niacin non-responding patients exhibited an even lower overall test performance. Delayed niacin flush also correlated inversely with psychomotor function and IQ in the patients. CONCLUSION The findings support the hypothesis of a neurodevelopment disturbance affecting both autonomic function and higher cortical function in schizophrenia.
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Affiliation(s)
- B M Nilsson
- Department of Neuroscience, Psychiatry, Uppsala University, SE-751 85 Uppsala, Sweden.
| | - G Holm
- Department of Neuroscience, Psychiatry, Uppsala University, SE-751 85 Uppsala, Sweden
| | - C M Hultman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, SE-17177 Stockholm, Sweden
| | - L Ekselius
- Department of Neuroscience, Psychiatry, Uppsala University, SE-751 85 Uppsala, Sweden
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Diwadkar VA, Bustamante A, Rai H, Uddin M. Epigenetics, stress, and their potential impact on brain network function: a focus on the schizophrenia diatheses. Front Psychiatry 2014; 5:71. [PMID: 25002852 PMCID: PMC4066368 DOI: 10.3389/fpsyt.2014.00071] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/04/2014] [Indexed: 01/21/2023] Open
Abstract
The recent sociodevelopmental cognitive model of schizophrenia/psychosis is a highly influential and compelling compendium of research findings. Here, we present logical extensions to this model incorporating ideas drawn from epigenetic mediation of psychiatric disease, and the plausible effects of epigenetics on the emergence of brain network function and dysfunction in adolescence. We discuss how gene-environment interactions, effected by epigenetic mechanisms, might in particular mediate the stress response (itself heavily implicated in the emergence of schizophrenia). Next, we discuss the plausible relevance of this framework for adolescent genetic risk populations, a risk group characterized by vexing and difficult-to-explain heterogeneity. We then discuss how exploring relationships between epigenetics and brain network dysfunction (a strongly validated finding in risk populations) can enhance understanding of the relationship between stress, epigenetics, and functional neurobiology, and the relevance of this relationship for the eventual emergence of schizophrenia/psychosis. We suggest that these considerations can expand the impact of models such as the sociodevelopmental cognitive model, increasing their explanatory reach. Ultimately, integration of these lines of research may enhance efforts of early identification, intervention, and treatment in adolescents at-risk for schizophrenia.
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Affiliation(s)
- Vaibhav A Diwadkar
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit, MI , USA
| | - Angela Bustamante
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine , Detroit, MI , USA
| | - Harinder Rai
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit, MI , USA
| | - Monica Uddin
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit, MI , USA ; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine , Detroit, MI , USA
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Subotnik KL, Schell AM, Chilingar MS, Dawson ME, Ventura J, Kelly KA, Hellemann GS, Nuechterlein KH. The interaction of electrodermal activity and expressed emotion in predicting symptoms in recent-onset schizophrenia. Psychophysiology 2012; 49:1035-8. [PMID: 22680838 DOI: 10.1111/j.1469-8986.2012.01383.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 02/23/2012] [Indexed: 11/29/2022]
Abstract
In the present study, expressed emotion (EE) was assessed among immediate family members of 94 recent-onset schizophrenia patients at initial study entry point, and patients' electrodermal activity (EDA) was measured without the presence of family members at a baseline outpatient stabilization assessment. Psychiatric symptoms were also rated, both at the baseline outpatient test and at 1-year follow-up. Electrodermal activity × expressed emotion interactions were observed at both test points. In each case, the highest levels of negative symptoms were observed among those who exhibited greater EDA and lived in a high-EE environment. These results support the view that the combination of high family EE and sympathetic nervous system arousal confer especially high risk for poor negative symptom outcomes.
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Affiliation(s)
- Kenneth L Subotnik
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles 90095-8346, USA.
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Kim JH, Ann JH, Lee J. Relationship between heart rate variability and the severity of psychotic symptoms in schizophrenia. Acta Neuropsychiatr 2011; 23:161-6. [PMID: 25379793 DOI: 10.1111/j.1601-5215.2011.00549.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Kim J-H, Ann J-H, Lee J. Relationship between heart rate variability and the severity of psychotic symptoms in schizophrenia.Objective: The relationship between autonomic neurocardiac function and schizophrenia remains elusive. This study investigated the relationship between the heart rate variability (HRV) parameters and the severity of psychotic symptoms in schizophrenic patients.Methods: Twenty-one patients receiving risperidone monotherapy and 21 matched normal control subjects were evaluated for HRV analysis. The severity of schizophrenic symptoms was assessed using the Positive and Negative Syndrome Scale (PANSS) and a five-factor model of the PANSS was used.Results: The value of the ratio of low-to-high frequency spectral power was significantly higher in the patient group. The patient group also showed a significantly lower value of approximate entropy. After controlling the dosage of risperidone, the PANSS total score had significant negative correlations with the standard deviation of all RR intervals (SDNN) and the square root of the mean squared differences of successive normal sinus intervals (RMSSD). With respect to the PANSS factors, the score of the PANSS cognitive/disorganisation factor had significant negative correlations with SDNN and RMSSD.Conclusion: These results provide some evidence that the severity of psychotic symptoms, especially cognitive/disorganisation symptom dimensions, may be associated with reduced HRV, suggesting a potential involvement of neuroautonomic dysfunction in the pathophysiology of specific symptoms of schizophrenia.
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Affiliation(s)
- Jong-Hoon Kim
- Department of Psychiatry, Gil Hospital, Gachon University of Medicine and Science, Namdong-Gu, Incheon, South Korea
| | - Jun-Hyung Ann
- School of Medicine, Gachon University of Medicine and Science, Namdong-Gu, Incheon, South Korea
| | - Jinyoung Lee
- Department of Psychiatry, Gil Hospital, Gachon University of Medicine and Science, Namdong-Gu, Incheon, South Korea
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Bejaoui M, Pedinielli JL. Flexibilité cognitive, attention sélective et fluidité verbale sémantique dans trois dimensions de schizophrénie : psychotique, négative et de désorganisation. PRAT PSYCHOL 2010. [DOI: 10.1016/j.prps.2009.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Disorganization and reality distortion in schizophrenia: a meta-analysis of the relationship between positive symptoms and neurocognitive deficits. Schizophr Res 2010; 121:1-14. [PMID: 20579855 PMCID: PMC3160271 DOI: 10.1016/j.schres.2010.05.033] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 05/23/2010] [Accepted: 05/26/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Factor analytic studies have shown that in schizophrenia patients, disorganization (e.g., conceptual disorganization and bizarre behavior) is a separate dimension from other types of positive symptoms such as reality distortion (delusions and hallucinations). Although some studies have found that disorganization is more strongly linked to neurocognitive deficits and poor functional outcomes than reality distortion, the findings are not always consistent. METHODS A meta-analysis of 104 studies (combined n=8015) was conducted to determine the magnitude of the relationship between neurocognition and disorganization as compared to reality distortion. Additional analyses were conducted to determine whether the strength of these relationships differed depending on the neurocognitive domain under investigation. RESULTS The relationship between reality distortion and neurocognition was weak (r=-.04; p=.03) as compared to the moderate association between disorganization and neurocognition (r=-.23; p<.01). In each of the six neurocognitive domains that were examined, disorganization was more strongly related to neurocognition (r's range from -.20 to -.26) than to reality distortion (r's range from .01 to -.12). CONCLUSIONS The effect size of the relationship between neurocognition and disorganization was significantly larger than the effect size of the relationship between neurocognition and reality distortion. These results hold across several neurocognitive domains. These findings support a dimensional view of positive symptoms distinguishing disorganization from reality distortion.
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Bejaoui M, Pédinielli JL. Stratégies de résolution de problèmes et attention sélective dans la schizophrénie : critères typologiques et multidimensionnels de la Positive and Negative Syndrome Scale (PANSS). ANNALES MEDICO-PSYCHOLOGIQUES 2009. [DOI: 10.1016/j.amp.2009.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lindsberg J, Poutiainen E, Kalska H. Clarifying the diversity of first-episode psychosis: Neuropsychological correlates of clinical symptoms. Nord J Psychiatry 2009; 63:493-500. [PMID: 19685368 DOI: 10.3109/08039480903118182] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Psychosis is marked by heterogeneity, which complicates effective treatment. AIMS Subgroups of first-episode psychosis could be found by identifying neuropsychological correlates of psychiatric symptoms. METHODS Ninety-two outpatients with first-episode psychosis were evaluated with the Positive and Negative Syndrome Scale (PANSS) and a comprehensive neuropsychological test battery. RESULTS Factor analysis of PANSS revealed five symptom dimensions. Negative symptoms were correlated with widespread neuropsychological dysfunction. Disorganization symptoms were correlated with more focused deficits in executive function, attention and processing speed implicating dysfunction in frontal-subcortical circuits. Asocial, positive and affective symptoms were not associated with cognition. CONCLUSIONS In first-episode psychosis, neuropsychological deficits are associated with negative and disorganization symptom dimensions, which appear to be marked by different cognitive profiles. These findings have implications for improving symptom-specific treatment.
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Affiliation(s)
- Jenni Lindsberg
- Department of Psychiatry, Jorvi Hospital, Helsinki University Central Hospital, Espoo, Finland.
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Ventura J, Hellemann GS, Thames AD, Koellner V, Nuechterlein KH. Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: a meta-analysis. Schizophr Res 2009; 113:189-99. [PMID: 19628375 PMCID: PMC2825750 DOI: 10.1016/j.schres.2009.03.035] [Citation(s) in RCA: 374] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 03/16/2009] [Accepted: 03/16/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neurocognitive functioning in schizophrenia has received considerable attention because of its robust prediction of functional outcome. Psychiatric symptoms, in particular negative symptoms, have also been shown to predict functional outcome, but have garnered much less attention. The high degree of intercorrelation among all of these variables leaves unclear whether neurocognition has a direct effect on functional outcome or whether that relationship to functional outcome is partially mediated by symptoms. METHODS A meta-analysis of 73 published English language studies (total n=6519) was conducted to determine the magnitude of the relationship between neurocognition and symptoms, and between symptoms and functional outcome. A model was tested in which symptoms mediate the relationship between neurocognition and functional outcome. Functional outcome involved measures of social relationships, school and work functioning, and laboratory assessments of social skill. RESULTS Although negative symptoms were found to be significantly related to neurocognitive functioning (p<.01) positive symptoms were not (p=.97). The relationship was moderate for negative symptoms (r=-.24, n=4757, 53 studies), but positive symptoms were not at all related to neurocogniton (r=.00, n=1297, 25 studies). Negative symptoms were significantly correlated with functional outcome (r=-.42, p<.01), and again the correlation was higher than for positive symptoms (r=-.03, p=.55). Furthermore, our findings support a model in which negative symptoms significantly mediate the relationship between neurocognition and functional outcome (Sobel test p<.01). CONCLUSIONS Although neurocognition and negative symptoms are both predictors of functional outcome, negative symptoms might at least partially mediate the relationship between neurocognition and outcome.
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Affiliation(s)
- Joseph Ventura
- UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA 90095-6968, USA.
| | | | - April D. Thames
- Alliant International University, Alhambra, California, United States
| | | | - Keith H. Nuechterlein
- UCLA Department of Psychiatry and Biobehavioral Sciences, United States,UCLA Department of Psychology, United States
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Dibben CRM, Rice C, Laws K, McKenna PJ. Is executive impairment associated with schizophrenic syndromes? A meta-analysis. Psychol Med 2009; 39:381-392. [PMID: 18588741 DOI: 10.1017/s0033291708003887] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A key neuropsychological proposal in schizophrenia is that negative and disorganization symptoms are associated with different patterns of impairment on executive tasks. METHOD Studies reporting correlations between positive, negative or disorganization symptoms and any type of executive test were meta-analysed. The influence of moderating factors was also examined, including age, treatment and stage of illness and whether symptoms were relapsing or persistent. The magnitudes of the correlations were compared with those for general intellectual impairment. RESULTS Pooled correlations between executive impairment and both negative symptoms and disorganization were significant in the small-to-moderate range. That for positive symptoms ('reality distortion'), however, was close to zero. The pattern of correlations among different executive tests differed significantly for negative symptoms and disorganization. Patients with stable clinical pictures showed significantly higher correlations with executive impairment than those with relapsing and remitting illnesses. Both negative symptoms and disorganization also correlated significantly with general intellectual function as indexed by current IQ. CONCLUSIONS Meta-analysis supports the view that negative symptoms and disorganization are associated with partially dissociable patterns of executive impairment. However, co-existent general intellectual impairment has been an important confounding factor in the studies to date.
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Correlations between cognitive performances and psychotic or schizotypal dimensions. Eur Psychiatry 2008; 24:244-50. [PMID: 19070994 DOI: 10.1016/j.eurpsy.2008.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 10/30/2008] [Accepted: 10/30/2008] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To test if specific correlations exist between cognitive measures and psychotic dimensions in schizophrenic subjects and if similar correlations, between cognition and schizotypal dimensions, are present in non-psychotic subjects. METHODS We administered the same battery of cognitive tests (Source Monitoring, Verbal Fluency [VF] and Stroop tests) to schizophrenic subjects (N=54), their first-degree relatives (N=37) and controls (N=41). Scores of negative, positive and disorganisation dimensions were derived from the Signs and Symptoms of Psychotic Illness scale in schizophrenic subjects, and from the Schizotypal Personality Questionnaire in relatives and controls. RESULTS In schizophrenic subjects, as hypothesised, the negative dimension correlated with performance on VF and disorganisation with performance in the Stroop test. The positive dimension did not correlate with any cognitive measure. With only one exception, the significant correlations observed in non-psychotic subjects did not match correlations seen in schizophrenic subjects. In non-psychotic subjects greater disorganisation was associated with more clustered words in VF suggesting that excessive automatic spreading of activation in semantic networks could underlie this dimension. CONCLUSION As a whole, data lent partial support to our hypothesis of specific cognitive-clinical correlations in schizophrenic subjects but did not support the existence of similar correlations in non-psychotic subjects.
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Peer JE, Kupper Z, Long JD, Brekke JS, Spaulding WD. Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods. Clin Psychol Rev 2007; 27:696-714. [PMID: 17343964 DOI: 10.1016/j.cpr.2007.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Accepted: 01/08/2007] [Indexed: 10/23/2022]
Abstract
The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.
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Affiliation(s)
- Jason E Peer
- Department of Psychology, University of Nebraska-Lincoln, USA.
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Bell MD, Mishara AL. Does negative symptom change relate to neurocognitive change in schizophrenia? Implications for targeted treatments. Schizophr Res 2006; 81:17-27. [PMID: 16297601 DOI: 10.1016/j.schres.2005.09.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 09/20/2005] [Accepted: 09/23/2005] [Indexed: 11/26/2022]
Abstract
Negative symptoms and cognitive dysfunction are among the most challenging obstacles in the treatment of schizophrenia. It is unknown to what extent they are overlapping or independent disease processes. In the search for targeted treatments of negative symptoms and cognitive impairments, it is imperative to determine their longitudinal relationship. 267 stable outpatients with schizophrenia in a work and cognitive rehabilitation program were evaluated using symptom measures and a comprehensive neuropsychological test battery at baseline and at the conclusion of rehabilitation, 6 months later. Baseline negative symptom, neuropsychological variables and change scores from intake to follow-up on these variables were correlated. These analyses were repeated with a subsample (n = 161) who had clinically significant negative symptoms at baseline. ANCOVA's were performed to compare patients whose negative symptoms improved by 5 points or more (n = 69) with those whose negative symptoms got worse by 5 points or more (n = 26) on their neurocognitive performance at follow-up. Intake negative symptoms were significantly associated with theory of mind and visuomotor processing. Results failed to support a lawful relationship between change in negative symptoms and neurocognition. These findings suggest that negative symptoms and neurocognition should be viewed as relatively independent targets for intervention.
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Affiliation(s)
- Morris D Bell
- Psychology Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA.
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Longevialle-Hénin R, Bourdel MC, Willard D, Lôo H, Olié JP, Poirier MF, Krebs MO, Amado I. [Visuospatial context processing in untreated schizophrenic patients and relation to disorganization syndrome]. Encephale 2005; 31:323-9. [PMID: 16142047 DOI: 10.1016/s0013-7006(05)82397-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Previous studies on schizophrenia have suggested that context-processing disturbances were one of the core cognitive deficits present in schizophrenia. Schizophrenic patients have a failure either of inhibition strategy and maintenance of visuospatial information (25) in condition of contextual interference. In the present study, we explored the performances of untreated schizophrenic patients with 2 tasks exploring detection and long term retention of complex visual features and field dependence-independence tasks were selected. These abilities involve temporary maintenance of visuospatial information and executive functioning of visual working memory system. Several studies have shown that cognitive deficit may depend on schizophrenic symptomatology. However results remain controversial in determining the specific influence of negative and positive symptomatologies as well as clinical disorganization. Our goal was to explore the processing of spatial context and its relation to disorganized syndrome. This study was approved by the local ethic committee. METHODOLOGY Thirty-six schizophrenic patients were included according to DSM IV criteria (19 neuroleptic naïve, 17 unmedicated patients during more than 3 months). Thirty-six healthy controls were matched to patients for age, gender and level of education. Absence of axis 1 pathology was attested for controls with SCID-NP. Current symptomatology was evaluated by the Positive and Negative Syndrome Scale (PANSS) (14). Clinical disorganisation was evaluated with the disorganisation score established upon a factorial analysis of PANSS by Lepine and Lançon. Items selected to distinguish the disorganised group were abstraction, disorganization, orientation, and attention. PROCEDURE Two tasks of embedded figures were administered individually to patients and controls. The Faverge task (Research of Figures-RF) (10) evaluates the ability to recognize the target from spatial complex geometrical figures. The Group Embedded Figure Task (GEFT - Oltman) assesses the detection and maintenance of visual target and its recognition within a complex figure. Performance between patients and controls were compared with the Student T test. The comparison of two clinical subgroups of disorganized and low disorganized patients and control group was performed with an ANOVA. Tuckey test was used for pairwise comparisons. RESULTS We defined two subgroups of patients, disorganized patients (subscore 12, n=17) and low disorganized patients (subscore<12, n=19). Theses 2 subgroups were similar for age and level of education. Concerning the two tasks, there was no significant difference between schizophrenic patients and normal controls. The comparison between subgroups of disorganized and low disorganized patients, for RF task, showed a decrease of correct answers with disorganized patients (p<0.05). For GEFT task, disorganized patients had a decrease of correct answers p<0.01) and more errors (p<0.01) and omissions (p<0.05). The low disorganized patients exhibited for the two tests comparable performance to controls. The disorganized patients had a decrease of right answers (p<0.05) and more errors (p<0.05) than controls for GEFT task and no significant difference for RF. However, with IQ (evaluated with an abstract reasoning test) introduced as covariate, only correct answers for GEFT task remain significant (p<0.05). DISCUSSION The weak performance of disorganized schizophrenic patients for two tasks RF and GEFT showed that treatment of visuospatial information was impaired in the first perceptive phase of selection and in the organization of information (RF), especially with the maintenance of visual information in memory (GEFT). By contrast, low disorganized patients demonstrated a correct analytic treatment of elementary processing and visuospatial working memory. CONCLUSION The severity of disorganization influences the visuospatial context processing and visuospatial working memory. These results show the heterogeneity of cognitive functioning regarding to schizophrenic symptomatologies. This difficulty could be related to a problem of central executive functioning in the visuospatial component of working memory, possibly mediated by the dysfunction of dorsolateral prefrontal cortex.
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Schell AM, Dawson ME, Rissling A, Ventura J, Subotnik KL, Gitlin MJ, Nuechterlein KH. Electrodermal predictors of functional outcome and negative symptoms in schizophrenia. Psychophysiology 2005; 42:483-92. [PMID: 16008777 DOI: 10.1111/j.1469-8986.2005.00300.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The ability of electrodermal variables to predict negative symptoms and functional outcome over a 1-year period in schizophrenia was investigated in 78 young, recent-onset outpatients. Patients were stabilized on standardized medication and largely free of psychotic symptoms. Higher levels of both tonic (skin conductance level, nonspecific skin conductance response rate) and phasic (number of skin conductance orienting responses) activity were associated with more negative symptoms and with a combination of poorer social and occupational outcome at 1-year follow-up. This pattern was seen in both male and female patients, and in older and younger patients. Results are interpreted as suggesting that high levels of arousal and overreactivity to the environment may interfere with efficient cognitive processing in schizophrenia, contributing to poor outcome, and that negative symptoms might partially serve as a means of coping with overarousal.
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Affiliation(s)
- Anne M Schell
- Department of Psychology, Occidental College, Los Angeles, California 90041, USA.
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Valkonen-Korhonen M, Tarvainen MP, Ranta-Aho P, Karjalainen PA, Partanen J, Karhu J, Lehtonen J. Heart rate variability in acute psychosis. Psychophysiology 2003; 40:716-26. [PMID: 14696725 DOI: 10.1111/1469-8986.00072] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Heart rate variability (HRV) provides reliable tools to assess the integrity and reactivity of autonomic nervous function. Our aim was to examine HRV in the resting condition and during different mental loads in acute psychosis compared to healthy controls. HRV was measured in 17 first-episode drug-naive patients with psychosis and 21 healthy controls during oddball tasks and while performing the Wisconsin Card Sorting Test. A discrete event series was constructed by an adaptive QRS detector algorithm and power spectrum estimation was carried out. The RMSSD (representing interval differences of successive heartbeats) and the amount of high frequency (HF) power were significantly reduced in patients. Moreover, the patients' HRV remained unaltered during the tasks, whereas in controls the HRV diminished with increasing mental load of the task. Patients with psychosis displayed less short-term HR reactivity than healthy controls. They also failed to adapt HRV according to the task-connected strain. Acute psychosis is characterized by a limited capacity to respond to external demands at the level of autonomic nervous system.
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Minzenberg MJ, Poole JH, Vinogradov S, Shenaut GK, Ober BA. Slowed lexical access is uniquely associated with positive and disorganised symptoms in schizophrenia. Cogn Neuropsychiatry 2003; 8:107-27. [PMID: 16571554 DOI: 10.1080/135468000247] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This study addressed the relationship of both semantic priming and slowed lexical access to the symptoms of schizophrenia, and evaluated their association with other neurocognitive deficits. METHODS 57 outpatients with schizophrenia and 20 nonpsychiatric control subjects performed a lexical decision semantic priming task (LDT), and a brief neuropsychological battery. The schizophrenia group was also assessed with an extended Positive and Negative Symptom Scale. RESULTS As expected, the schizophrenia group had significantly slower reaction times (RTs) than the control group, and poorer performance on most neuropsychological tasks. Both groups exhibited semantic priming effects in both automatic and controlled processing conditions; these effects were not significantly different between groups. RT was unrelated to age, illness duration, GAF scores, or neuroleptic dose; controlled semantic priming effects were related to illness duration only. RT to real word targets (but not to nonwords) on the LDT was significantly correlated with positive and disorganised, but not negative symptoms. The neurocognitive correlates of RT slowing were: full-scale IQ and verbal fluency, but not attention; working memory; episodic memory retrieval; executive function, or manual speed. Both controlled semantic priming effects as well as the difference between controlled and automatic priming effects were related to executive functions in general. Severity of symptoms in the three major symptom groups was generally unassociated with impairment on the neuropsychological battery. The associations of RT slowing to positive and disorganised symptoms remained even after controlling for each of the above clinical and neurocognitive measures. CONCLUSIONS These findings suggest that in schizophrenia, slowed lexical access is uniquely related to positive and disorganised symptoms. This relationship is not accounted for by more general cognitive deficits, overall illness severity, or generalised effects of symptoms on cognitive function. This relationship may reflect a specific impairment in the access to semantic memory.
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Daban C, Amado I, Baylé F, Gut A, Willard D, Bourdel MC, Loo H, Olié JP, Millet B, Krebs MO, Poirier MF. Correlation between clinical syndromes and neuropsychological tasks in unmedicated patients with recent onset schizophrenia. Psychiatry Res 2002; 113:83-92. [PMID: 12467948 DOI: 10.1016/s0165-1781(02)00228-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of this study is to circumscribe the cognitive deficits according to schizophrenic syndromes in a population of sub-acute untreated patients. We have studied the cross-sectional correlation between cognitive deficits and schizophrenic symptoms, in a group of 24 untreated patients (including 17 neuroleptic-naive patients) with recent onset of the disease. A task of alertness, a working memory (WM) test (including two levels of difficulty) and an abbreviated version of the Wisconsin Card Sorting Test (WCST) were selected. WM deficits and poor performance on the WCST were highly correlated with disorganized symptoms, modestly with the positive syndrome and not with the negative syndrome. Thus, disorganized symptoms, more than any other, appear to be related to the impairment of executive function and WM in recent onset unmedicated patients with schizophrenia.
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Affiliation(s)
- Claire Daban
- E0117 INSERM Paris V, Service Hospitalo-Universitaire, Hôpital Sainte-Anne, 7 rue Cabanis, 75014, Paris, France.
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Abstract
Various dysfunctions in electrodermal activity (EDA) have been found in schizophrenic patients. The present paper reviews evidence that the electrodermal dysfunctions may carry prognostic information regarding subsequent symptoms, as well as social and occupational outcome. Although the findings are not entirely consistent, heightened electrodermal activity as indicated by frequent orienting responses to innocuous stimuli, elevated skin conductance level (SCL), and frequent non-specific skin conductance responses (NS-SCR) is most often associated with poor symptomatic, social, and occupational outcome in schizophrenic patients. There have been no studies that have directly examined electrodermal prognostic indicators in schizotypal individuals. However, high-risk studies suggest that heightened electrodermal activity may be prognostic of poor outcome in schizotypals as well. Thus, abnormally high electrodermal arousal and reactivity is predictive of poor outcome in at least some patients. The theoretical implications of these findings and directions for further research are briefly discussed.
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Affiliation(s)
- Michael E Dawson
- Department of Psychology, University of Southern California, Los Angeles, CA 90089-1061, USA.
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Moritz S, Andresen B, Jacobsen D, Mersmann K, Wilke U, Lambert M, Naber D, Krausz M. Neuropsychological correlates of schizophrenic syndromes in patients treated with atypical neuroleptics. Eur Psychiatry 2001; 16:354-61. [PMID: 11585716 DOI: 10.1016/s0924-9338(01)00591-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
There is widespread evidence that schizophrenic symptomatology is best represented by three syndromes (positive, negative, disorganized). Both the disorganized and negative syndrome have been found to correlate with several neurocognitive dysfunctions. However, previous studies investigated samples predominantly treated with typical neuroleptics, which frequently induce parkinsonian symptoms that are hard to disentangle from primary negative symptoms and may have inflated correlations with neurocognition. A newly developed psychopathological instrument called the Positive and Negative and Disorganized Symptoms Scale (PANADSS) was evaluated in 60 schizophrenic patients. Forty-seven participants treated with atypical neuroleptics performed several neurocognitive tasks.A three-factor solution of schizophrenic symptomatology emerged. Negative symptomatology was associated with diminished creative verbal fluency and digit span backward, whereas disorganization was significantly correlated with impaired Stroop, WCST and Trail-Making Test B performance.Data suggest that disorganization is associated with tasks that demand executive functioning. Previous findings reporting correlations between negative symptomatology and neurocognition may have been confounded by the adverse consequences of typical neuroleptics.
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Affiliation(s)
- S Moritz
- Universitäts-Krankenhaus Hamburg-Eppendorf, Klinik für Psychiatrie und Psychotherapie, Martinistrasse 52, D-20246, Hamburg, Germany.
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Harris AW, Bahramali H, Slewa-Younan S, Gordon E, Williams L, Li WM. The topography of quantified electroencephalography in three syndromes of schizophrenia. Int J Neurosci 2001; 107:265-78. [PMID: 11328695 DOI: 10.3109/00207450109150689] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study investigated the association between quantified electroencephalography (qEEG) and three psychopathological syndromes, derived by a factor analysis of the symptom profile of a group of 40 subjects diagnosed with schizophrenia. An initial comparison with aged and sex matched normal controls showed an overall increase in slow wave activity in subjects with schizophrenia. The symptomatology of the subjects with schizophrenia was then factor analysed into three psychopathological syndromes that closely resembled Liddle's (1987b) original delineation. Correlations were undertaken between the three syndrome scores and qEEG. The "psychomotor poverty" factor was associated with increased beta activity most marked posteriorly and increased delta activity (accounted for by the effects of medication). The "disorganisation" factor was associated with widespread negative correlations in the alpha and beta bands and the "reality distortion" factor was associated positively with left anterior alpha activity. These distinct patterns of qEEG that clearly differentiate between the three syndromes, may contribute towards elucidating the underlying pathophysiological processes in schizophrenia. The results support the use of symptom based syndromes in reducing the diversity of findings in schizophrenia.
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Affiliation(s)
- A W Harris
- Department of Psychological Medicine, University of Sydney, NSW 2008, Australia.
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Basso MR, Nasrallah HA, Olson SC, Bornstein RA. Neuropsychological correlates of negative, disorganized and psychotic symptoms in schizophrenia. Schizophr Res 1998; 31:99-111. [PMID: 9689714 DOI: 10.1016/s0920-9964(98)00023-1] [Citation(s) in RCA: 131] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recent studies suggest that three dimensions (negative, disorganized and psychotic) categorize schizophrenic symptoms. A developing literature indicates distinct cerebral correlates of each symptom cluster, but few investigations have determined their neuropsychological correlates. In the present study, the Schedules of Negative and Positive Symptoms measured symptom severity in 62 schizophrenics, and a subsequent principal components analysis revealed three symptom dimensions. Factor scores, age and parental socio-economic status were simultaneously entered into regression equations to explain variance across a broad neuropsychological test battery. Negative symptoms were associated with deficits involving intelligence, executive function, memory, sustained-attention and sensory-motor function, whereas disorganized symptoms correlated with decreased intelligence, attention-span and sensory-motor function. Psychotic symptoms were unrelated to deficits. These data are consistent with hypotheses that these three symptom dimensions have distinct neurobehavioral correlates.
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Affiliation(s)
- M R Basso
- Department of Psychology, University of Tulsa, OK 74104, USA.
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