The disabilities of chronic schizophrenia--their nature and the factors contributing to their development

Subtyping chronic catatonia: Clinical and neuropsychological characteristics of progressive periodic catatonia and chronic system catatonias vs. non-catatonic schizophrenia

Catatonia has been defined by ICD-11 as a nosologically unspecific syndrome. Previous neuropsychiatric conceptions of catatonia such as Wernicke-Kleist-Leonhard's (WKL) one, have isolated chronic catatonic entities, such as progressive periodic catatonia (PPC) and chronic system catatonias (CSC). This study aimed at comparing the clinical and neuropsychological features of PPC, CSC and non-catatonic patients, all diagnosed with a schizophrenia spectrum disorder (SSD). The clinical and cognitive measures were compared among 53 SSD patients, first by separating catatonic (C-SSD, n = 27) and non-catatonic patients (NC-SSD, n = 26), and second, by separating PPC (n = 20), CSC (n = 6) and NC-SSD patients. Bayes factors were used to compare the model with 1 or 2 catatonic groups. We found that PPC had a more frequent schizo-affective presentation, higher levels of depression and less positive psychotic symptoms than both CSC and NC-SSD. CSC patients had an earlier illness onset, a poorer cognitive functioning, and higher antipsychotics doses than both PPC and NC-SSD. Most differences between C- and NC-SSD were accounted by characteristics of either PPC or CSC. The model with 2 catatonic groups clearly outperformed that with 1 catatonic group. Our results point to a substantial clinical heterogeneity of 'catatonia' within the SSD population and suggest that distinguishing (at least) 2 chronic catatonic phenotypes (PPC and CSC) may represent a relevant step to apprehend this heterogeneity. It is also a more parsimonious attempt than considering the around 32.000 distinct catatonic presentations resulting from the combinations of 3 out of 15 polythetic criteria for ICD-11 catatonia.

Managing antipsychotic-related sexual dysfunction in patients with schizophrenia

INTRODUCTION

Schizophrenia is a psychotic disorder and one of the most severe and impactful mental illnesses. Sexual dysfunction is highly prevalent in patients with schizophrenia but remains underdiagnosed and undertreated. Sexual dysfunction is frequently attributed to antipsychotics which may reduce medication adherence, but negative symptoms can also reduce sexual drive.

AREAS COVERED

This review provides an overview of the current knowledge about sexual dysfunction in patients with schizophrenia. The authors first review the literature concerning the mechanisms of sexual dysfunction and explore the impact of antipsychotics on sexual function. Finally, they present the available non-pharmacological and pharmacological treatment strategies for sexual dysfunction in patients with schizophrenia.

EXPERT OPINION

Sexual dysfunction in patients with schizophrenia is still underrated by clinicians despite having a negative impact on the quality of life and therapeutic adherence. Antipsychotic treatment is still perceived as a major cause of sexual impairment. Psychiatrists must be aware of this condition and actively question the patients. A comprehensive approach, addressing pharmacological and non-pharmacological aspects, is fundamental for managing sexual dysfunction in schizophrenia. Pharmacological strategies include (1) Serum-level adjustment of the antipsychotic dose, if possible (2) switching to a well-tolerable antipsychotic (aripiprazole, brexpiprazole) and (3) adding a coadjuvant drug (phosphodiesterase-5 inhibitors).

Schizophrenia

Schizophrenia, characterised by psychotic symptoms and in many cases social and occupational decline, remains an aetiological and therapeutic challenge. Contrary to popular belief, the disorder is modestly more common in men than in women. Nor is the outcome uniformly poor. A division of symptoms into positive, negative, and disorganisation syndromes is supported by factor analysis. Catatonic symptoms are not specific to schizophrenia and so-called first rank symptoms are no longer considered diagnostically important. Cognitive impairment is now recognised as a further clinical feature of the disorder. Lateral ventricular enlargement and brain volume reductions of around 2% are established findings. Brain functional changes occur in different subregions of the frontal cortex and might ultimately be understandable in terms of disturbed interaction among large-scale brain networks. Neurochemical disturbance, involving dopamine function and glutamatergic N-methyl-D-aspartate receptor function, is supported by indirect and direct evidence. The genetic contribution to schizophrenia is now recognised to be largely polygenic. Birth and early life factors also have an important aetiological role. The mainstay of treatment remains dopamine receptor-blocking drugs; a psychological intervention, cognitive behavioural therapy, has relatively small effects on symptoms. The idea that schizophrenia is better regarded as the extreme end of a continuum of psychotic symptoms is currently influential. Other areas of debate include cannabis and childhood adversity as causative factors, whether there is progressive brain change after onset, and the long-term success of early intervention initiatives.

Principal-component analysis of PANSS and SANS - SAPS global ratings in schizophrenic patients

The aim of this study was to test whether a positive and a negative component could be found in broadly defined schizophrenic patients. Therefore, 70 patients either in an exacerbated or in a stabilized phase were selected according to the criteria of at least 1 of the 4 following diagnostic systems: DSM III-R, Schneider, Carpenter, Langfeldt; principal component analyses (PCA) were carried out with the 9 global ratings of the Scales for Assessment of Negative and Positive Symptoms (SANS and SAPS) and with the Positive and Negative Syndrome Scale (PANSS). The PCA of the SANS-SAPS global ratings yielded a 3-factor solution explaining 72.14% of the total variance, depicting a negative, a positive and a disorganization component. The PCA of the PANSS provided a 5-factor solution with a total explained variance of 55.98%. The first 3 factors were similar to those of the SANS-SAPS global rating analysis. The results showed that the positive and negative components described in a homogeneous schizophrenic population could be replicated in a larger and more heterogeneous group of schizophrenic patients. The question regarding the sufficiency of the positive-negative dichotomy was strengthened by the presence of a third disorganization component which explained as much of the variance as the positive component.

Neurological soft signs (NSS) and cognitive impairment in chronic schizophrenia

Recent studies indicate that neurological soft signs (NSS) in schizophrenia are associated with generalized cognitive impairments rather than changes in specific neuropsychological domains. However, the majority of studies solely included first-episode patients or patients with a remitting course and did not consider age, course, education or severity of global cognitive deficits as potential confounding variables. Therefore, we examined NSS with respect to cognitive deficits in chronic schizophrenia, i.e. patients who are particularly vulnerable to both, NSS and cognitive impairments.

Eighty patients with chronic schizophrenia (43.36 ± 15a) and 60 healthy controls (47.52 ± 14.8a) matched for age, sex and years of education were examined on the Heidelberg NSS scale and a broad neuropsychological battery including short term, working, logical and autobiographic memory (AM), theory of mind (ToM), psychomotor speed and cognitive flexibility.

When contrasted with the controls, patients showed significantly higher NSS scores and impairments in all neuropsychological domains but short-term memory. NSS were significantly associated with all neuropsychological domains considered but short-term memory and semantic AM. Except for episodic AM (which was significantly correlated with NSS in patients only) these correlations applied to both groups and were confirmed when age, years of education and severity of global cognitive deficits (Mini Mental State Examination) were controlled for.

Results demonstrate that NSS reflect a rather wide range of cognitive impairments in schizophrenia, which also involves episodic AM and ToM. These associations were not accounted for by age, education or severity of global cognitive deficits and facilitate the clinical usage of NSS as a screening instrument.

Factor analysis of symptom dimensions (psychotic, affective and obsessive compulsive symptoms) in schizophrenia

AIM

To carryout factor analysis of symptom profile of patients with schizophrenia assessed by using positive and negative syndrome scale (PANSS), Calgary depression rating scale (CDSS), Young mania rating scale (YMRS) and YBOCS checklist.

METHODOLOGY

181 patients of schizophrenia were assessed on PANSS, CDSS, YMRS and YBOCS checklist.

RESULTS

Factor analysis of PANSS yielded 3 factor structure (positive, negative, anxiety). When the items of CDSS were added to the PANSS items, total number of factors increased to 4 with depression emerging as a separate factor. Addition of YMRS to PANSS and CDSS led to emergence of 5 factor model. Further addition of YBOCS checklist led to emergence of a 7 factor model (positive, depressive, obsessive compulsive, negative, manic, anxiety and obsessive compulsive-2), which explained 49.85% variance of the data. Positive symptoms emerged as the factor-1. Depressive symptoms loaded on the factor-2, negative symptoms loaded on to factor-4, manic symptoms loaded onto factor-5 and anxiety symptoms loaded onto factor-6. OC symptoms loaded onto factor 3 and 7.

CONCLUSIONS

Present study suggests that when multiple scales are used for assessment of various symptoms of schizophrenia, the symptoms separate out into 7 factors. This finding suggests that clinical assessment of schizophrenia should not be limited to core psychotic symptoms only and structured instruments must be used to elicit other symptoms too while monitoring the clinical picture of patients with schizophrenia.

Motor Dysfunction as a Risk Factor for Conversion to Psychosis Independent of Medication Use in a Psychosis-Risk Cohort

The Structured Interview for Psychosis-Risk Syndromes (SIPS) contains criteria for the Attenuated Positive Symptom Syndrome (APSS), a period of subthreshold positive symptoms that predates full-blown psychosis. Motor abnormalities are often associated with these symptoms but have not been adequately studied. We assessed a diverse sample of 192 APSS participants (27.1% female; 47.9% white; mean age = 20.03 years) for motor dysfunction (SIPS G.3. score) at baseline and conversion to psychosis every 3 months for up to 2 years. Fifty-nine (30.7%) participants converted to psychosis. Baseline G.3. score was significantly higher among converters than nonconverters (mean difference = 0.66; t[95.929] = 2.579, p < 0.05). No significant differences in baseline G.3. were found between demographic groups or those with differential medication use. These results point to the use of G.3. as a potential predictor of psychosis among APSS individuals and potentially implicate the shared biological underpinnings of motor dysfunction in the APSS and full-blown psychotic illnesses.

Social morbidity of a long-stay mental hospital population with chronic schizophrenia

As part of the shift towards community care, a number of the large mental hospitals throughout the United Kingdom have now closed and many more are due for closure. In a review of deinstitutionalisation, Thornicroft & Bebbington (1989) concluded that the run-down of hospitals was outstripping the provision of new community facilities. Between 1974 and 1984 the mental hospital population fell by 25,000. However, the increase in residential places provided by local authorities and by the private and voluntary sectors totalled only 3,000. Inadequate planning and provision could give rise to discharged patients facing the prospect of isolated, segregated and impoverished lives with a high likelihood of homelessness and recurrent admission.

The physical health of old long stay in-patients in one psychiatric hospital

The provision of care for patients with chronic mental illness is changing with the gradual closure of mental hospitals and the expectation that this group will be largely cared for in the community. In Scotland the process is only beginning. A recent Scottish survey examined the demographic, social and clinical characteristics of 2605 “old long-stay” in-patients, defined as those in hospital more than six years and under 65 years of age at the time of last admission (McCreadie et al, 1991). Patients in 18 psychiatric hospitals serving 83% of the Scottish population were studied. Results showed the population was elderly, 70% being over 60 years of age, and nearly 40% over 70 years. The aim of the present study was to look at the physical health of the old long-stay population in one hospital, namely Crichton Royal, Dumfries, because of the implications of physical health care needs for the management of this group in the community.

The Effect of Nutritional Education on the Shopping and Eating Habits of a Small Group of Chronic Schizophrenic Patients Living in the Community

Eleven people with chronic schizophrenia were the subjects of an 8-week study which asked three research questions. How did these individuals with a chronic mental illness function as deinstitutionalised persons? Did participation in a 6-week nutritional education programme affect cognitive performance and behaviour? And did the nutritional education package require further refinement? This experiment produced qualitative data which were analysed using descriptive statistics and evaluation of questionnaires. The pre-test and post-test scores of the subjects suggested that improved nutritional knowledge did not relate to attitudes or to the shopping and eating behaviour of people with chronic schizophrenia living in the community. A future need to address this lack of generalisation of skills was identified.

Abnormal involuntary movements are linked to psychosis-risk in children and adolescents: Results of a population-based study

BACKGROUND

Altered motor behavior has consistently been reported in medication-naive adult patients with schizophrenia and first episode psychosis and adults at clinical high risk for psychosis (CHR). This study is the first to evaluate the prevalence of abnormal involuntary movements in a community sample of children and adolescents with and without CHR.

METHODS

We examined CHR in 102 children and adolescents aged 8-17years from the general population of the Canton Bern. Attenuated and brief intermittent psychotic symptoms, as well as basic symptoms, were assessed using the Structured Interview for Psychosis Risk Syndromes and the Schizophrenia Proneness Instrument, Child & Youth Version. Motor symptoms were assessed using the Abnormal Involuntary Movement Scale (AIMS). Additionally, psychosocial functioning, a neurocognitive test battery, and DSM-IV Axis I disorders were examined.

RESULTS

Eleven (10.8%) participants met CHR criteria, 13 (12.7%, 5 with and 8 without CHR) met criteria for increased abnormal involuntary movements (AIMS≥2). Both AIMS total scores and the percentage of children with AIMS≥2 were significantly higher in the CHR group. Psychosocial functioning was reduced in subjects with abnormal involuntary movements, and movement abnormalities were linked to deficits in attention and perception but not to the presence of non-psychotic mental disorders.

CONCLUSIONS

Our findings suggest that abnormal involuntary movements are linked to psychosis risk in children and adolescents from the general population. Thus, abnormal involuntary movements might represent an additional useful and easily accessible predictor of psychosis.

Sulpiride versus placebo for schizophrenia

BACKGROUND

Sulpiride is a relatively old antipsychotic drug reputed to have a low incidence of adverse effects and an effect on the negative symptoms of schizophrenia. This relatively inexpensive antipsychotic drug has a similar neuropharmacological profile to several novel atypical drugs.

OBJECTIVES

To evaluate the effects of sulpiride for schizophrenia and other similar serious mental illnesses in comparison with placebo.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (September 2008) and references of all identified studies for further trial citations. We contacted pharmaceutical companies and authors of trials for additional information. We updated this search 7th November 2012.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing sulpiride with placebo for people with schizophrenia and other types of schizophrenia-like psychoses. The primary outcome of interest was clinically significant response in global state.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and abstracts, ordered papers, re-inspected and quality-assessed these. IMO and JW extracted data. We analysed dichotomous data using a random-effects risk ratio (RR) and estimated the 95% confidence interval (CI) around this. Where continuous data were included, we analysed these data using random-effects mean difference (MD) with a 95% CI.

MAIN RESULTS

No new trials were included from the 2012 search. The review still includes two trials of short duration comparing sulpiride with placebo (total n = 113). No study reported our primary outcome of interest of 'global state: clinically significant response', nor our secondary outcomes of interest of 'quality of life', 'severe adverse effects', and 'safety assessments'. As regards mental state, there were no clear differences between groups for either positive or negative symptoms; measured positive symptoms using the Manchester scale were skewed and therefore not included in meta-analysis (n = 18, 1 RCT, very low quality evidence). Measured negative symptoms using the Manchester scale also demonstrated no clear difference (n = 18, 1 RCT, MD -3.0 CI -1.66 to 1.06, very low quality evidence). Few people left these studies by three months (n = 113, 2 RCTs, RR 1.00 CI 0.25 to 4.00). One subscore finding demonstrated a significant improvement in social behaviour using the Current Behaviour Schedule (CBS) when receiving placebo (n = 18, 1 RCT, MD -2.90 CI -5.60 to -0.20). There were no data for many important outcomes such as global outcomes, service use or adverse effects.

AUTHORS' CONCLUSIONS

Sulpiride may be an effective antipsychotic drug but evidence of its superiority over placebo from randomised trials is very limited. Practice will have to use evidence from sources other than trials until better evidence is generated.

Mismatch negativity indexes illness-specific impairments of cortical plasticity in schizophrenia: a comparison with bipolar disorder and Alzheimer's disease

Cognitive impairment is an important predictor of functional outcome in patients with schizophrenia, yet its neurobiology is still incompletely understood. Neuropathological evidence of impaired synaptic connectivity and NMDA receptor-dependent transmission in superior temporal cortex motivated us to explore the correlation of in vivo mismatch negativity (MMN) with cognitive status in patients with schizophrenia. MMN elicited in a roving stimulus paradigm displayed a response proportional to the number of stimulus repetitions (memory trace effect). Preliminary evidence in patients with chronic schizophrenia suggests that attenuation of this MMN memory trace effect was correlated with the degree of neuropsychological memory dysfunction. Here we present data from a larger confirmatory study in patients with schizophrenia, bipolar disorder, probable Alzheimer's disease and healthy controls. We observed that the diminution of the MMN memory trace effect and its correlation with memory impairment was only found in the schizophrenia group. Recent pharmacological studies using the roving paradigm suggest that attenuation of the MMN trace effect can be understood as abnormal modulation of NMDA receptor-dependent plasticity. We suggest that the convergence of the previously identified synaptic pathology in supragranular cortical layers with the intracortical locus of MMN generation accounts for the remarkable robustness of MMN impairments in schizophrenia. We further speculate that this layer-specific synaptic pathology identified in supragranular neurons plays a pivotal computational role, by weakening the encoding and propagation of prediction errors to higher cortical modules. According to predictive coding theory such breakdown will have grave implications not only for perception, but also for higher-order cognition and may thus account for the MMN-cognition correlations observed here. Finally, MMN is a sensitive and specific biomarker for detecting the early prodromal phase of schizophrenia and is well suited for the exploration of novel cognition-enhancing agents in humans.

Psychiatric symptoms of noradrenergic dysfunction: a pathophysiological view

What psychiatric symptoms are caused by central noradrenergic dysfunction? The hypothesis considered in this review is that noradrenergic dysfunction causes the abnormalities in arousal level observed in functional psychoses. In this review, the psychiatric symptoms of noradrenergic dysfunction were inferred pathophysiologically from the neuroscience literature. This inference was examined based on the literature on the biology of psychiatric disorders and psychotropics. Additionally, hypotheses were generated as to the cause of the noradrenergic dysfunction. The central noradrenaline system, like the peripheral system, mediates the alarm reaction during stress. Overactivity of the system increases the arousal level and amplifies the emotional reaction to stress, which could manifest as a cluster of symptoms, such as insomnia, anxiety, irritability, emotional instability and exaggerated fear or aggressiveness (hyperarousal symptoms). Underactivity of the system lowers the arousal level and attenuates the alarm reaction, which could result in hypersomnia and insensitivity to stress (hypoarousal symptoms). Clinical data support the hypothesis that, in functional psychoses, the noradrenergic dysfunction is in fact associated with the arousal symptoms described above. The anti-noradrenergic action of anxiolytics and antipsychotics can explain their sedative effects on the hyperarousal symptoms of these disorders. The results of animal experiments suggest that excessive stress can be a cause of long-term noradrenergic dysfunction.

Amygdala volume in a population with special educational needs at high risk of schizophrenia

BACKGROUND

The mildly learning disabled population has a three-fold elevated risk for schizophrenia. It has been proposed that in some individuals this cognitive limitation is a pre-psychotic manifestation of early onset schizophrenia. We examined clinical and neuroanatomical measures of a putative extended phenotype of schizophrenia in an adolescent population receiving special educational assistance. We predicted that people with intellectual impairment and schizotypal features would exhibit amygdala volume reduction as one of the neuroanatomical abnormalities associated with schizophrenia.

METHOD

Assessment by clinical interview, neuropsychological assessment and magnetic resonance imaging scanning was carried out in 28 intellectually impaired individuals identified as being at elevated risk of schizophrenia due to the presence of schizotypal traits, 39 intellectually impaired controls and 29 non-intellectually impaired controls. Amygdala volume was compared in these three groups and the relationship between symptomatology and amygdala volume investigated.

RESULTS

Right amygdala volume was significantly increased in the elevated risk group compared with the intellectually impaired controls (p=0.05). A significant negative correlation was seen between left amygdala volume and severity of negative symptoms within this group (p<0.05), but not in either control group.

CONCLUSIONS

Intellectually impaired subjects judged to be at elevated risk of schizophrenia on the basis of clinical assessment exhibit structural imaging findings which distinguish them from the generality of learning disabled subjects. Within this population reduced amygdala volume may be associated with negative-type symptoms and be part of an extended phenotype that reflects particularly elevated risk and/or early manifestations of the development of psychosis.

Duration of untreated illness and outcome in schizophrenia: test of predictions in relation to relapse risk

BACKGROUND

The nature of the relationship between duration of the pre-diagnostic interval in schizophrenia and better outcomes remains unclear.

AIMS

To re-examine data from one of the earliest studies suggesting an association between long pre-treatment interval and compromised outcome, assessing the relationship between symptomatic and social variables and increased relapse risk at 1 year.

METHOD

Symptomatic, social and demographic data from participants in the Northwick Park Study of First Episodes who completed 12-month follow-up (n = 101) were re-analysed in the context of duration of untreated illness (DUI).

RESULTS

At admission, those with long DUI were more likely to have lower scores on tension derived from the Present State Examination, exhibited more behaviour threatening to others and more bizarre behaviour, were more likely to be single, to live alone or dependently, to be unemployed and to have experienced more adverse life events prior to admission. Logistic regression showed that diminished tension, bizarre behaviour and unemployed status independently increased the risk of relapse, bizarre behaviour making the single biggest contribution. Tension did not remain significant with log-transformation of data.

CONCLUSIONS

Findings are consistent with the conclusion that long DUI can reflect characteristics of the psychosis itself rather than delay in treatment.

Potential Endophenotype for Schizophrenia: Neurological Soft Signs

Introduction: Neurological soft signs (NSS) are suggested as a candidate endophenotype for schizophrenia. This article aims to review relevant literature and discuss the role of NSS in understanding schizophrenia. Methods: This is an update on a review article published in 2003. Articles from 2003 onwards were specifically reviewed and discussed with relevance to the role of NSS as endophenotype for schizophrenia. Results: Consistent data suggest an excess of NSS in schizophrenic patients. NSS appear to be related to schizophrenic symptoms, in particular negative symptoms and disorganisation. Information on NSS and demographic correlates is scarce, and the confounding effects between age, education and intelligence on NSS constitute an important gap in current knowledge. Longitudinal data suggest NSS as both a trait and state variable in the course of disease. NSS are not specific with regard to diagnosis, although there are claims that individual sub-components may be more specific. The weight of evidence raises question on the specificity of NSS for schizophrenia. Conclusions: The usefulness and feasibility of NSS as a specific endophenotype target for schizophrenia is unclear. However, NSS remain an important feature and symptom correlate of schizophrenia. Future research should focus on delineating the effects of NSS from those of confounding demographic variables, and the stability of NSS over the course of illness to elucidate its role in schizophrenia. Key words: Diagnostic specificity, Neurological examination abnormalities, Psychotic symptoms, Review, Trait

Life events and high-trait reactivity together predict psychotic symptom increases in schizophrenia

Psychotic symptoms are exacerbated by stressful life events in schizophrenia patients as a group. Some individuals appear to be more vulnerable than others in this regard. This study tested whether schizophrenia patients are highly emotionally reactive compared with controls and whether the level of trait emotional reactivity in patients influences the degree to which they respond to life stressors with exacerbations of psychosis. Schizophrenic outpatients and nonpsychiatric controls were assessed for levels of trait emotional reactivity, arousability, and trait anxiety. Severity of symptoms was also rated in the patients. Patients were then followed up 9 months later, assessed for independent stressful life events occurring during the month before the follow-up session, and reassessed for symptom levels. The patients scored higher than the control subjects on all 3 measures of reactivity at the initial assessment. At follow-up, the occurrence of potentially stressful life events predicted increases in psychotic symptoms in patients, and there was a significant interaction between level of initial trait reactivity and the occurrence of life events in the prediction of these increases. High-trait-reactive patients showed increases in psychotic symptoms in response to life stressors, whereas low-trait-reactive patients did not. These findings support the idea that patients as a group have higher than normal levels of trait reactivity and also that patients with very high levels of trait reactivity are at elevated risk of psychotic relapse under stress. Such patients might benefit particularly from interventions designed to assist them in coping with potentially stressful life events and circumstances.

Sulpiride versus placebo for schizophrenia

BACKGROUND

Sulpiride is a relatively old antipsychotic drug reputed to have low incidence of adverse effects and an effect on the negative symptoms of schizophrenia. This relatively inexpensive antipsychotic drug has a similar neuropharmacological profile to several novel atypical drugs.

OBJECTIVES

To evaluate the effects of sulpiride for schizophrenia and other similar serious mental illnesses in comparison with placebo.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (September 2008) and references of all identified studies for further trial citations. We contacted pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing sulpiride with placebo for people with schizophrenia and other types of schizophrenia-like psychoses. The primary outcome of interest was clinically significant response in global state.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and abstracts, ordered papers, re-inspected and quality assessed these. IMO and JW extracted data. We analysed dichotomous data using random-effects relative risk (RR) and estimated the 95% confidence interval (CI) around this. Where continuous data were included, we analysed this data using random-effects weighted mean difference (WMD) with a 95% confidence interval.

MAIN RESULTS

Two trials of short duration compare sulpiride with placebo (total n=113). As regards mental state, there were no clear differences between groups for either positive or negative symptoms (n=18, 1 RCT, WMD Manchester scale negative subscore -0.30 CI -1.66 to 1.06; n=18, 1 RCT, WMD SANS 2.90 CI -0.14 to 5.94). Few people left these studies by three months (n=113, 2 RCTs, RR 1.00 CI 0.25 to 4.00). One subscore finding found sulpiride improved social behavior (n=18, 1 RCT, WMD -2.90 CI -5.60 to -0.20). There were no data for many important outcomes such as general functioning, service use or adverse effects.

AUTHORS' CONCLUSIONS

Sulpiride may be an effective antipsychotic drug but evidence of its superiority over placebo from randomised trials is very limited. Practice will have to use evidence from sources other than trials until better evidence is generated.

Schizotypal cognitions as a predictor of psychopathology in adolescents with mild intellectual impairment

BACKGROUND

There is evidence to suggest that among young people with mild intellectual disability there are those whose cognitive difficulties may predict the subsequent manifestation of a schizophrenic phenotype. It is suggested that they may be detectable by simple means.

AIMS

To gain adequate cooperation from educational services, parents and students so as to recruit a sufficiently large sample to test the above hypothesis, and to examine the hypothesis in the light of the findings.

METHOD

The sample was screened with appropriate instruments, and groups hypothesised as being likely or not likely to have the phenotype were compared in terms of psychopathology and neuropsychology.

RESULTS

Simple screening methods detect a sample whose psychopathological and neuropsychological profile is consistent with an extended phenotype of schizophrenia.

CONCLUSIONS

Difficulties experienced by some young people with mild and borderline intellectual disability are associated with enhanced liability to schizophrenia. Clinical methods can both identify those with this extended phenotype and predict those in whom psychosis will occur.

Very poor outcome schizophrenia: clinical and neuroimaging aspects

In spite of significant advances in treatment of patients with schizophrenia and continued efforts towards their deinstitutionalization, a considerable group of patients remain chronically hospitalized or otherwise dependent on others for basic necessities of life. It has been proposed that these patients belong to a distinct etiopathological subgroup, termed Kraepelinian, whose course of illness may be progressive and resistant to treatment. Indeed, longitudinal studies appear to show that elderly Kraepelinian patients follow a course of rapid cognitive and functional deterioration, commensurate with a dementing process, and that their poor functional status is closely correlated with the cognitive deterioration. Recent neuroimaging studies described a pattern of posteriorization of grey and white matter deficits with poor outcome in schizophrenia, and produced a constellation of findings implicating primary processing of visual and auditory information as central to the impaired functional status in this patient group. These studies are summarized in detail in this review and future directions for neuroimaging assessment of very poor outcome patients with schizophrenia are suggested.

Neurological soft signs, clinical symptoms and treatment reactivity in patients suffering from first episode schizophrenia

OBJECTIVE

(a) To investigate the correlation between clinical symptoms and neurological soft signs in patients suffering from their first episode of schizophrenia and (b) to examine the relationship between soft signs and the reactivity of first episode treatment.

METHODS

The trial included 92 male patients undergoing a first episode of schizophrenia. The clinical symptoms of the patients were rated on the positive and negative syndrome scale (PANSS). The PANSS scale was used to provide a measure for three syndromes: psychomotor poverty, disorganisation, and reality distortion. Neurological soft signs were assessed with the help of the neurological evaluation scale.

RESULTS

The findings corroborated significant positive correlations between soft neurological signs on the one hand and negative symptoms and reduced treatment response on the other.

CONCLUSION

Our study of the population of patients with first episode schizophrenia has corroborated the findings of those trials that found a correlation between neurological soft signs and the negative symptomatic dimension of schizophrenia. Another finding of the trial is that neurological soft signs were associated with poorer response to treatment of the first episode of schizophrenia.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase

This study set out to determine the frequency of catatonic syndrome in chronic schizophrenia and its association with sociodemographic, clinical, and treatment variables. A cross-sectional assessment of a randomly selected cohort of patients (n=225; mean age=42+/-7 years; mean length of illness=20.4+/-7.5 years) with DSM-IV schizophrenia was employed using standard rating instruments for catatonia, drug-induced extrapyramidal symptoms (EPS), and psychotic, depressive, and obsessive-compulsive symptoms. Using a rather narrow definition of catatonia [the presence of four or more signs/symptoms with at least one having a score '2' or above on the Bush-Francis Catatonia Rating Scale (BFCRS)], 72 subjects (32%) met the criteria for the catatonia group (mean number of catatonic signs/symptoms=5.9+/-2.0; mean sum score of 8.7+/-3.4 on the BFCRS). The frequency distribution of catatonic signs/symptoms in the catatonic group and in the whole sample was very similar, with mannerisms, grimacing, stereotypes, posturing, and mutism being the most frequent. In the logistic regression analysis, catatonic subjects had a significantly earlier age of onset, more negative symptoms, and were more likely to receive benzodiazepines than their noncatatonic counterparts. In multiple regression analysis, the severity of catatonia as indicated by the sum score of BFCRS was predicted only by earlier age of onset and negative symptoms. Using relatively narrow criteria, this study confirmed that, if methodically assessed, catatonic signs and symptoms are prevalent in patients with chronic schizophrenia. Catatonia can be differentiated from EPS. Catatonic features indicate a generally poor prognosis in the chronic phase of schizophrenia.

Mismatch negativity potentials and cognitive impairment in schizophrenia

Cognitive impairment in schizophrenia is an important predictor of clinical and social outcome. In this preliminary study, the correlation between cognitive status and deficits in mismatch negativity (MMN) generation was explored. The MMN response to tone duration deviants was recorded using a new stimulation protocol with continuously changing ('roving') standard stimuli in order to measure the effect of standard repetitions on MMN (memory trace effect). Cognitive status of the patient group (n=28) was assessed using neuropsychological screening. Healthy participants (n=20) served as age-matched comparison group. In patients, MMN amplitude in frontal electrodes as well as the MMN memory trace effect was diminished compared to controls. While both measures were inversely related to patient's age and disease severity, only the MMN memory trace effect was robustly correlated with the degree of neuropsychological impairment. This suggests that ERP measures of auditory system adaptability more appropriately characterise the pathophysiological processes underlying cognitive impairment in schizophrenia than static measures of ERP magnitude.

Proposal for a noradrenaline hypothesis of schizophrenia

In this article, we have reevaluated the role of noradrenergic dysfunction in the pathogenesis of schizophrenia in the light of today's neuroscience and clinical data. Neurophysiological, psychophysiological, psychopharmacological, and biochemical findings that have accumulated in last decades indicate that certain noradrenergic dysfunctions play important roles in the pathogenesis of the disorder. Moreover, these findings provide us with consistent evidence for the existence of two syndromes generated by either overactivity or underactivity of the central noradrenaline (NA) system. The former appears to correspond to the type I syndrome (positive symptoms) and the latter to the type II syndrome (negative symptoms). We conclude that the involvement of brain NA in cerebral metabolism and blood flow as well as the amine's role in brain development and neuronal differentiation may provide the mechanisms underlying the disease process in schizophrenia. Development of chemical agents acting specifically on the brain noradrenergic mechanisms may be a promising approach to novel treatments of the disorder.

Spontaneous improvement in severe, chronic schizophrenia and its neuropsychological correlates

Cognitive impairment is well established in schizophrenia but its relationship to the course of the illness remains incompletely understood. Here we document two patients with schizophrenia who underwent neuropsychological testing while chronically unwell, and this was repeated after improvement took place. Both patients showed significant recovery of general intellectual function, accompanied by improvements in some but not all areas of neuropsychological function: executive function remained particularly impaired.

Motor overflow in schizophrenia

The occurrence of motor dysfunction as a sign of schizophrenia, in addition to being a side effect of medication, has received considerable support in recent years. The current study aimed to systematically investigate both the presence and pattern of one such motor dysfunction, motor overflow. It was hypothesised that patients with schizophrenia would show significantly greater motor overflow than controls, and that the pattern of motor overflow occurrence would also vary significantly between the groups. A finger flexion task was used to examine the presence and pattern of motor overflow. Subjects were asked to maintain target forces, using either their index or small finger, representing 25, 50 or 75% of the maximum strength capacity for whichever finger was performing the task. Patients were found to exhibit significantly greater motor overflow than controls. There were also significant findings with respect to the patterns of motor overflow produced, specifically in regards to fine motor control and performance variability. In summary, patients differed significantly from controls in both the degree and pattern of overflow exhibited.

Stability of formal thought disorder and referential communication disturbances in schizophrenia

This study examined the degree to which different types of communication disturbances in the speech of 48 schizophrenia patients and 28 controls were variable and state related versus stable and traitlike. Clinically rated formal thought disorder and 5 types of referential disturbance showed substantial stability within participants over time. The sixth type of referential disturbance, the vague reference, was not stable over time. Formal thought disorder was associated with the severity of core psychotic symptoms in patients. whereas referential disturbances showed little or no association with positive or negative symptom severity. Furthermore, changes in psychotic symptoms over time were accompanied by corresponding changes in formal thought disorder but not referential disturbances. These results support the idea that some types of referential disturbances are traitlike and may be reflective of vulnerability as well as manifest illness.

Beneficial effect of donepezil augmentation for the management of comorbid schizophrenia and dementia

Comorbid schizophrenia and dementia is a common clinical phenomenon; however, management of the coexisting illnesses remains incomplete. Donepezil, a cholinesterase inhibitor, may be beneficial for the management of symptoms of Alzheimer's disease, a disease in which cholinergic pathways in the cerebral cortex and basal forebrain are well known to be compromised. Furthermore, impaired cognition in elderly schizophrenic patients has been observed to be more than two thirds; however, there are no published controlled studies reporting the use of cholinesterase inhibitors in the management of schizophrenia in patients with associated dementia. In this study, six patients with chronic schizophrenia and comorbid dementia were administered donepezil, 5 mg, in single-blind fashion as augmentation to their standard antipsychotic medication for a 4-week period. Patients were evaluated with the Mini Mental State Examination (MMSE); Alzheimer's Disease Assessment Scale, Cognitive subscale; Positive and Negative Symptom Scale (PANSS); and the Clinical Global Impression (CGI) scales. A significant improvement was noted in MMSE scores (P < 0.01) and for CGI scores (P < 0.01). In addition, three patients demonstrated improvement on the PANSS. Donepezil appears to be an effective treatment for the management of symptoms of dementia accompanying patients with comorbid schizophrenia and dementia. Since cholinergic dysfunction may be present in some patients with schizophrenia, the authors' findings further demonstrate the possibility that this disorder may be managed with cholinergic medications as augmenting agents, at least in this specific subpopulation of patients with comorbid dementia. To confirm the findings of this preliminary trial, further investigation is mandated with a larger sample of subjects in the context of a double-blind medication trial.

Neurological soft signs in first-episode psychosis: a systematic review

BACKGROUND

Neurological soft signs (NSS) are minor neurological signs indicating non-specific cerebral dysfunction. Their presence has been documented extensively in schizophrenia but not during the first psychotic episode.

AIMS

To review studies that have specifically investigated NSS at the time of the first psychotic episode.

METHOD

A review of studies investigating neurological function in first-episode psychosis, using a clinical examination.

RESULTS

Patients with first-episode psychosis show an excess of NSS, particularly in the areas of motor coordination and sequencing, sensory integration and in developmental reflexes. Furthermore, NSS may be associated with a specific laterality pattern.

CONCLUSIONS

More studies on first-onset schizophrenia are needed, evaluating both sensory and motor neurological domains (scoring separately for the two sides of the body), integrating this knowledge with neuroimaging findings and clarifying the role of NSS as markers of cognitive dysfunction.

Cognitive decline in schizophrenics with Alzheimer's disease: a mini-review of neuropsychological and neuropathological studies

Cognitive decline in elderly schizophrenic patients is an important clinical symptom, but it is often difficult to analyze in detail due to the patient's original residual psychotic symptoms. In this article, the authors provide neuropsychological and neuropathological research information about cognitive decline in elderly schizophrenic patients, especially with reference to Alzheimer's disease (AD). Neuropsychological and neuropathological reports about cognitive impairments are reviewed. The effect of long-term antipsychotic medication upon cognitive function is also discussed. As a result, it is apparent that elderly schizophrenic patients often show cognitive impairments, however, such impairments do not have the characteristics of progressive degenerative illnesses such as AD, and the speed of their progress is very slow. Neuropathological studies have shown that AD brain pathology appears no more frequently among schizophrenic patients than in the normal population. Since making a diagnosis of AD means that the progressive deterioration not only of cognitive function, but also of physical ability, paralleling the degeneration of the central nervous system, can be expected within a few years and appropriate care will be required. One should be very cautious in adding a diagnosis of AD to elderly schizophrenic patients with cognitive impairments.

Dementia as a complication of schizophrenia

OBJECTIVES

Cognitive impairment is known to occur in schizophrenia, and may be marked in institutionalised patients. The aim of this study was to determine whether it ever warrants an additional diagnosis of dementia.

METHODS

A population of chronic schizophrenic patients who were aged 65 or younger and showed no organic risk factors for dementia were screened for presence of disorientation. Any showing this underwent neuropsychological testing, physical investigations, and structural and functional neuroimaging. Information about day to day cognitive function was also obtained from carers.

RESULTS

Eight patients aged 28 to 64 were identified who showed disorientation; in all cases this was accompanied by general intellectual impairment and objective evidence of a dementia syndrome. The patients' schizophrenic symptoms were unexceptional and did not seem sufficient to account for their cognitive impairment. Neuropsychological testing disclosed relative sparing of visual and visuospatial function and language syntax, but pervasive deficits in memory and executive function. Brain CT demonstrated only minor abnormalities but most of the patients showed frontal or temporal hypoperfusion on SPECT.

CONCLUSIONS

Dementia in schizophrenia seems to be a real entity with a neuropsychological signature similar to that of frontotemporal dementia. Functional but not structural imaging abnormalities may also be characteristic.

Nithsdale Schizophrenia Surveys. 20. Cognitive function in a catchment-area-based population of patients with schizophrenia

BACKGROUND

Cognitive deficits are a core aspect of schizophrenia but there has been no study of cognitive function in a catchment-area-based population of patients with schizophrenia.

AIMS

To assess cognitive function in a population of patients with schizophrenia, and relate it to community functioning.

METHOD

All patients with schizophrenia in Nithsdale, south-west Scotland, were identified (n = 182). Measures of assessment were: National Adult Reading Test (NART), Mini-Mental State Examination (MMSE), Rivermead Behavioural Memory Test (RBMT), Executive Interview (EXIT), FAS Verbal Fluency and Health of the Nation Outcome Scales (HoNOS).

RESULTS

We assessed 138 patients, mean age 48 years (standard deviation (s.d.) 15). Only 14% were in-patients. The mean premorbid IQ as assessed by NART was 98 (s.d. 14); 15% of patients had significant global cognitive impairment (MMSE); 81% had impaired memory (RBMT); 25% had executive dyscontrol (EXIT); and 49% had impaired verbal fluency (FAS). Scores on the functional impairment sub-scale of HoNOS correlated with all measures of cognitive impairment.

CONCLUSIONS

Cognitive dysfunction is pervasive in a community-based population of patients with schizophrenia.

Sulpiride for schizophrenia

BACKGROUND

The antipsychotic drug sulpiride was formulated over 20 years ago and was marked as having a low incidence of adverse effects and an effect on the negative symptoms of schizophrenia. This relatively inexpensive antipsychotic drug has a similar neuropharmacological profile to several novel atypical drugs.

OBJECTIVES

To estimate the clinical efficacy and tolerability of sulpiride.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), CINAHL (1982-1998), Cochrane Schizophrenia Group's Register (March 1998), Cochrane Library (Issue 1, 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1997), SIGLE (1994-1998), and Sociofile (1974-1997) were supplemented by reference searching, contacting authors and the manufacturers of sulpiride.

SELECTION CRITERIA

All randomised or quasi-randomised clinical trials focusing on the use of different doses of sulpiride or comparing sulpiride to (i) placebo; (ii) typical antipsychotic drugs; or (iii) atypical antipsychotic drugs, for those with schizophrenia or serious mental illness were selected.

DATA COLLECTION AND ANALYSIS

Trials were reliably selected and quality rated. Data were independently extracted, by two reviewers (BGOS, MF), and analysed on an intention-to-treat basis. It was assumed that people who did not complete the follow up had no improvement. Authors of trials were contacted for additional and missing data. Relative risk (RR) and 95% confidence intervals (CI) of dichotomous data were calculated with the random effects model and weighted mean difference (WMD) was calculated for continuous data.

MAIN RESULTS

The review currently includes 18 studies (30 citations). Studies are generally small and of poor quality. Limited evidence suggests that there is little difference between sulpiride and other drugs although the incidence of side effects may be less for sulpiride. There are no clear findings relating to negative symptoms.

REVIEWER'S CONCLUSIONS

Sulpiride may be an effective antipsychotic drug but evidence is limited and data relating to claims for its value against negative symptoms is not trial-based.

Autopsy study of Alzheimer's disease brain pathology in schizophrenia

The brains of 125 schizophrenic patients (DSM-IV criteria) without other major diseases likely to affect brain morphology were examined at autopsy in our hospital for an evaluation of the number of neurofibrillary tangles (NFT) and senile plaques (SP) as indicators of the incidence of Alzheimer's disease (AD) brain pathology. The clinical degree of dementia and the presence or absence of delirium and Parkinsonism were determined in a review of the patients' charts. No significant difference in the degree of AD brain pathology between the 12 schizophrenics more than 75 years old and 12 age-matched normal controls was present. We conclude that AD pathology seems to be no more frequent among schizophrenic patients than in the normal population, and that the severe cognitive impairment observed in schizophrenics is based on neither neuronal degeneration nor neuronal loss like that occurring in AD. We believe that future morphological studies of cognitive impairments in schizophrenics will require a more detailed investigation at the receptor level.

On the distinction between access and store disorders in schizophrenia: a question of deficit severity?

This study documents a severe face naming impairment in schizophrenic patients. A series of twelve patients was examined further to determine whether this deficit conformed to either an access or store disorder as described originally by Warrington and Shallice. This analysis of consistency across time, effects of cueing and familiarity effects revealed heterogeneous performance patterns; pointing to access disorders in some patients and store disorders in others. However, the difference between access-like and store-like patterns of performance was strongly correlated with quantitative differences in patient deficit-severity. Hence, the notion of dichotomous access and store disorders, in schizophrenic patients, may be deceptive; with the naming performance of schizophrenics varying according to the extent of their stored knowledge, rather than any qualitative differences between patients. These findings have implications for our understanding of: cognitive deficits in both schizophrenic and neurological patients; the relationship between psychotic and neurological disorders and perhaps for the underlying neurophysiological dysfunction.

Prevalence of spontaneous dyskinesia in schizophrenic and non-schizophrenic psychiatric patients

BACKGROUND

Although movement disorders have been noted among patients never exposed to neuroleptic medications, the specificity of spontaneous dyskinesia to schizophrenia has rarely been examined.

METHOD

By abstracting detailed case records, we compared the prevalence of dyskinetic movements between 94 neuroleptic-naïve schizophrenic patients and 179 patients with other psychiatric disorders.

RESULTS

Dyskinetic movements were more common among patients with schizophrenia than among those with all other diagnoses, and were most often noted in the body areas typically associated with tardive dyskinesia.

CONCLUSIONS

Spontaneous dyskinesia appears to be relatively specific to schizophrenia and may be intrinsic to the pathophysiology of the disorder.

Memory and intellectual deficits do not decline with age in schizophrenia

Cognitive deficits in schizophrenia are reported to be more consistent with a static encephalopathy than a dementing disorder. This study investigates memory and intellectual decline in 62 chronic schizophrenic subjects using the Wechsler Adult Intelligence Scale-Revised (WAIS-R), the Rivermead Behavioural Memory Test and the National Adult Reading Test (NART) in a cross-sectional study using five age cohorts (18-29, 30-39, 40-49, 50-59 and 60-69 years of age) and then by two cohorts (young: 18-39; older: 40-69). A second method of investigating intellectual decline was implemented by estimating the discrepancy score between WAIS-R (current IQ) and NART (premorbid IQ) for each subject. No significant differences were found in WAIS-R Full Scale. Verbal and Performance IQ and memory functioning across the five age cohorts (and when using two age groups). A significant difference in test scores was found using the Picture Completion and Digit Symbol subtests of the WAIS-R. The differences were not related to age or duration of illness. No significant difference in scores were evident in the remaining WAIS-R subtests. These results support previous findings that schizophrenia is more consistent with a static encephalopathy than a dementing disorder and that intellectual and memory function does not markedly decline with age.

Cognitive function in schizophrenia--do neuroleptics make a difference?

Valid cognitive deficits in schizophrenia are now well characterised: general poor performance with disproportionate deficits in aspects of memory and executive function. Symptomatology, motivation, institutionalization, etc. cannot explain these deficits, which are of considerable importance for both the testing of theoretical models of schizophrenia and the determination of patients' functional outcome. The receptor blocking properties of neuroleptic treatments afford them the potential for interacting with monoaminergic, indoleaminergic, and cholinergic arousal systems in the brain and, hence, for modifying cognitive processes. However, the effects of conventional neuroleptics on cognition in schizophrenia are minor according to numerous studies. Atypical neuroleptics may, owing to their novel mechanisms of action, have the capacity to remediate cognitive impairment in schizophrenia: there is some evidence that clozapine has a "cognitive sparing" effect, but further research is needed in this area, particularly with other new drugs. Future studies should employ more appropriate methodology, particularly in terms of psychological/neurophysiological sophistication, patient evaluation, and applicability to real life, and should be hypothesis driven rather than purely empirical.

Neurocognitive deficits and neurological signs in schizophrenia

OBJECTIVE

This is a comprehensive study designed to examine the association between specific clusters of neurological abnormalities and several clinically relevant aspects of schizophrenia such as positive and negative symptoms, neurocognitive deficits and psychosocial performance.

METHODS

Thirty-seven clinically stable schizophrenic (DSM-III-R) patients maintained on antipsychotic medication were comprehensively examined and Convit's Quantified Neurologic Scale (QNS) was completed. In addition, patients' psychopathology was rated on the Positive and Negative Syndromes Scale (PANSS); psychosocial performance was rated on the Global Scale of Adaptive Functioning (GAF) and the Social Performance Schedule (SPS); and neurocognitive deficits were measured with a computer-assisted neurocognitive test battery, COGLAB. The association between these factors was determined using Pearson's correlation coefficients.

RESULTS

Frontal and soft neurological scores on the QNS correlated significantly with negative syndrome scores (r = 0.45-0.51, p < 0.05) and general psychopathology scores (r = 0.46-0.49, p < 0.02) on PANSS; poor psychosocial performance on GAF (r = 0.43-0.56, p < 0.02) and SPS (r = 0.37-0.54, p < 0.007); and performance on the span of apprehension (r = 0.48-0.67, p < 0.0001), backward masking (r = 0.34-0.54, p < 0.01) and Wisconsin card sorting (r = 0.48-0.67, p < 0.001) tasks.

CONCLUSION

Frontal and soft neurological signs in schizophrenic patients are associated with prominent negative symptoms, relatively poor psychosocial performance and significantly more cognitive impairment. Past research has associated soft neurological signs, cognitive impairment and structural brain abnormalities with poor outcome and prognosis in patients with schizophrenia.

Construct validity of negative symptoms: an empirical and conceptual review

The construct validity of negative symptoms is reviewed, and findings on deficit negative symptoms are also incorporated. A valid negative symptom construct should: (a) have replicable relationships with observable phenomena and other constructs; (b) have good reliability, temporal stability, and homogeneity; and (c) predict prognosis and response to treatment, possess convergent and discriminant validity, and be useful to clinicians. Although a number of well-replicated findings provide support for the validity of the construct, modification is warranted. Specifically, the data suggest that there is a highly correlated set of negative symptoms, which includes flat affect, alogia, anhedonia, and avolition. Primary and enduring symptoms from this set have good predictive and discriminant validity and can be studied in the context of the deficit syndrome, as well as with current negative symptom rating scales. Future studies should examine whether deficit negative symptoms are better conceptualized as a dimension or a category, elucidate the relationship between deficit symptoms and additional clinical and behavioral variables (e.g., response to newer neuroleptic medications and diminished emotional responding), and explore differences between the pattern of correlates of deficit symptoms and those of the positive and thought disorder symptoms.

The neurodevelopmental theory of schizophrenia: evidence concerning structure and neuropsychology

Severe schizophrenics as a group show subtle abnormalities of cerebral structure. Cerebral ventricular enlargement is the best replicated finding, and this tends to be associated with impairment of neuropsychological performance. The idea that these abnormalities have a neurodevelopmental origin gains indirect support from the, admittedly less consistent, evidence of abnormalities of cerebral asymmetry and of neuronal migration in adult schizophrenics, as well as from the better established behavioural, psychomotor, and cognitive impairments reported in preschizophrenic children. However, the relationship between childhood and adult neuropsychological and brain structural findings has not been proven, and we don not know whether only some schizophrenia has a developmental origin, or whether patients differ only in the degree of developmental impairment that they show.

Reconsidering the gospel according to group studies: a neuropsychological case study approach to schizophrenia

Individual patterns of performance on tests of: visual perception, language, executive function, memory, and face-processing, were examined in 10 schizophrenic patients who were preselected for having current WAIS IQ and premorbid NART IQ scores in the normal range. Although the patients showed some heterogeneity in the type, pervasiveness, and degree of cognitive impairment, a majority had severely impaired verbal recall and familiar face-naming. This contrasted with the low incidence and severity of impairment on tests of executive function, visual recall, recognition memory, naming, and unfamiliar faceprocessing. Contrasts between individual patients indicated that verbal recall and executive performance are independent in some patients and that memory appears to be the core deficit. The profile of impaired and preserved cognitive function revealed some important dissimilarities from the pattern that has emerged from group studies. Finally, face-naming correlated highly with the learning of unrelated paired associates, confirming a similarity with neurological patients who have person name anomia. It is suggested that both deficits might reflect a problem with learning ''meaninglessness'' associations; this interpretation is discussed with reference to a deficit at the level of the Supervisory Attentional System (Shallice, 1988).