Three-year follow-up of older schizophrenics: extrapyramidal syndromes, psychiatric symptoms, and ventricular brain ratio

Schizophrenia as a progressive brain disease

There is convincing evidence that schizophrenia is characterized by abnormalities in brain volume. At the Department of Psychiatry of the University Medical Centre Utrecht, Netherlands, we have been carrying out neuroimaging studies in schizophrenia since 1995. We focused our research on three main questions. First, are brain volume abnormalities static or progressive in nature? Secondly, can brain volume abnormalities in schizophrenia be explained (in part) by genetic influences? Finally, what environmental factors are associated with the brain volume abnormalities in schizophrenia?

Based on our findings we suggest that schizophrenia is a progressive brain disease. We showed different age-related trajectories of brain tissue loss suggesting that brain maturation that occurs in the third and fourth decade of life is abnormal in schizophrenia. Moreover, brain volume has been shown to be a useful phenotype for studying schizophrenia. Brain volume is highly heritable and twin and family studies show that unaffected relatives show abnormalities that are similar, but usually present to a lesser extent, to those found in the patients. However, also environmental factors play a role. Medication intake is indeed a confounding factor when interpreting brain volume (change) abnormalities, while independent of antipsychotic medication intake brain volume abnormalities appear influenced by the outcome of the illness.

In conclusion, schizophrenia can be considered as a progressive brain disease with brain volume abnormalities that are for a large part influenced by genetic factors. Whether the progressive volume change is also mediated by genes awaits the results of longitudinal twin analyses. One of the main challenges for the coming years, however, will be the search for gene-by-environment interactions on the progressive brain changes in schizophrenia.

Study factors influencing ventricular enlargement in schizophrenia: a 20 year follow-up meta-analysis

A meta-analysis was performed on studies employing the ventricular-brain ratio to compare schizophrenic subjects to that of normal controls. This was a follow-up to a similar meta-analysis published in 1992 in which study-, in addition to clinical-, factors were found to contribute significantly to the reported difference between patients with schizophrenia and controls. Seventy-two (N=72) total studies were identified from the peer reviewed literature, 39 from the original meta-analysis, and 33 additional studies published since which met strict criteria for inclusion and analysis - thus representing ~30 years of schizophrenia ventricular enlargement research. Sample characteristics from schizophrenics and controls were coded for use as predictor variables against within sample VBR values as well as for between sample VBR differences. Additionally, a number of factors concerning how the studies were conducted and reported were also coded. Obtained data was subjected to unweighted univariate as well as multiple regression analyses. In particular, results indicated significant differences between schizophrenics and controls in ventricular size but also the influence of the diagnostic criteria used to define schizophrenia on the magnitude of the reported VBR. This suggests that differing factors of the diagnostic criteria may be sensitive to ventricular enlargement and might be worthy of further examination. Interestingly, we observed an inverse relationship between VBR difference and the number of co-authors on the study. This latter finding suggests that larger research groups report smaller VBR differences and may be more conservative or exacting in their research methodology. Analyses weighted by sample size provided identical conclusions. The effects of study factors such as these are helpful for understanding the variation in the size of the reported differences in VBR between patients and controls as well as for understanding the evolution of research on complex clinical syndromes employing neuroimaging morphometrics.

Are there progressive brain changes in schizophrenia? A meta-analysis of structural magnetic resonance imaging studies

BACKGROUND

It is well established that schizophrenia is associated with structural brain abnormalities, but whether these are static or progress over time remains controversial.

METHODS

A systematic review of longitudinal volumetric studies using region-of-interest structural magnetic resonance imaging in patients with schizophrenia and healthy control subjects. The percentage change in volume between scans for each brain region of interest was obtained, and data were combined using random effects meta-analysis.

RESULTS

Twenty-seven studies were included in the meta-analysis, with 928 patients and 867 control subjects, and 32 different brain regions of interest. Subjects with schizophrenia showed significantly greater decreases over time in whole brain volume, whole brain gray matter, frontal gray and white matter, parietal white matter, and temporal white matter volume, as well as larger increases in lateral ventricular volume, than healthy control subjects. The time between baseline and follow-up magnetic resonance imaging scans ranged from 1 to 10 years. The differences between patients and control subjects in annualized percentage volume change were -.07% for whole brain volume, -.59% for whole brain gray matter, -.32% for frontal white matter, -.32% for parietal white matter, -.39% for temporal white matter, and +.36% for bilateral lateral ventricles.

CONCLUSIONS

These findings suggest that schizophrenia is associated with progressive structural brain abnormalities, affecting both gray and white matter. We found no evidence to suggest progressive medial temporal lobe involvement but did find evidence that this may be partly explained by heterogeneity between studies in patient age and illness duration. The causes and clinical correlates of these progressive brain changes should now be the focus of investigation.

What happens after the first episode? A review of progressive brain changes in chronically ill patients with schizophrenia

Numerous imaging studies have revealed structural brain changes in schizophrenia. Decreases in brain tissue are accompanied by increases in ventricle volumes and cerebrospinal fluid. Whether or not these brain changes are progressive beyond the first episode is subject to debate. To assess if progressive brain changes occur in chronically ill patients, 11 longitudinal magnetic resonance imaging and computed tomography studies were reviewed. Patients were ill for on average 10 years at their initial scan. Follow-up intervals varied between 1 and 10 years. Overall, the findings suggest continuous progressive brain tissue decreases and lateral ventricle volume increases in chronically ill patients, up to at least 20 years after their first symptoms. The extent of progressive brain tissue decrease in patients (-0.5% per year) is twice that of healthy controls (-0.2% per year). These findings are consistent with the extent of postmortem brain tissue loss in schizophrenia. Progressive volume loss seems most pronounced in the frontal and temporal (gray matter) areas. Progressive lateral ventricle volume increases are also found. More pronounced progressive brain changes in patients is associated with poor outcome, more negative symptoms, and a decline in neuropsychological performance in one or some of the studies, but not consistently so. Higher daily cumulative dose of antipsychotic medication intake is either not associated with brain volume changes or with less prominent brain volume changes. The progressive brain changes present in chronic schizophrenia may represent a continuous pathophysiological process taking place in the brains of these patients that warrants further study.

Gender related differences in clinical characteristics and hospital based resource utilization among older adults with schizophrenia

OBJECTIVE

This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period.

METHODS

This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use.

RESULTS

There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication.

CONCLUSIONS

In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders.

Broad therapeutic uses of atypical antipsychotic medications

The atypical antipsychotics have a low incidence of extrapyramidal side effects (EPS), have improved tardive dyskinesia profiles, and have a broad range of therapeutic efficacy. These agents offer important therapeutic advantages that extend beyond their initial regulatory approval in several conditions and patient groups. The use of atypical antipsychotics is most relevant in the treatment of mood disorders, where these medications are being used increasingly for acute mood stabilization and in patients who are resistant to other treatments. Similar circumstances and clinical advantages pertain to the use of atypical antipsychotics in the treatment of behavioral disturbances in patients with dementia and in the management of personality disorders-both circumstances where conventional antipsychotics were initially poorly tolerated because of EPS. The low incidence of EPS associated with atypical antipsychotics is highly beneficial in several neuropsychiatric conditions. The extent to which endocrine and metabolic dysregulations associated with atypical antipsychotics will influence antipsychotics' role remains to be determined. As therapeutic opportunities evolve and diversify, atypical antipsychotics, because of favorable adverse-effect profiles, will have enhanced patient tolerability and use in nonpsychiatric conditions.

A longitudinal study of hippocampal volume in first episode psychosis and chronic schizophrenia

Brain abnormalities have been identified in patients with schizophrenia, but what is unclear is whether these changes are progressive over the course of the disorder. In this longitudinal study, hippocampal and temporal lobe volumes were measured at two time points in 30 patients with first episode psychosis (mean follow-up interval=1.9 years, range 0.54-4.18 years) and 12 with chronic schizophrenia (mean follow-up interval=2.3 years, range 1.03-4.12 years) and compared to 26 comparison subjects (mean follow-up interval 2.2 years, range 0.86-4.18 years). Hippocampal, temporal lobe, whole-brain and intracranial volumes (ICV) were estimated from high-resolution magnetic resonance images. Only whole-brain volume showed significant loss over the follow-up interval in both patient groups. The rate of this volume loss was not different in the first episode group compared to the chronic group. There were no changes in either hippocampal or temporal lobe volumes. The negative findings for the hippocampus and temporal lobes may mean that the abnormalities in these regions are stable features of schizophrenia. Alternatively, the period before the onset of frank psychotic symptoms may be the point of greatest risk for progressive change.

Evidence for progression of brain structural abnormalities in schizophrenia: beyond the neurodevelopmental model

OBJECTIVE

Clinical, neuroimaging, neuropathological and neuropsychological evidence suggests that, in schizophrenia, there is structural and functional disturbance of the hippocampus. The purpose of this paper is to present published findings concerning the nature, timing and course of these putative disturbances of hippocampal function and the pathophysiological mechanisms involved, and to explore whether schizophrenia is a disorder of neurodevelopment, neurodegeneration or a combination of both processes.

METHOD

The available cross-sectional and longitudinal evidence for hippocampal involvement in schizophrenia is reviewed and a model of hippocampal involvement in this disorder, which derives from our own cross-sectional and longitudinal hippocampal imaging data, is described.

RESULTS

We propose a three-hit model in which an early neurodevelopmental lesion renders the hippocampus vulnerable to further insult later in life during the transition phase to active illness. The available evidence suggests that the left hippocampus is particularly vulnerable during these early stages, while further insult involving the hippocampus bilaterally occurs in those who develop a chronic form of the illness.

CONCLUSIONS

Intervention strategies should target the most vulnerable stages of the illness, in particular the transition phase to psychosis, when novel treatments may prevent the illness or ameliorate its effects.

P300 reduction and prolongation with illness duration in schizophrenia

BACKGROUND

The P300 component of the auditory event-related potential (ERP) is both reduced in amplitude and delayed in schizophrenia. P300 is prolonged and, less consistently, reduced with normal aging. Additional latency delays are observed in neurodegenerative disorders. We asked whether P300 is reduced and delayed with longer illness duration in schizophrenia, consistent with a neurodegenerative process.

METHODS

P300 amplitude and latency were recorded to infrequent auditory target stimuli from 35 men with schizophrenia (DSM-III-R) and 26 control men. Effects of current age, age of onset, and duration of illness on P300 were assessed using regression analysis.

RESULTS

P300 amplitude showed no age-related decrease in either group; however, among schizophrenic participants, P300 amplitude correlated positively with onset age and negatively with illness duration. P300 latency correlated positively with age in schizophrenic participants and also tended to increase with age in controls. Slopes of the latency-age relationships were significantly greater in schizophrenic participants than in control participants. Latency also correlated positively with illness duration but showed no relationship to onset age.

CONCLUSIONS

P300 amplitude and latency are reduced and delayed with longer illness duration in schizophrenia, consistent with a progressive pathophysiological process. Reduced P300 amplitude may also be a marker of an early onset variant of schizophrenia.

Progressive atrophy of the frontal lobes in first-episode schizophrenia: interaction with clinical course and neuroleptic treatment

OBJECTIVE

This prospective study examined the interaction of clinical course of disease and brain structure with time in schizophrenic patients.

METHOD

A total of 21 first-episode schizophrenic patients, 10 patients with other psychiatric disorders and a control group of 9 healthy volunteers had CT at first admission and at reinvestigation 5 years later.

RESULTS

At first admission all of the patients had enlarged cortical fissures and sulci compared to controls, and the duration of untreated psychosis was significantly correlated with sulcal enlargement. At reinvestigation, frontal and central brain atrophy had progressed in schizophrenic patients.

CONCLUSION

The study indicated that ongoing psychosis and lifetime dose of classical antipsychotics were the main candidates accounting for the finding of progressively disturbed brain structure during the first 5 years of schizophrenia.

Structural brain imaging in schizophrenia: a selective review

Structural neuroimaging studies have provided some of the most consistent evidence for brain abnormalities in schizophrenia. Since the initial computed tomography study by Johnstone and co-workers, which reported lateral ventricular enlargement in schizophrenia, advances in brain imaging technology have enabled further and more refined characterization of abnormal brain structure in schizophrenia in vivo. This selective review discusses the major issues and findings in structural neuroimaging studies of schizophrenia. Among these are evidence for generalized and regional brain volume abnormalities, the specificity of anatomic findings to schizophrenia and to men versus women with schizophrenia, the contribution of genetic influences, and the timing of neuroanatomic pathology in schizophrenia. The second section reviews new approaches for examining brain structure in schizophrenia and their applications to studies on the pathophysiology of schizophrenia.

Is schizophrenia a lifetime disorder of brain plasticity, growth and aging?

Chronic schizophrenia is characterized by change in the normal brain cortical structure, asymmetric reduction, and ventricular enlargement. The debate continues as to whether these anomalies occur early in development or represent an active progressive process continuing after the onset of psychosis. The case is made in the present manuscript for a continuing aberrant lifetime brain process. It is proposed that the underlying basis for the neuropathology of schizophrenia resides in the periodic activation of a defective gene or genes that determine the rate of cerebral growth. This process causes subtle cortical maldevelopment prenatally and through early childhood, is activated again during adolescent pruning of neurons, and again during the gradual aging process in the brain throughout adulthood. The case for a progressive active brain process in schizophrenia is thus presented.

Selected quantitative EEG (QEEG) and event-related potential (ERP) variables as discriminators for positive and negative schizophrenia

Heterogeneity is a major obstacle in the search for biological substrates in schizophrenia. The positive and negative distinction, even if too simplistic, may improve our understanding of underlying processes. Frontostriatal deficits have been related to negative symptoms, while dysfunction of the dominant temporal lobe appears more relevant to the generation of positive symptoms. Despite interactions between the subsystems, different neurophysiological profiles could be expected for patients predominantly affected at each of those levels. We performed discriminant analysis on 10 neurophysiological variables (hypothesis-related) in schizophrenic patients grouped by positive or negative symptoms (PANSS), obtaining a discriminant that correctly classified the sample. The function was then tested in a new sample of patients with schizophrenia, affective psychoses, and controls, classifying subjects with 78% sensitivity and 85% specificity. Our findings suggest that predominantly negative and positive schizophrenics have different neurophysiological profiles, which are consistent with the hypotheses of hypofrontality and temporal lobe dysfunction, respectively. A linear relation between discriminant scores and PANSS ratings might reflect coexisting pathologies or compensatory interactions in the mixed subgroup.

Treatment of schizophrenia: a clinical and preclinical evaluation of neuroleptic drugs

Forty years after the first clinical report on the effectiveness of chlorpromazine in psychiatric patients, neuroleptic drugs are still the most widely used drugs in the treatment of schizophrenia. Indeed, there are no other drugs which have proven to be as effective in the treatment of this severe psychiatric disorder. Yet, there are still many unresolved problems relating to neuroleptic drugs. The present review gives a comprehensive overview of our knowledge (and our lack of knowledge) with respect to the clinical and preclinical effects of neuroleptic drugs and tries to integrate this knowledge in order to identify the neuronal mechanisms underlying the therapeutic and side effects of neuroleptic drugs.