Classification of first-episode psychosis using cortical thickness: A large multicenter MRI study

Machine learning classifications of first-episode psychosis (FEP) using neuroimaging have predominantly analyzed brain volumes. Some studies examined cortical thickness, but most of them have used parcellation approaches with data from single sites, which limits claims of generalizability. To address these limitations, we conducted a large-scale, multi-site analysis of cortical thickness comparing parcellations and vertex-wise approaches. By leveraging the multi-site nature of the study, we further investigated how different demographical and site-dependent variables affected predictions. Finally, we assessed relationships between predictions and clinical variables. 428 subjects (147 females, mean age 27.14) with FEP and 448 (230 females, mean age 27.06) healthy controls were enrolled in 8 centers by the ClassiFEP group. All subjects underwent a structural MRI and were clinically assessed. Cortical thickness parcellation (68 areas) and full cortical maps (20,484 vertices) were extracted. Linear Support Vector Machine was used for classification within a repeated nested cross-validation framework. Vertex-wise thickness maps outperformed parcellation-based methods with a balanced accuracy of 66.2% and an Area Under the Curve of 72%. By stratifying our sample for MRI scanner, we increased generalizability across sites. Temporal brain areas resulted as the most influential in the classification. The predictive decision scores significantly correlated with age at onset, duration of treatment, and positive symptoms. In conclusion, although far from the threshold of clinical relevance, temporal cortical thickness proved to classify between FEP subjects and healthy individuals. The assessment of site-dependent variables permitted an increase in the across-site generalizability, thus attempting to address an important machine learning limitation.

BDNF Val66Met polymorphism is associated with aggressive behavior in schizophrenia

Brain-derived neurotrophic factor (BDNF) gene variants may potentially influence behaviour. In order to test this hypothesis, we investigated the relationship between BDNF Val66Met polymorphism and aggressive behaviour in a population of schizophrenic patients. Our results showed that increased number of BDNF Met alleles was associated with increased aggressive behaviour.

Designing a mHealth clinical decision support system for Parkinson's disease: a theoretically grounded user needs approach

Background

Despite the established evidence and theoretical advances explaining human judgments under uncertainty, developments of mobile health (mHealth) Clinical Decision Support Systems (CDSS) have not explicitly applied the psychology of decision making to the study of user needs. We report on a user needs approach to develop a prototype of a mHealth CDSS for Parkinson’s disease (PD), which is theoretically grounded in the psychological literature about expert decision making and judgement under uncertainty.

Methods

A suite of user needs studies was conducted in 4 European countries (Greece, Italy, Slovenia, the UK) prior to the development of PD_Manager, a mHealth-based CDSS designed for Parkinson’s disease, using wireless technology. Study 1 undertook Hierarchical Task Analysis (HTA) including elicitation of user needs, cognitive demands and perceived risks/benefits (ethical considerations) associated with the proposed CDSS, through structured interviews of prescribing clinicians (N = 47). Study 2 carried out computational modelling of prescribing clinicians’ (N = 12) decision strategies based on social judgment theory. Study 3 was a vignette study of prescribing clinicians’ (N = 18) willingness to change treatment based on either self-reported symptoms data, devices-generated symptoms data or combinations of both.

Results

Study 1 indicated that system development should move away from the traditional silos of ‘motor’ and ‘non-motor’ symptom evaluations and suggest that presenting data on symptoms according to goal-based domains would be the most beneficial approach, the most important being patients’ overall Quality of Life (QoL). The computational modelling in Study 2 extrapolated different factor combinations when making judgements about different questions. Study 3 indicated that the clinicians were equally likely to change the care plan based on information about the change in the patient’s condition from the patient’s self-report and the wearable devices.

Conclusions

Based on our approach, we could formulate the following principles of mHealth design: 1) enabling shared decision making between the clinician, patient and the carer; 2) flexibility that accounts for diagnostic and treatment variation among clinicians; 3) monitoring of information integration from multiple sources. Our approach highlighted the central importance of the patient-clinician relationship in clinical decision making and the relevance of theoretical as opposed to algorithm (technology)-based modelling of human judgment.

Cerebellar GABAergic correlates of cognition-mediated verbal fluency in physiology and schizophrenia

OBJECTIVE

Defective cerebellar GABAergic inhibitory control may participate to the cognitive impairments seen in SZ. We tested the prediction of a model for the relationship between cerebellar GABA concentration and the associative/executive processes required by verbal fluency in patients with schizophrenia (SZ) and matched healthy controls (HC).

METHOD

Magnetic resonance spectroscopy of GABA was performed using a 3 Tesla scanner and verbal fluency assessed by the Controlled Word (WFT) and Semantic (SFT) Fluency tests. Cerebellar GABA measurements were obtained using the MEGA-PRESS acquisition sequence. Linear correlations between cerebellar GABA levels and the WFT, SFT score were performed to test differences between correlation coefficients of SZ and HC. Quantile regressions between GABA levels and the WFT score were performed.

RESULTS

Higher cerebellar GABA concentration was associated in SZ with lower phonemic fluency and reduced number of switches among subcategories as opposed to what observed in HC (with higher cerebellar GABA associated with higher number of words and phonemic switches). GABA levels explained phonemic fluency in SZ performing above the group mean.

CONCLUSION

Studying cerebellar GABA provides a valid heuristic to explore the molecular mechanisms of SZ. This is crucial for developing pharmacological treatments to improve cognition and functional recovery in SZ.

Widespread white matter microstructural differences in schizophrenia across 4322 individuals: results from the ENIGMA Schizophrenia DTI Working Group

The regional distribution of white matter (WM) abnormalities in schizophrenia remains poorly understood, and reported disease effects on the brain vary widely between studies. In an effort to identify commonalities across studies, we perform what we believe is the first ever large-scale coordinated study of WM microstructural differences in schizophrenia. Our analysis consisted of 2359 healthy controls and 1963 schizophrenia patients from 29 independent international studies; we harmonized the processing and statistical analyses of diffusion tensor imaging (DTI) data across sites and meta-analyzed effects across studies. Significant reductions in fractional anisotropy (FA) in schizophrenia patients were widespread, and detected in 20 of 25 regions of interest within a WM skeleton representing all major WM fasciculi. Effect sizes varied by region, peaking at (d=0.42) for the entire WM skeleton, driven more by peripheral areas as opposed to the core WM where regions of interest were defined. The anterior corona radiata (d=0.40) and corpus callosum (d=0.39), specifically its body (d=0.39) and genu (d=0.37), showed greatest effects. Significant decreases, to lesser degrees, were observed in almost all regions analyzed. Larger effect sizes were observed for FA than diffusivity measures; significantly higher mean and radial diffusivity was observed for schizophrenia patients compared with controls. No significant effects of age at onset of schizophrenia or medication dosage were detected. As the largest coordinated analysis of WM differences in a psychiatric disorder to date, the present study provides a robust profile of widespread WM abnormalities in schizophrenia patients worldwide. Interactive three-dimensional visualization of the results is available at www.enigma-viewer.org.

Comparison of psychotic bipolar disorder, schizoaffective disorder, and schizophrenia: an international, multisite study

OBJECTIVE

Nosological distinctions among schizoaffective disorder (SA), bipolar I disorder with psychotic features (BDp), and schizophrenia (SZ) remain unresolved.

METHOD

We compared 2269 subjects with psychotic features in DSM-IV-TR diagnoses (1435 BDp, 463 SZ, 371 SA) from 8 collaborating international sites, by 12 sociodemographic and clinical measures, all between diagnostic pairs.

RESULTS

In bivariate comparisons, SA was consistently intermediate between BDp and SZ for 11/12 features (except onset stressors), and SZ vs. BDp differed in all 12 factors. SA differed from both BDp and SZ in 9/12 factors: SA and BDp were similar in education and suicidal ideation or acts; SA and SZ were similar in education, onset stressors, and substance abuse. Meta-analytic comparisons of diagnostic pairs for 10 categorical factors indicated similar differences of SA from both SZ and BDp. Multivariate modeling indicated significantly independent differences between BDp and SZ (8 factors), SA vs. SZ (5), and BDp vs. SA (3). Measurement variance was similar for all diagnoses.

CONCLUSION

SA was consistently intermediate between BDp and SZ. The three diagnostic groups ranked: BDp > SA > SZ related to lesser morbidity or disability. The findings are not consistent with a dyadic Kraepelinian categorization, although the considerable overlap among the three DSM-IV diagnostic groups indicates uncertain boundaries if they represent distinct disorders.

Brain structure, cognition and negative symptoms in schizophrenia are associated with serum levels of polysialic acid-modified NCAM

The neural cell adhesion molecule (NCAM) is a glycoprotein implicated in cell-cell adhesion, neurite outgrowth and synaptic plasticity. Polysialic acid (polySia) is mainly attached to NCAM (polySia-NCAM) and has an essential role in regulating NCAM-dependent developmental processes that require plasticity, that is, cell migration, axon guidance and synapse formation. Post-mortem and genetic evidence suggests that dysregulation of polySia-NCAM is involved in schizophrenia (SZ). We enrolled 45 patients diagnosed with SZ and 45 healthy individuals who were submitted to polySia-NCAM peripheral quantification, cognitive and psychopathological assessment and structural neuroimaging (brain volumes and diffusion tensor imaging). PolySia-NCAM serum levels were increased in SZ patients, independently of antipsychotic treatment, and were associated with negative symptoms, blunted affect and declarative memory impairment. The increased polySia-NCAM levels were associated with decreased volume in the left prefrontal cortex, namely Brodmann area 46, in patients and increased volume in the same brain area of healthy individuals. As this brain region is involved in the pathophysiology of SZ and its associated phenomenology, the data indicate that polySia-NCAM deserves further scrutiny because of its possible role in early neurodevelopmental mechanisms of the disorder.

Neuropsychiatric disease relevance of circulating anti-NMDA receptor autoantibodies depends on blood-brain barrier integrity

In 2007, a multifaceted syndrome, associated with anti-NMDA receptor autoantibodies (NMDAR-AB) of immunoglobulin-G isotype, has been described, which variably consists of psychosis, epilepsy, cognitive decline and extrapyramidal symptoms. Prevalence and significance of NMDAR-AB in complex neuropsychiatric disease versus health, however, have remained unclear. We tested sera of 2817 subjects (1325 healthy, 1081 schizophrenic, 263 Parkinson and 148 affective-disorder subjects) for presence of NMDAR-AB, conducted a genome-wide genetic association study, comparing AB carriers versus non-carriers, and assessed their influenza AB status. For mechanistic insight and documentation of AB functionality, in vivo experiments involving mice with deficient blood-brain barrier (ApoE(-/-)) and in vitro endocytosis assays in primary cortical neurons were performed. In 10.5% of subjects, NMDAR-AB (NR1 subunit) of any immunoglobulin isotype were detected, with no difference in seroprevalence, titer or in vitro functionality between patients and healthy controls. Administration of extracted human serum to mice influenced basal and MK-801-induced activity in the open field only in ApoE(-/-) mice injected with NMDAR-AB-positive serum but not in respective controls. Seropositive schizophrenic patients with a history of neurotrauma or birth complications, indicating an at least temporarily compromised blood-brain barrier, had more neurological abnormalities than seronegative patients with comparable history. A common genetic variant (rs524991, P=6.15E-08) as well as past influenza A (P=0.024) or B (P=0.006) infection were identified as predisposing factors for NMDAR-AB seropositivity. The >10% overall seroprevalence of NMDAR-AB of both healthy individuals and patients is unexpectedly high. Clinical significance, however, apparently depends on association with past or present perturbations of blood-brain barrier function.

Polygenic determinants of white matter volume derived from GWAS lack reproducibility in a replicate sample

A recent publication reported an exciting polygenic effect of schizophrenia (SCZ) risk variants, identified by a large genome-wide association study (GWAS), on total brain and white matter volumes in schizophrenic patients and, even more prominently, in healthy subjects. The aim of the present work was to replicate and then potentially extend these findings. According to the original publication, polygenic risk scores-using single nucleotide polymorphism (SNP) information of SCZ GWAS-(polygenic SCZ risk scores; PSS) were calculated in 122 healthy subjects, enrolled in a structural magnetic resonance imaging (MRI) study. These scores were computed based on P-values and odds ratios available through the Psychiatric GWAS Consortium. In addition, polygenic white matter scores (PWM) were calculated, using the respective SNP subset in the original publication. None of the polygenic scores, either PSS or PWM, were found to be associated with total brain, white matter or gray matter volume in our replicate sample. Minor differences between the original and the present study that might have contributed to lack of reproducibility (but unlikely explain it fully), are number of subjects, ethnicity, age distribution, array technology, SNP imputation quality and MRI scanner type. In contrast to the original publication, our results do not reveal the slightest signal of association of the described sets of GWAS-identified SCZ risk variants with brain volumes in adults. Caution is indicated in interpreting studies building on polygenic risk scores without replication sample.

Meta-analysis of 74,046 individuals identifies 11 new susceptibility loci for Alzheimer's disease

Eleven susceptibility loci for late-onset Alzheimer's disease (LOAD) were identified by previous studies; however, a large portion of the genetic risk for this disease remains unexplained. We conducted a large, two-stage meta-analysis of genome-wide association studies (GWAS) in individuals of European ancestry. In stage 1, we used genotyped and imputed data (7,055,881 SNPs) to perform meta-analysis on 4 previously published GWAS data sets consisting of 17,008 Alzheimer's disease cases and 37,154 controls. In stage 2, 11,632 SNPs were genotyped and tested for association in an independent set of 8,572 Alzheimer's disease cases and 11,312 controls. In addition to the APOE locus (encoding apolipoprotein E), 19 loci reached genome-wide significance (P < 5 × 10(-8)) in the combined stage 1 and stage 2 analysis, of which 11 are newly associated with Alzheimer's disease.

Effects of hemochromatosis and transferrin gene mutations on peripheral iron dyshomeostasis in mild cognitive impairment and Alzheimer's and Parkinson's diseases

Deregulation of iron metabolism has been observed in patients with neurodegenerative diseases. We have carried out a molecular analysis investigating the interaction between iron specific gene variants [transferrin (TF, P589S), hemochromatosis (HFE) C282Y and (H63D)], iron biochemical variables [iron, Tf, ceruloplasmin (Cp), Cp:Tf ratio and % of Tf saturation (% Tf-sat)] and apolipoprotein E (APOE) gene variants in 139 Alzheimer's disease (AD), 27 Mild Cognitive Impairment (MCI), 78 Parkinson's disease (PD) patients and 139 healthy controls to investigate mechanisms of iron regulation or toxicity. No difference in genetic variant distributions between patients and controls was found in our Italian sample, but the stratification for the APOEε4 allele revealed that among the APOEε4 carriers was higher the frequency of those carriers of at least a mutated TF P589S allele. Decreased Tf in both AD and MCI and increased Cp:Tf ratio in AD vs. controls were detected. A multinomial logistic regression model revealed that increased iron and Cp:Tf ratio and being man instead of woman increased the risk of having PD, that increased values of Cp:Tf ratio corresponded to a 4-fold increase of the relative risk of having MCI, while higher Cp levels were protective for PD and MCI. Our study has some limitations: the small size of the samples, one ethnic group considered, the rarity of some alleles which prevent the statistical power of some genetic analysis. Even though they need confirmation in larger cohorts, our data suggest the hypothesis that deregulation of iron metabolism, in addition to other factors, has some effect on the PD disease risk.

The structure of the corpus callosum in obsessive compulsive disorder

Abnormal brain connectivity has recently been reported in obsessive compulsive disorder (OCD). However, structural differences in the corpus callosum (CC), the primary structure connecting the two hemispheres, have not been extensively studied. In this case-control study, we recruited 30 patients with OCD and 30 healthy control subjects carefully matched for age, sex and handedness. Combining surface-based mesh-modeling and voxel-based morphometry (VBM), we compared callosal thickness and white matter (WM) density in patients and controls. We investigated associations between callosal structure and cortical gray matter (GM) density, and we related CC measures to neuropsychological performance in OCD. OCD patients showed small anterior and posterior callosal regions compared to healthy control subjects. In the OCD group, anterior callosal thickness was positively correlated with GM density of the right mid-dorso-lateral prefrontal (BA 9/46) area, while posterior callosal thickness was positively correlated with GM density in the left supramarginal gyrus (BA 40). Moreover, posterior callosal WM density was positively correlated with verbal memory, visuo-spatial memory, verbal fluency, and visuo-spatial reasoning performances. Callosal attributes were related to GM density in cortical areas innervated by the CC, and were also related to performance in cognitive domains impaired in the disorder. The CC may therefore be integrally involved in OCD.

The potential prognostic role of cardiovascular autonomic failure in α-synucleinopathies

Cardiovascular autonomic failure is the second most common dysautonomic feature of α-synucleinopathies and has significant impact on daily activities and quality of life. Here we provide a systematic review of cardiovascular autonomic failure in α-synucleinopathies, emphasizing its impact on cognitive functions and disease outcomes. Articles spanning the period between January 1985 and April 2012 were identified from the PubMed database using a keyword-based search. Epidemiological studies highlight the negative prognostic effect of cardiovascular autonomic failure on cardiovascular and cerebrovascular outcomes and overall mortality in all α-synucleinopathies. Altered cerebral perfusion, vascular pressure stress, and related disruption of the blood-brain barrier may also contribute to the white matter hyperintensities and cognitive dysfunction frequently found in patients affected by neurocardiovascular instability. These findings support the hypothesis that cardiovascular autonomic failure may play a negative prognostic role in α-synucleinopathies and suggest that precocious screening and therapeutic management of cardiovascular autonomic failure may positively impact disease course.

WITHDRAWN: The structure of the corpus callosum in obsessive compulsive disorder

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APOE and Alzheimer disease: a major gene with semi-dominant inheritance

Apolipoprotein E (APOE) dependent lifetime risks (LTRs) for Alzheimer Disease (AD) are currently not accurately known and odds ratios alone are insufficient to assess these risks. We calculated AD LTR in 7351 cases and 10 132 controls from Caucasian ancestry using Rochester (USA) incidence data. At the age of 85 the LTR of AD without reference to APOE genotype was 11% in males and 14% in females. At the same age, this risk ranged from 51% for APOE44 male carriers to 60% for APOE44 female carriers, and from 23% for APOE34 male carriers to 30% for APOE34 female carriers, consistent with semi-dominant inheritance of a moderately penetrant gene. Using PAQUID (France) incidence data, estimates were globally similar except that at age 85 the LTRs reached 68 and 35% for APOE 44 and APOE 34 female carriers, respectively. These risks are more similar to those of major genes in Mendelian diseases, such as BRCA1 in breast cancer, than those of low-risk common alleles identified by recent GWAS in complex diseases. In addition, stratification of our data by age groups clearly demonstrates that APOE4 is a risk factor not only for late-onset but for early-onset AD as well. Together, these results urge a reappraisal of the impact of APOE in Alzheimer disease.

Overcoming endocrine resistance in breast cancer

Approximately 70% of breast cancers express the estrogen receptor (ER) and endocrine therapy is the most important component of systemic therapy for hormone-responsive breast cancer. Unfortunately, endocrine-resistant ER-positive disease represents up to one-quarter of all breast cancers and a number of different mechanisms have been implicated in endocrine resistance, either intrinsic, occurring de novo at the initial exposure to endocrine therapies or acquired, occurring after an initial response to therapy. In the present work a number of molecular mechanisms accounting for intrinsic and acquired resistance to hormonal therapies have been reviewed and the most promising strategies to overcome endocrine resistance have been highlighted.

When, where, and how the corpus callosum changes in MCI and AD: a multimodal MRI study

BACKGROUND

The corpus callosum (CC) has been shown to be susceptible to atrophy in Alzheimer disease (AD) as a correlate of wallerian degeneration or retrogenesis. However, when and where these 2 mechanisms intervene is still unclear.

METHODS

In 3 memory clinics, we recruited 38 patients with amnestic mild cognitive impairment (MCI), 38 patients with mild AD, and 40 healthy controls (HC). Combining voxel-based morphometry and diffusion tensor imaging, we investigated CC white matter (WM) density and fractional anisotropy (FA), radial diffusivity (DR), and axial diffusivity (DA).

RESULTS

Compared with HC, patients with amnestic MCI showed reduced WM density in the anterior CC subregion; however, FA, DR, and DA did not differ between the 2 groups. Significant changes were found in patients with mild AD compared with HC in the anterior and posterior CC regions. These differences were evident in both voxel-based morphometry and diffusion tensor imaging analyses. Specifically, we found reduced callosal WM density in the genu, posterior body, and splenium; decreased FA and increased DR in the anterior CC subregion; and increased DA, with no difference in the FA, in the posterior CC subregion.

CONCLUSIONS

Callosal changes are already present in patients with amnestic mild cognitive impairment (MCI) and mild Alzheimer disease (AD). The precocious involvement of the anterior callosal subregion in amnestic MCI extends to posterior regions in mild AD. Two different mechanisms might contribute to the white matter changes in mild AD: wallerian degeneration in posterior subregions of the corpus callosum (suggested by increased axial diffusivity without fractional anisotropy modifications) and a retrogenesis process in the anterior callosal subregions (suggested by increased radial diffusivity without axial diffusivity modifications).

Met158 variant of the catechol-O-methyltransferase genotype is associated with thicker cortex in adult brain

Cortical thickness has been proposed as a new promising brain imaging endophenotype in elucidating the nature of gene-brain relationships. Here, we define the morphological impact of the Val(158)Met polymorphism in the catechol-O-methyltransferase (COMT) gene on human brain anatomy. One hundred and forty-nine adult healthy subjects (mean age: 40.7+/-16.1; ranging from 19 to 76 years) were genotyped (38 in the homozygous Val(158) group; 80 in the Val(158)Met group; 31 in the homozygous Met(158) group) for the COMT polymorphism and underwent morphological examination. Surface-based analysis of the cortical mantle showed that the COMT genotype was associated with structural differences in the right superior temporal sulcus and inferior prefrontal sulcus, where the individuals carrying the Met(158) allele had a thicker cortex with respect to their Val(158) counterparts. Our study extends the previous evidence found on pediatric population to the adult population, demonstrating that the higher synaptic dopamine levels associated with the presence of the Met(158) allele may influence neuronal architecture in brain structures important for executive and emotional processing.

The evaluation of anosognosia in stroke patients

BACKGROUND

Anosognosia in stroke patients showed a relevant detrimental effect on the rehabilitation course and patients' quality of life, especially in those with brain injury. Although a number of reliable scales for the assessment of anosognosia in stroke and traumatic brain injury have been developed, at present no single measure fully explores the multifaceted nature of the phenomenon.

METHOD

A PubMed search with appropriate terms was carried out in order to critically review the issue.

RESULTS

The main dimensions to consider in the investigation of anosognosia in brain-injured patients are (a) awareness of deficit and related functional implications, (b) modality specificity, (c) causal attribution, (d) expectations of recovery, (e) implicit knowledge and (f) differential diagnosis with psychological denial. Time elapsed from stroke, aetiology, laterality, aphasia and clinical complications may influence all these characteristics and must be taken into consideration. Finally, an adequate association of the anosognosia evaluation with other neuropsychological and behavioural aspects is relevant for a modern holistic approach to the patient.

CONCLUSIONS

This review is meant to stimulate the development of a new comprehensive assessment procedure for anosognosia in brain injury and particularly in stroke, in order to catch the multidimensionality of the phenomenon and to shape rehabilitation programmes suitable to the specific clinical features of every single patient.

Anosognosia for hemiplegia after stroke is a multifaceted phenomenon: a systematic review of the literature

Anosognosia is the lack of awareness or the underestimation of a specific deficit in sensory, perceptual, motor, affective or cognitive functioning due to a brain lesion. This self-awareness deficit has been studied mainly in stroke hemiplegic patients, who may report no deficit, overestimate their abilities or deny that they are unable to move a paretic limb. In this review, a detailed search of the literature was conducted to illustrate clinical manifestations, pathogenetic models, diagnostic procedures and unresolved issues in anosognosia for motor impairment after stroke. English and French language papers spanning the period January 1990-January 2007 were selected using PubMed Services and utilizing research words stroke, anosognosia, awareness, denial, unawareness, hemiplegia. Papers reporting sign-based definitions, neurological and neuropsychological data and the results of clinical trials or historical trends in diagnosis were chosen. As a result, a very complex and multifaceted phenomenon emerges, whose variable behavioural manifestations often produce uncertainties in conceptual definitions and diagnostic procedures. Although a number of questionnaires and diagnostic methods have been developed to assess anosognosia following stroke in the last 30 years, they are often limited by insufficient discriminative power or a narrow focus on specific deficits. As a consequence, epidemiological estimates are variable and incidence rates have ranged from 7 to 77% in stroke. In addition, the pathogenesis of anosognosia is widely debated. The most recent neuropsychological models have suggested a defect in the feedforward system, while neuro-anatomical studies have consistently reported on the involvement of the right cerebral hemisphere, particularly the prefrontal and parieto-temporal cortex, as well as insula and thalamus. We highlight the need for a multidimensional assessment procedure and suggest some potentially productive directions for future research about unawareness of illness.

The etiology of poststroke depression: a review of the literature and a new hypothesis involving inflammatory cytokines

Although poststroke depression is unlikely to represent a single disorder and numerous etiologies for different kinds of poststroke depression will likely emerge as the result of future research, we believe that a number of poststroke depressive disorders are likely to be the result of specific changes in brain pathology and neurophysiology. Nevertheless, there are relatively few hypotheses about the pathophysiology of poststroke depression. This paper, therefore, proposes a new hypothesis for poststroke depression involving increased production of proinflammatory cytokines resulting from brain ischemia in cerebral areas linked to the pathogenesis of mood disorders. This paper reviews the evidence supporting the hypothesis that proinflammatory cytokines are involved in the occurrence of stroke as well as mood disorders linked to the brain damage. The increased production of proinflammatory cytokines such as IL-1beta, TNF-alpha or IL-18 resulting from stroke may lead to an amplification of the inflammatory process, particularly in limbic areas, and widespread activation of indoleamine 2,3-dioxygenase (IDO) and subsequently to depletion of serotonin in paralimbic regions such as the ventral lateral frontal cortex, polar temporal cortex and basal ganglia. The resultant physiological dysfunction may lead to poststroke depression. Future investigations may explore this hypothesis through more extensive studies on the role of proinflammatory cytokines, such as IL-1beta, TNF-alpha or even IL-18, in patients with poststroke depression.

Delusion symptoms are associated with ApoE epsilon4 allelic variant at the early stage of Alzheimer's disease with late onset

Alzheimer's disease (AD) is a neurodegenerative disorder with mixed cognitive and behavioural clinical manifestations. The possession of apolipoprotein-E (ApoE) epsilon4 allelic variant is one of the most important risk factors for developing late-onset AD (LOAD). In this study we analysed the relationship between the entire range of behavioural symptoms, cognitive deficit, and sociodemographic characteristics and ApoE epsilon4 allele possession with multivariate logistic regression models in LOAD patients. Patients included (n = 171) were consecutively admitted in a memory clinic for the first diagnostic visit. Levels of behaviour and cognition within the last month were assessed by the Neuropsychiatric Inventory and Mini Mental State Examination. Presence of clinically significant psychosis, delusions and hallucinations at the early stage of the illness, from the onset to the first visit, was measured with diagnostic criteria. ApoE epsilon4 allele possession was associated with increased levels of delusions within the last month from the first visit (OR 1.23; 95% CI 1.01-1.50; P < 0.05) and with the presence of categorical delusions at the early stage until the first visit (OR 3.11; 95% CI 1.21-8.01; P < 0.02). In this study, which considers the entire range of behavioural expressions in LOAD patients at the early stage of the illness, the relationship between behaviour and ApoE epsilon4 allele is confirmed for delusions only.

Prefrontal blood flow dysregulation in drug naive ADHD children without structural abnormalities

Recent studies suggest a role for prefrontal cortex abnormalities in the pathogenesis of attention deficit/hyperactivity disorder (ADHD). We evaluated young drug-naive ADHD outpatients without MRI structural abnormalities to detect prefrontal cortex regional cerebral blood flow (rCBF) functional dysregulation; correlation between age and rCBF; and correlation between symptoms profile and rCBF. Functional brain activities (i.e. rCBF), neuropsychological attention performance and symptom profile were evaluated respectively by single photon emission computerized tomography (SPECT) scan, Stroop Test and the Child Attention Problem Rating Scale. There was a decreased rCBF in the left dorso lateral prefrontal cortex (DLPFC) compared to the right DLPFC of the subjects. In addition, there were positive correlations between age and relative rCBFs of the dorsolateral and orbital prefrontal cortex, and negative correlations between age and absolute rCBFs of the dorsolateral and orbital prefrontal cortex. Finally, higher levels of right relative rCBF and lower levels of left relative rCBF were predictors of higher severity of clinical symptom expression and neuropsychological attention impairment. The results of this study highlight the role of the DLPFC blood flow impairment in the pathogenesis of ADHD even in young subjects without structural abnormalities.

Alexithymic features in stroke: effects of laterality and gender

OBJECTIVE

Stroke patients suffer from a high rate of behavioral disorders, and the laterality of the lesion may affect the expression of emotional disturbances. This study tested the hypothesis that stroke patients with a lesion in the right hemisphere are at high risk of developing alexithymic features.

METHODS

Forty-eight patients were interviewed with the Structured Clinical Interview for DSM-IV (patient edition), the Mini-Mental State Examination, the State-Trait Anxiety Inventory (state form), the Beck Depression Inventory, and the Toronto Alexithymia Scale (20-item version). Alexithymic differences between stroke patients with a lesion in the right hemisphere and those with a lesion in the left hemisphere were computed by analysis of covariance, using scores on the Mini-Mental State Examination, Beck Depression Inventory (psychic subscore), and State-Trait Anxiety Inventory as covariates and the score on the Toronto Alexithymia Scale as the dependent variable. A multivariate analysis of covariance and a series of follow-up analyses of covariance with the same covariates were used to discriminate differences in subscores on the Toronto Alexithymia Scale. An exploratory analysis of covariance was also performed to determine the effect of gender on alexithymic features in both groups of stroke patients.

RESULTS

The 21 stroke patients with a lesion in the right hemisphere were more alexithymic than the 27 patients with a lesion in the left hemisphere. This evidence was strengthened by the categorical analysis: 48% of the patients with a right-hemisphere lesion had alexithymia, compared with 22% of patients with a left-hemisphere lesion. Univariate analyses of covariance showed significant differences between the two groups in difficulty identifying feelings and difficulty describing feelings, but not in externally oriented thinking. The last exploratory analysis of covariance suggested that gender may influence alexithymic features.

CONCLUSIONS

This study provides direct evidence that alexithymia, and more specifically difficulty identifying feelings and difficulty describing feelings, is more common in stroke patients with a right-hemisphere lesion than in those with a left-hemisphere lesion. It also provides preliminary evidence that gender may affect alexithymic expression.

Season of birth, gender and negative symptoms in schizophrenia

The aim of this study was to ascertain whether the symptom profile distinguishes between schizophrenic patients born in the winter and early spring and those born in other seasons. The sample consisted of 204 patients with a DSM-III-R diagnosis of schizophrenia who had been hospitalized for acute psychotic decompensation. Symptom ratings were based on the Positive and Negative Syndrome Scale (PANSS). The use of demographic and anamnestic data as dependent variables did not detect any season-of-birth effect. In contrast, clear gender-specific differences emerged from the comparison focusing on symptom dimensions and clinical subtype. Female patients born in the winter and early spring had higher scores on the PANSS negative scale and anergia factor whereas male patients born in other seasons had higher scores on the PANSS anergia factor. In addition, we found a gender-specific association between season of birth and clinical subtype. Most paranoid female patients were born in the non-winter months whereas, among men, a slightly higher percentage of paranoid patients were born in winter months. These results suggest that gender plays a role in modulating the effect of the season of birth on symptoms of schizophrenia.

Association study of a promoter polymorphism of UFD1L gene with schizophrenia

Schizophrenia or schizoaffective disorders are often found in patients affected by DiGeorge/velo-cardio-facial syndrome (DGS/VCFS) as a result of hemizygosity of chromosome 22q11.2. We evaluated the UFD1L gene, mapping within the DGS/VCFS region, as a potential candidate for schizophrenia susceptibility. UFD1L encodes for the ubiquitin fusion degradation 1 protein, which is expressed in the medial telencephalon during mouse development. Using case control, simplex families (trios), and functional studies, we provided evidence for association between schizophrenia and a single nucleotide functional polymorphism, -277A/G, located within the noncoding region upstream the first exon of the UFD1L gene. The results are supportive of UFD1L involvement in the neurodevelopmental origin of schizophrenia and contribute in delineating etiological and pathogenetic mechanism of the schizophrenia subtype related to 22q11.2 deletion syndrome.

Fluoxetine decreases concentrations of 3 alpha, 5 alpha-tetrahydrodeoxycorticosterone (THDOC) in major depression

There is evidence for a differential alteration in the concentrations of 3 alpha-reduced neuroactive steroids in major depression. Because it has been suggested that fluoxetine may shift the activity of the 3 alpha-hydroxysteroid oxidoreductase towards the reductive direction, treatment of major depression may be accompanied by a further increase in plasma 3 alpha, 5 alpha-tetrahydrodeoxycorticosterone (THDOC) concentration. We studied eight male depressed patients before and after treatment with fluoxetine and compared them to healthy age-matched control subjects. Blood samples were quantified for 3 alpha, 5 alpha-tetrahydroprogesterone, 3 alpha,5 beta-tetrahydroprogesterone (THP) and THDOC by means of a highly sensitive combined gas chromatography/mass spectrometry analysis. Compared to control subjects, concentrations of THDOC were higher in depressed patients and decreased after fluoxetine treatment. In contrast, THP concentrations were lower in depressed patients and increased after fluoxetine treatment. Our results give further evidence for a disequilibrium of 3 alpha-reduced neuroactive steroids in major depression, which is normalized by treatment with fluoxetine.

Concentrations of 3 alpha-reduced neuroactive steroids and their precursors in plasma of patients with major depression and after clinical recovery

BACKGROUND

There is preclinical and clinical evidence that plasma concentrations of 3 alpha-hydroxy-5 alpha-pregnan-20-one (3 alpha,5 alpha-tetrahydroprogesterone; 3 alpha,5 alpha-THP), a neuroactive steroid that is a positive allosteric modulator of the GABAA receptor, are altered in depression and normalize as a result of antidepressant treatment. However, no data are available on the concentrations of 3 alpha,21-dihydroxy-5 alpha-pregnan-20-one (3 alpha,5 alpha-tetrahydrodeoxycorticosterone; 3 alpha,5 alpha-THDOC), another GABA ergic neuroactive steroid, in depression.

METHODS

We studied nine depressed patients before and after treatment with various antidepressants and compared them to healthy matched control subjects. Blood samples were quantified by means of a highly sensitive combined gas chromatography/mass spectrometry analysis.

RESULTS

Compared to control subjects, plasma concentrations of 3 alpha,5 alpha-THDOC and its precursor 5 alpha-dihydrodeoxycorticosterone (5 alpha-DHDOC) were increased in depressed patients and were not significantly influenced by antidepressant treatment. However, 3 alpha,5 alpha-THP plasma concentrations were decreased in depression and clinically effective antidepressant treatment was accompanied by an increase of 3 alpha,5 alpha-THP concentrations in these patients.

CONCLUSIONS

Our results provide the first evidence for a differential alteration in the plasma concentrations of the 3 alpha-reduced neuroactive steroids 3 alpha,5 alpha-THDOC and 3 alpha,5 alpha-THP in major depression, which is only partially reversed by successful antidepressant treatment.

Neuroactive steroid concentrations following metyrapone administration in depressed patients and healthy volunteers

BACKGROUND

There is evidence that treatment with the 11 beta-hydroxylase inhibitor metyrapone may represent an alternative treatment strategy in major depression. As a consequence of inhibition of cortisol synthesis the overdrive of corticotropin leads to an accumulation of precursor steroids. However, the effects of metyrapone on the concentrations of endogenous neuroactive steroids that modulate ion channels, e.g., the GABAA receptor, have not yet been studied systematically.

METHODS

Therefore, we quantified the concentrations of an array of neuroactive steroids following administration of 1.5 g metyrapone before and after pretreatment with 1 mg dexamethasone in 19 patients suffering from severe depression in comparison to 13 healthy controls by means of a highly sensitive gas chromatography/mass spectrometry analysis.

RESULTS

The administration of metyrapone induced a pronounced increase in all neuroactive steroids studied both in patients and controls that was prevented by dexamethasone pretreatment.

CONCLUSIONS

Thus, the psychotropic properties of endogenous neuroactive steroids may contribute to the antidepressant properties of metyrapone in the treatment of major depression.

Effects of antidepressant treatment on neuroactive steroids in major depression

OBJECTIVE

There is evidence from animal studies that fluoxetine may enhance the concentrations of neuroactive steroids. Therefore, the authors investigated whether clinically effective treatment with antidepressants may alter the concentrations of neuroactive steroids in patients suffering from a major depressive episode.

METHOD

In the first study, eight drug-naive outpatients with major depression were studied during treatment with fluoxetine. In a complementary study, 11 inpatients with major depression were studied during a severe depressive episode and after recovery following treatment with different antidepressants. Plasma samples were quantified for neuroactive steroids by means of a highly sensitive and specific combined gas chromatography/mass spectrometry analysis.

RESULTS

During depression, there was a significant decrease in 3 alpha, 5 alpha-tetrahydroprogesterone (3 alpha, 5 alpha-THP) and 3 alpha, 5 beta-THP concentrations, both of which are positive modulators of the gamma-aminobutyric acidA receptor, and a concomitant increase in 3 beta, 5 alpha-THP levels. This dysequilibrium of neuroactive steroids could be corrected by treatment with different antidepressants.

CONCLUSIONS

These results provide the first clinical evidence of a possible role of neuroactive steroids in successful antidepressant therapy.

Psychiatric symptoms in male cannabis users not using other illicit drugs

AIM

To assess the prevalence of DSM-III-R axes I and II disorders and the severity of psychiatric symptoms in cannabis users who did not use other illicit drugs.

DESIGN

Cross-sectional psychiatric examination of subjects with different patterns of cannabis use: cannabis dependence, abuse and occasional use.

PARTICIPANTS

One hundred and thirty-three cannabis users identified through random urine testing of draftees to the Italian army and interviewed after 2-5 days of abstinence from drug use.

MEASUREMENTS

The subjects completed the Beck Depression Inventory, the Spielberger State-Trait Anxiety Index and the 20-item revised Toronto Alexithymia Scale and were then interviewed with the Structured Clinical Interview for DSM-III-R.

FINDINGS

The prevalence of co-morbid psychiatric disorders varied with the pattern of cannabis use: 83% of subjects with DSM-III-R cannabis dependence, 46% of those with DSM-III-R cannabis abuse and 29% of occasional users received at least one DSM-III-R psychiatric diagnosis. The severity of depressive, anxious and alexithymic symptoms increased progressively with the degree of involvement with cannabis.

CONCLUSIONS

In this sample of young men, the risk of associated psychiatric disabilities varied with the pattern of cannabis use. Chronic use of cannabis was associated with a high prevalence of co-morbid psychiatric disorders.

Non-verbal behaviour deficits in schizophrenia: an ethological study of drug-free patients

The aims of this study were (i) to define the dimensions of non-verbal behaviour which distinguish between schizophrenic patients and control subjects and (ii) to examine the relationship between patients' non-verbal behaviour and clinical symptoms. The non-verbal behaviour of 28 drug-free patients with schizophrenia according to Research Diagnostic Criteria (RDC) and 25 control subjects was videotaped during interviews and scored according to an ethological scoring system. Patients' symptoms were rated on the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms and the Brief Psychiatric Rating Scale. As a group, schizophrenic patients showed a global restriction of non-verbal expressiveness, as indicated by their lower scores on prosocial behaviour, gesture and conflict. However, some patients had normal ethological profiles. Non-verbal behaviour was largely independent of negative and positive symptoms. Deficits in non-verbal behaviour may play a role in determining or aggravating dysfunctional patterns of relating in schizophrenia. Ethological analysis provides further support for the model that conceptualizes positive symptoms, negative symptoms and disorders of social relationships as three separate dimensions of the schizophrenic syndrome.

Patients with deficit, nondeficit, and negative symptom schizophrenia: do they differ during episodes of acute psychotic decompensation?

The aims of this study were (1) to test the hypothesis that the clinical profiles of deficit, nondeficit, and negative symptom patients are difficult to distinguish during episodes of acute psychotic decompensation; and (2) to compare these groups of schizophrenic patients in terms of sociodemographic and anamnestic variables. Patients admitted for acute psychotic decompensation were retrospectively diagnosed as having deficit (N = 18) or nondeficit (N = 40) forms of schizophrenia and their symptom profiles were evaluated cross-sectionally by using various rating scales (SAPS, SANS, and PANSS). As a whole, nondeficit patients were clearly differentiated from deficit patients by lower severity of negative symptoms. However, the subgroup (N = 24) of nondeficit patients with prominent negative symptoms that were secondary and/or nonenduring showed a symptom profile largely overlapping with that of deficit patients. Attentional impairment was the only measure distinguishing deficit and negative symptom patients. As for trait variables, deficit patients had lower education than the other two groups and, among male subjects, there was a higher percentage of left-handers in the deficit group than in the negative symptom subgroup. These results confirm the importance of diagnosing the deficit syndrome during periods of clinical stability in order to avoid the risk of misclassifying negative symptom patients into the deficit group.

Paranoid/belligerence and neuroleptic dosage in newly admitted schizophrenic patients

The aim of this study was to determine if the severity of paranoid/belligerence was a major determinant of neuroleptic dosage in newly admitted patients with acute or exacerbated schizophrenia. Two clinical psychiatrists, who had no clinical responsibility for drug treatment and were blind to neuroleptic dosage regimens, jointly interviewed 155 patients who were cooperative enough to be carefully interviewed with the Structured Clinical Interview for the DSM-III-R, Positive and Negative Syndrome Scale (PANSS) Edition. The large majority of the patients were receiving moderate dosages of neuroleptics (mean peak dosage: 500 mg/day of chlorpromazine equivalents). There was a positive correlation between the score on the PANSS paranoid/belligerence cluster and the daily dosage of neuroleptic treatment. Splitting the sample by gender, the correlations remained highly significant. In a multivariate analysis controlling for the effects of other clinical variables, paranoid/belligerence and gender emerged as significant predictors of neuroleptic dosage. Clinicians prescribed lower doses of neuroleptics for female patients and higher doses for patients with higher ratings on the PANSS paranoid/belligerence cluster. These findings suggest that clinicians' strategy of increasing neuroleptic dosage at the manifestation of hostility is not limited to assaultive or uncooperative schizophrenic patients who are on very high dosages of neuroleptics.

Marked decrease of plasma neuroactive steroids during alcohol withdrawal

The neuroactive steroids allopregnanolone (ALLO) and allotet-rahydrodeoxycorticosterone (THDOC) are the most potent endogens positive modulators of gamma-aminobutyric acid (GABA) on GABAA receptors, a receptor system presumably responsible for some behavioral responses to alcohol withdrawal. In a group of nine alcoholic subjects, the levels of plasma ALLO and THDOC were markedly lower than those of control subjects during the early withdrawal phase (day 4 and 5), when anxiety and depression scores were higher. In contrast ALLO and THDOC plasma levels did not differ from those of control subjects during the late withdrawal phase when anxiety and depression scores were low. These results suggest that the decrease of neuroactive steroid biosynthesis may contribute to the withdrawal symptoms.

Symptom profile, Axis II comorbidity and suicidal behaviour in young males with DSM-III-R depressive illnesses

We assessed the descriptive validity of DSM-III-R major depression (MDD), dysthymia (DD) and adjustment disorder with depressed mood (ADDM) by comparing the clinical profiles of 176 young male patients. The severity of depression increased progressively across the three diagnostic groups (ADDM < DD < MDD). Symptom presentation did not distinguish clearly between the diagnostic groups, even though somatic symptoms were more frequent among MDD patients. The prevalence of personality disorders was much higher (43%) among DD patients than among MDD (22%) and ADDM (15%) patients. The lifetime prevalence of suicide attempts differed in the three diagnostic groups (MDD 27%, DD 17%, ADDM 4%). Assessment of Axis II comorbidity and suicidal behavior can improve the diagnostic distinction between these DSM-III-R depressive illnesses.