Self-assessment scale of auditory verbal hallucinations (SAVH): A novel tool for patients with schizophrenia

BACKGROUND

A scale for self-assessment of auditory verbal hallucinations (SAVH) was developed for patients, and this study aimed to validate the scale by investigating its psychometric properties.

METHODS

Forty one patients with schizophrenia or schizoaffective disorders (DSM-5) self-assessed their hallucinations using nine SAVH questions. Each question was scored from 0 to 5, indicating the severity of the symptoms. Patients were also evaluated with the Brief Psychiatric Rating Scale (BPRS), Auditory Hallucination Rating Scale (AHRS), and Birchwood Insight Scale (BIS). The psychometric properties of the SAVH were assessed by the face, internal consistency, construct, convergent and discriminant validities.

RESULTS

SAVH scores were used to examine the psychometric properties. Cronbach's α and Guttman's Lambda-6 were 0.67 and 0.73 respectively. Significant correlations were observed between SAVH and AHRS total scores, as well as BPRS hallucinatory behavior subscores. No significant correlations were found between total SAVH scores and (i) levels of insight or (ii) negative BPRS subscores. Factor analysis on SAVH revealed three factors accounting for 59.3 % of the variance. Most patients found the questions clear, appropriate, and of adequate length.

CONCLUSIONS

SAVH demonstrated good psychometric properties, suggesting its utility in assessing auditory verbal hallucinations (AVH). This self-assessment could be valuable in evaluating AVH treatment efficacy, monitoring AVH, and empowering patients.

A digital tool for self-assessment of auditory verbal hallucinations in schizophrenia

Auditory verbal hallucinations (AVH) are experienced by approximately 70 % of patients with schizophrenia and are frequently associated with high levels of distress. Therefore, alleviating hallucinations is an important therapeutic challenge. However, for prescribing a personalized treatment adapted to the patient, an accurate and detailed assessment of AVH is necessary. Until now, there have been no self-evaluations; instead, only scales based on observer ratings have been used to assess AVH. Nevertheless, self-assessments may enhance patient symptom awareness and increase their insight and involvement in the treatment, promoting empowerment (Eisen et al., 2000). In this context, a mobile app called MIMO was devised in order to monitor AVHs assessed by the patients themselves. This app, including the Self-assessment of Auditory verbal Hallucinations (SAVH-https://sns-dollfus.com/), was devised as an ecological momentary assessment tool. The present study aimed to demonstrate the feasibility and acceptability of this app.

Sulcal pits of the superior temporal sulcus in schizophrenia patients with auditory verbal hallucinations

Auditory verbal hallucinations (AVHs) are among the most common and disabling symptoms of schizophrenia. They involve the superior temporal sulcus (STS), which is associated with language processing; specific STS patterns may reflect vulnerability to auditory hallucinations in schizophrenia. STS sulcal pits are the deepest points of the folds in this region and were investigated here as an anatomical landmark of AVHs. This study included 53 patients diagnosed with schizophrenia and past or present AVHs, as well as 100 healthy control volunteers. All participants underwent a 3-T magnetic resonance imaging T1 brain scan, and sulcal pit differences were compared between the two groups. Compared with controls, patients with AVHs had a significantly different distributions for the number of sulcal pits in the left STS, indicating a less complex morphological pattern. The association of STS sulcal morphology with AVH suggests an early neurodevelopmental process in the pathophysiology of schizophrenia with AVHs.

The priming effect of repetitive transcranial magnetic stimulation on clinical response to electroconvulsive therapy in treatment-resistant depression: a randomized, double-blind, sham-controlled study

BACKGROUND

Electroconvulsive therapy (ECT) is one of the most effective treatments for treatment-resistant depression (TRD). However, due to response delay and cognitive impairment, ECT remains an imperfect treatment. Compared to ECT, repetitive transcranial magnetic stimulation (rTMS) is less effective at treating severe depression, but has the advantage of being quick, easy to use, and producing almost no side effects. In this study, our objective was to assess the priming effect of rTMS sessions before ECT on clinical response in patients with TRD.

METHODS

In this multicenter, randomized, double-blind, sham-controlled trial, 56 patients with TRD were assigned to active or sham rTMS before ECT treatment. Five sessions of active/sham neuronavigated rTMS were administered over the left dorsolateral prefrontal cortex (20 Hz, 90% resting motor threshold, 20 2 s trains with 60-s intervals, 800 pulses/session) before ECT (which was active for all patients) started. Any relative improvements were then compared between both groups after five ECT sessions, in order to assess the early response to treatment.

RESULTS

After ECT, the active rTMS group exhibited a significantly greater relative improvement than the sham group [43.4% (28.6%) v. 25.4% (17.2%)]. The responder rate in the active group was at least three times higher. Cognitive complaints, which were assessed using the Cognitive Failures Questionnaire, were higher in the sham rTMS group compared to the active rTMS group, but this difference was not corroborated by cognitive tests.

CONCLUSIONS

rTMS could be used to enhance the efficacy of ECT in patients with TRD. ClinicalTrials.gov: NCT02830399.

Clinical features and outcomes of COVID-19 patients hospitalized for psychiatric disorders: a French multi-centered prospective observational study

BACKGROUND

Patients with psychiatric disorders are exposed to high risk of COVID-19 and increased mortality. In this study, we set out to assess the clinical features and outcomes of patients with current psychiatric disorders exposed to COVID-19.

METHODS

This multi-center prospective study was conducted in 22 psychiatric wards dedicated to COVID-19 inpatients between 28 February and 30 May 2020. The main outcomes were the number of patients transferred to somatic care units, the number of deaths, and the number of patients developing a confusional state. The risk factors of confusional state and transfer to somatic care units were assessed by a multivariate logistic model. The risk of death was analyzed by a univariate analysis.

RESULTS

In total, 350 patients were included in the study. Overall, 24 (7%) were transferred to medicine units, 7 (2%) died, and 51 (15%) patients presented a confusional state. Severe respiratory symptoms predicted the transfer to a medicine unit [odds ratio (OR) 17.1; confidence interval (CI) 4.9-59.3]. Older age, an organic mental disorder, a confusional state, and severe respiratory symptoms predicted mortality in univariate analysis. Age >55 (OR 4.9; CI 2.1-11.4), an affective disorder (OR 4.1; CI 1.6-10.9), and severe respiratory symptoms (OR 4.6; CI 2.2-9.7) predicted a higher risk, whereas smoking (OR 0.3; CI 0.1-0.9) predicted a lower risk of a confusional state.

CONCLUSION

COVID-19 patients with severe psychiatric disorders have multiple somatic comorbidities and have a risk of developing a confusional state. These data underline the need for extreme caution given the risks of COVID-19 in patients hospitalized for psychiatric disorders.

European Validation of the Self-Evaluation of Negative Symptoms (SNS): A Large Multinational and Multicenter Study

BACKGROUND

Negative symptoms are usually evaluated with scales based on observer ratings and up to now self-assessments have been overlooked. The aim of this paper was to validate the Self-evaluation of Negative Symptoms (SNS) in a large European sample coming from 12 countries. We wanted to demonstrate: (1) good convergent and divergent validities; (2) relationships between SNS scores and patients' functional outcome; (3) the capacity of the SNS compared to the Brief Negative Symptom Scale (BNSS) to detect negative symptoms; and (4) a five-domain construct in relation to the 5 consensus domains (social withdrawal, anhedonia, alogia, avolition, blunted affect) as the best latent structure of SNS.

METHODS

Two hundred forty-five subjects with a DSM-IV diagnosis of schizophrenia completed the SNS, the Positive and Negative Syndrome Scale (PANSS), the BNSS, the Calgary Depression Scale for Schizophrenia (CDSS), and the Personal and Social Performance (PSP) scale. Spearman's Rho correlations, confirmatory factor analysis investigating 4 models of the latent structure of SNS and stepwise multiple regression were performed.

RESULTS

Significant positive correlations were observed between the total score of the SNS and the total scores of the PANSS negative subscale (r = 0.37; P < 0.0001) and the BNSS (r = 0.43; p < 0.0001). SNS scores did not correlate with the level of insight, parkinsonism, or the total score of the PANSS positive subscale. A positive correlation was found between SNS and CDSS (r = 0.35; p < 0.0001). Among the 5 SNS subscores, only avolition subscores entered the regression equation explaining a lower functional outcome. The 1-factor and 2-factor models provided poor fit, while the 5-factor model and the hierarchical model provided the best fit, with a small advantage of the 5-factor model. The frequency of each negative dimension was systematically higher using the BNSS and the SNS vs. the PANSS and was higher for alogia and avolition using SNS vs. BNSS.

CONCLUSION

In a large European multicentric sample, this study demonstrated that the SNS has: (1) good psychometric properties with good convergent and divergent validities; (2) a five-factor latent structure; (3) an association with patients' functional outcome; and (4) the capacity to identify subjects with negative symptoms that is close to the BNSS and superior to the PANSS negative subscale.

Examining transcranial random noise stimulation as an add-on treatment for persistent symptoms in schizophrenia (STIM'Zo): a study protocol for a multicentre, double-blind, randomized sham-controlled clinical trial

Background

One out of three patients with schizophrenia failed to respond adequately to antipsychotics and continue to experience debilitating symptoms such as auditory hallucinations and negative symptoms. The development of additional therapeutic approaches for these persistent symptoms constitutes a major goal for patients. Here, we develop a randomized-controlled trial testing the efficacy of high-frequency transcranial random noise stimulation (hf-tRNS) for the treatment of resistant/persistent symptoms of schizophrenia in patients with various profiles of symptoms, cognitive deficits and illness duration. We also aim to investigate the biological and cognitive effects of hf-tRNS and to identify the predictors of clinical response.

Methods

In a randomized, double-blind, 2-arm parallel-group, controlled, multicentre study, 144 patients with schizophrenia and persistent symptoms despite the prescription of at least one antipsychotic treatment will be randomly allocated to receive either active (n = 72) or sham (n = 72) hf-tRNS. hf-tRNS (100–500 Hz) will be delivered for 20 min with a current intensity of 2 mA and a 1-mA offset twice a day on 5 consecutive weekdays. The anode will be placed over the left dorsolateral prefrontal cortex and the cathode over the left temporoparietal junction. Patients’ symptoms will be assessed prior to hf-tRNS (baseline), after the 10 sessions, and at 1-, 3- and 6-month follow-up. The primary outcome will be the number of responders defined as a reduction of at least 25% from the baseline scores on the Positive and Negative Syndrome Scale (PANSS) after the 10 sessions. Secondary outcomes will include brain activity and connectivity, source monitoring performances, social cognition, other clinical (including auditory hallucinations) and biological variables, and attitude toward treatment.

Discussion

The results of this trial will constitute a first step toward establishing the usefulness of hf-tRNS in schizophrenia whatever the stage of the illness and the level of treatment resistance. We hypothesize a long-lasting effect of active hf-tRNS on the severity of schizophrenia symptoms as compared to sham. This trial will also have implications for the use of hf-tRNS as a preventive intervention of relapse in patients with schizophrenia.

Trial registration

ClinicalTrials.gov NCT02744989. Prospectively registered on 20 April 2016

Validity and reliability of a Persian version of the self- evaluation of negative symptoms (SNS)

AIM

The Self-evaluation of Negative Symptoms (SNS) has been developed to allow schizophrenia patients to evaluate themselves in five dimensions of negative symptoms. The present study aimed to examine psychometric properties of the Persian version of SNS.

METHODS

A group of 50 patients with schizophrenia and a group of 50 healthy controls received the Persian-SNS. Severity of negative symptoms were evaluated by the Scale for Assessment of Negative symptoms (SANS) and the Brief Psychiatric Rating Scale (BPRS).

RESULTS

The results showed that the Cronbach's alpha for the Persian SNS was 0.95. The Persian-SNS and its subscales showed significant positive correlations with the total SANS score and SANS subscales as well as BPRS negative subscale, thus confirming the validity of the scale. Finally, the Persian-SNS showed the ability to discriminate patients with schizophrenia from healthy controls.

CONCLUSION

The acceptable properties of the Persian version of SNS demonstrated that it is a practical tool for screening negative symptoms in Persian-speaking schizophrenia patients.

Impact cérébral structurel et fonctionnel de la Clozapine chez les patients souffrant de schizophrénie : revue systématique des études longitudinales en neuroimagerie

OBJECTIF

L'objectif de cette revue est d'identifier les corrélats anatomo-fonctionnels cérébraux lors d'un traitement par clozapine (CLZ) ainsi que les marqueurs anatomo-fonctionnels prédictifs de la réponse à la CLZ.

MÉTHODES

Nous avons réalisé une revue systématique de la littérature avec les bases de données MEDLINE et Web of Science afin d'identifier et d'examiner toutes les études longitudinales en neuroimagerie investiguant l'impact cérébral de la CLZ.

RÉSULTATS

30 études ont été incluses et analysées. La CLZ induit une diminution du volume et de la perfusion dans les noyaux gris centraux chez les patients répondeurs. Un plus grand volume de substance grise et perfusion dans ces structures avant l'instauration de la CLZ étaient associés à une meilleure réponse au traitement. La diminution de volume et de perfusion au niveau du cortex préfrontal (CPF) est observée malgré l'instauration de CLZ mais de façon moins importante chez les patients sous CLZ que chez les patients sous antipsychotiques typiques. Un plus grand volume au niveau du CPF avant l'instauration de la CLZ est associé à une meilleure réponse clinique dans la majorité des études. Enfin, la CLZ semble induire une réduction des altérations au niveau de la substance blanche.

CONCLUSION

Les corrélats anatomo-fonctionnels de la CLZ différent de ceux des autres antipsychotiques avec une action spécifique de la CLZ au niveau des ganglions de la base et du CPF pouvant participer à sa supériorité en termes de réponse clinique. Plusieurs données cliniques et d'imagerie conduisent à l'hypothèse d'un meilleur pronostic associé à une instauration plus rapide de la CLZ.

Validation of the lithuanian version of the self-evaluation of negative symptoms scale (SNS)

PURPOSE

To validate the Lithuanian version of the Self-Evaluation Negative Symptoms Scale (Lith-SNS).

MATERIALS AND METHODS

A double translation from French to Lithuanian and back was performed. We included patients from in-patient and out-patient settings that had a diagnosis of paranoid schizophrenia according to ICD-10 criteria and were screened as free from acute psychotic symptoms using the Mini International Neuropsychiatric Interview (MINI). Participants were evaluated using the Brief Psychiatric Rating Scale (BRPS) and completed the Lith-SNS scale. We measured internal consistency, convergent validity, and discriminant validity of Lith - SNS comparing its scores with BPRS negative and positive symptom subscores.

RESULTS

A total of 67 participants were evaluated. Cronbach's alpha (α) for all 20 items of Lith-SNS (α = 0.82), and for the five subscores (α = 0.76) showed good internal consistency. Factor analysis showed a 2-factor solution which accounted for 70.12% of the variance with the first factor accounting for 53.3% and the second factor accounting for 16.8% of the variance. Lith-SNS total scores and all five subscores significantly correlated with BPRS negative symptoms subscores showing good convergent validity. There was a correlation between the Positive subscore of BPRS and the alogia subscore of Lith-SNS (r = 0.39, p = 0.001), but no correlations with other subscores or the total Lith-SNS score showing adequate discriminant validity.

CONCLUSIONS

Lithuanian version of SNS is a valuable tool to evaluate negative symptoms of schizophrenia with good internal consistency, convergent, and discriminant validity.

Anatomical Connectivity of the Visuospatial Attentional Network in Schizophrenia: A Diffusion Tensor Imaging Tractography Study

OBJECTIVE

In healthy individuals, the visuospatial attentional network consists of frontoparietal bundles; however, the anatomical organization of this network in persons with schizophrenia remains largely unknown. Using diffusion tensor imaging-based tractography, the authors investigated the white matter integrity and volume of frontoparietal and frontotemporo-occipital bundles in the right and left hemispheres and studied their structural asymmetry in persons with schizophrenia and in healthy individuals.

METHODS

This study included 34 participants with schizophrenia and 69 healthy individuals. Integrity parameters and volume were calculated in the three branches of the superior longitudinal fasciculus (SLF I, II, and III), the inferior longitudinal fasciculus, and the inferior fronto-occipital fasciculus in both hemispheres.

RESULTS

In the SLF II and SLF III of the right hemisphere, healthy individuals showed greater integrity, compared with participants with schizophrenia. Both groups presented increased integrity in the SLF III of the right hemisphere, compared with the SLF III of the left hemisphere, but only healthy individuals had this pattern regarding the SLF II. Bundle volumes did not differ between groups.

CONCLUSIONS

This study is the first to describe the structural hemispheric lateralization and organization of the visuospatial attentional network in persons with schizophrenia. The main findings indicate loss of integrity in the SLF II, associated with loss of asymmetry in participants with schizophrenia, compared with healthy individuals, suggesting a potential substrate of attentional deficits.

Negative symptoms in schizophrenia: correlation with clinical and genetic factors

Aim: Explore the possible association between clinical factors and genetic variants of the dopamine pathways and negative symptoms. Materials & methods: Negative symptoms were assessed in 206 patients with schizophrenia using the Arabic version of the self-evaluation of negative symptoms scale and the Positive and Negative Syndrome Scale. Genotyping for COMT, DRD2, MTHFR and OPRM1 genes was performed. Results: Multivariable analysis showed that higher self-evaluation of negative symptoms scale scores were significantly associated with higher age, higher chlorpromazine-equivalent daily dose for typical antipsychotics and in married patients. Higher negative Positive and Negative Syndrome Scale scores were significantly associated with women and having the CT genotype for MTHFR c.677C>T (β = 4.25; p = 0.008) compared with CC patients. Conclusion: Understanding both clinical/genetic factors could help improve the treatment of patients.

EPA guidance on treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms.

However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.

A web-based adapted physical activity program (e-APA) versus health education program (e-HE) in patients with schizophrenia and healthy volunteers: study protocol for a randomized controlled trial (PEPSY V@Si)

Patients with schizophrenia (SZ) have a high level of cardiovascular morbidity and some clinical symptoms of illness remain resistant to pharmacological approaches. A large number of studies support the effectiveness of physical activity (PA) in SZ. The aims of this trial is to assess the effects of a remote, web-based adapted PA program (e-APA) compared to a health education program (e-HE) on brain plasticity in SZ and healthy volunteers (HV) and on psychiatric, neurocognitive, circadian and physical variables. The study is an interventional, multicenter, randomized open-label trial. Forty-two SZ will be randomized to either the active group (e-APA, N = 21) or nonactive group (e-HE, N = 21), and 21 HV will be matched to SZ according to age, gender, and level of PA in both e-APA and e-HE groups. Interventions will consist of 32 sessions (2 × 60 min/week, for 16 weeks) via supervised home-based videoconferencing. Cerebral magnetic resonance imaging, psychiatric symptoms, neurocognitive and circadian rhythms assessments as well as physical tests and biological analyses will be assessed at baseline and 16 weeks after the intervention. To our knowledge, this is the first study aiming to evaluate the efficacy of APA delivered by supervised home-based videoconferencing in SZ. Moreover, using multimodal MRI, this study could clarify the pathophysiological mechanisms underlying the efficacy of APA. Finally, this innovative approach might also increase participation in long-term PA since PA-based programs are known to have low adherence and early dropout. Trial registration: ClinicalTrials.gov identifier: NCT03261817. Registered on 16 August 2017.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

A new 3-hit mouse model of schizophrenia built on genetic, early and late factors

Whether the etiology of schizophrenia remains unknown, its multifactorial aspect is conversely now well admitted. However, most preclinical models of the disease still rely on a mono-factorial construction and do not allow discover unequivocal treatments, particularly for negative and cognitive symptoms. The main interaction factors that have been implicated in schizophrenia are a genetic predisposition and unfavorable environmental factors. Here we propose a new animal model combining a genetic predisposition (1st hit: partial deletion of MAP-6 (microtubule-associated protein)) with an early postnatal stress (2nd hit: 24 h maternal separation at post-natal day 9), and a late cannabinoid exposure during adolescence (3rd hit: tetrahydrocannabinol THC from post-natal day 32 to 52; 8 mg/kg/day). The 2-hit mice displayed spatial memory deficits, decreased cortical thickness and fractional anisotropy of callosal fibers. The 3-hit mice were more severely affected as attested by supplementary deficits such a decrease in spontaneous activity, sociability-related behavior, working memory performances, an increase in anxiety-like behavior, a decrease in hippocampus volume together with impaired integrity of corpus callosum fibers (less axons, less myelin). Taken together, these results show that the new 3-hit model displays several landmarks mimicking negative and cognitive symptoms of schizophrenia, conferring a high relevance for research of new treatments. Moreover, this 3-hit model possesses a strong construct validity, which fits with gene x environment interactions hypothesis of schizophrenia. The 2-hit model, which associates maternal separation with THC exposure in wild-type mice gives a less severe phenotype, and could be useful for research on other forms of psychiatric diseases.

["Early detection of schizophrenia, why and who to contact?"]

"Early detection Of schizophrenia, why and who to contact? Schizophrenia usually occurs in late adolescence or early adulthood but is generally preceded by a prodromal phase or by a "high risk mental state" which corresponds to the onset of the disease. Early detection of symptoms and rapid specialized intervention begin at this stage. Medical intervention at this stage aims to influence the course of the disease and to limit the transition to a first-episode psychosis (FEP). Patients with FEP will require initiation of antipsychotic treatment. A long delay before antipsychotic treatment initiation will negatively impact the short and long term outcomes: more severe symptoms, worse treatment response and less global functioning. Early detection of schizophrenia involves general practitioners who will be firstly solicited by patients and their families. Patient should then be addressed without any delay to specialized psychiatric teams."

GeodesicSlicer: a Slicer Toolbox for Targeting Brain Stimulation

NonInvasive Brain Stimulation (NIBS) is a potential therapeutic tool with growing interest, but neuronavigation-guided software and tools available for the target determination are mostly either expensive or closed proprietary applications. To address these limitations, we propose GeodesicSlicer, a customizable, free, and open-source NIBS therapy research toolkit. GeodesicSlicer is implemented as an extension for the widely used 3D Slicer medical image visualization and analysis application platform. GeodesicSlicer uses cortical stimulation target from either functional or anatomical images to provide functionality specifically designed for NIBS therapy research. The provided algorithms are tested and they are accessible through a convenient graphical user interface. Modules have been created for NIBS target determination according to the position of the electrodes in the 10-20 system electroencephalogram and calculating correction factors to adjust the repetitive Transcranial Magnetic Stimulation (rTMS) dose for the treatment. Two illustrative examples are processing with the module. This new open-source software has been developed for NIBS therapy: GeodesicSlicer is an alternative for laboratories that do not have access to neuronavigation system. The triangulation-based MRI-guided method presented here provides a reproducible and inexpensive way to position the TMS coil that may be used without the use of a neuronavigation system.

[Accountability of anti-cholinergic drugs in increase of psychotic episodes: A case of tropatepine overdose]

INTRODUCTION

Corrective treatments for some neurological side effects due to antipsychotic treatments can induce anticholinergic adverse effects. However, the risk of triggering or increasing psychotic symptoms induced by these drugs is unknown with only one case-report concerning the tropatepine. In addition, recommendations for the use of these drugs remain imprecise regarding the management of this type of adverse effect.

CASE REPORT

We report the case of a psychotic episode in an 18-year-old patient potentially acutised after an auto-intoxication with tropatepine.

CONCLUSION

At high doses, anticholinergic treatments, including tropatepine, might increase psychotic episodes. In addition, the available epidemiological data reveal an inappropriate and excessive prescription of these drugs. Their use and risks should be better known and need an update of the available recommendations.

A new toolbox to compare target localizations for non-invasive brain stimulation: An application of rTMS treatment for auditory hallucinations in schizophrenia

BACKGROUND

Most repetitive transcranial magnetic stimulation (rTMS) studies aiming to reduce auditory verbal hallucinations (AVH) in schizophrenia target the left temporo-parietal junction (TPJ), but the efficacy of this approach remains controversial. The observed differences in efficacy could be attributed to inaccurate target localization. Here, to precisely quantify anatomical bias induced by localization method, we developed a free open-source software (GeodesicSlicer) that computes shortest curved path (i.e. geodesic) between rTMS targets. Here we compare a personalized target with accurate anatomical criteria with a standardized target based on the 10-20 EEG system (the middle between T3 and P3 electrodes: T3P3).

METHODS

We compare in 69 patients with schizophrenia the geodesic distances of two approaches for rTMS target localization within the left TPJ. In addition, we characterize the personalized target according to the 10-20 EEG system.

RESULTS

A differential of 3 cm in term of geodesic distance between rTMS localization approaches was observed. Moreover, this personalized target to treat AVH is located at 25% in the T3-P3 axis.

CONCLUSIONS

This software for rTMS localization comparison demonstrates the difference between standardized and personalized rTMS target. This difference has the potential to explain a part of the dissonant clinical results found in previous rTMS studies.

Validation of the Arabic version of the "self-evaluation of negative symptoms" scale (SNS)

BACKGROUND

The self-evaluation of negative symptoms scale (SNS) is a new easy-to-use self-administered questionnaire allowing clinicians to understand the clinical and genetic factors affecting the negative symptoms in patients with schizophrenia. There was a need to translate and validate this scale in Arabic so that Arab-speaking patients benefit from it. Therefore, the aim of our study was to validate the Arabic version of the SNS in a sample of Lebanese patients with schizophrenia.

METHODS

The Arabic SNS was used to quantify the disability associated with negative symptoms in patients with schizophrenia (n = 206). Six weeks after completing the SNS, the participants were interviewed again to assess test-retest reproducibility. The validity was confirmed by factor analyses using the principal component analysis technique with a varimax rotation. The Positive and Negative Syndrome Scale (PANSS) was also assessed.

RESULTS

None of the items of the SNS scale were removed; all items converged over a solution of five factors that had an eigenvalue > 1, explaining a total of 66.01% of the variance (Cronbach's alpha = 0.879; test part). The mean total SNS score was 17.33 ± 8.43 for the "test", and 16.35 ± 7.50 for the "retest". The correlation coefficients between the SNS total score and the PANSS scale and subscales were as follows: total PANSS (r = 0.044; p = 0.530), positive PANSS score (r = - 0.106; p = 0.131), negative PANSS score (r = 0.204; p = 0.003), and general psychopathological PANSS score (r = 0.03; p = 0.530).

CONCLUSION

This study is the first to validate the Arabic version of the SNS in patients with schizophrenia. Using this scale would help improve treatment by correctly assessing negative symptoms, thus optimizing treatment options.

La cohérence cardiaque : état des connaissances actuelles et bénéfices en psychiatrie

Le stress joue un rôle prépondérant dans un grand nombre d’affections psychiatriques. L’institut HeartMath® a développé une technique de gestion du stress appelée cohérence cardiaque. Cette technique se fonde sur une rééducation du système nerveux autonome en améliorant l’équilibre de la balance sympatho-vagale par augmentation de la Variabilité de la Fréquence Cardiaque (VFC). Par cela, on obtient une augmentation de la flexibilité de ce système nerveux autonome et ainsi une meilleure tolérance au stress.

À ce jour, la VFC peut se mesurer à l’aide d’un photopléthysmographe relié à un ordinateur permettant de visualiser le résultat (biofeedback). L’intérêt du biofeedback est la visualisation en direct de la VFC au cours de manœuvres respiratoires et techniques issues des thérapies cognitivo-comportementales Le lien entre une altération de la VFC et différentes pathologies organiques (telles que l’hypertension artérielle et l’infarctus du myocarde) mais aussi psychiatriques (telles que les troubles anxieux et thymiques) a été établi depuis plusieurs années. De même, l’administration de certaines molécules comme les bêta-bloquants et les antidépresseurs sont associés à l’augmentation de la VFC lors de l’amélioration des symptômes. Enfin, la cohérence cardiaque a déjà prouvé ses bénéfices dans le traitement de plusieurs troubles psychiatriques tels que les troubles anxieux et les troubles thymiques. Notre but est de réaliser une synthèse des connaissances actuelles sur la VFC et la cohérence cardiaque, de présenter cette thérapie, puis d’exposer ses bénéfices dans le traitement des pathologies psychiatriques allant des troubles anxieux jusqu’aux syndromes schizophréniques.

The subjective quality of life in deficit and nondeficit schizophrenic patients

We assessed the subjective quality of life (QOL) of 30 deficit schizophrenic patients compared to 112 nondeficit schizophrenic patients. The deficit patients did not differ in term of QOL, total score of positive symptoms, general psychopathology from the nondeficit patients. This result suggested an absence of impact of primary negative symptoms on the subjective QOL in schizophrenic patients.

Principal-component analyses of PANSS and SANS-SAPS in schizophrenia: their stability in an acute phase

Whether studies agree or disagree on the positive-negative dichotomy in schizophrenia, the relevance of a third component, disorganization, remains a point of debate. Disorganization, as expressed by the scale for the assessment of negative symptoms and positive symptoms (SANS-SAPS) and the positive and negative syndrome scale (PANSS) principal-component analyses, could be considered as permanent and determinant a dimension as the positive and negative components. The aim of this study therefore was to determine whether this disorganization, with the negative and positive components, is stable and has the same composition in the acute and postacute phases of illness. This study was carried out in 57 patients, broadly defined by at least one of four diagnostic criteria (American Psychiatric Association, Langfeldt, Carpenter and Schneider), established with a computerized checklist, and evaluated with SANS-SAPS and PANSS. Principal component analyses (PCA) of these scales were performed at admission and discharge from hospital.

The PCA of SANS-SAPS displayed a 3-factor solution, regardless of the phase of illness (acute or postacute), showing that the negative, positive and disorganization components were stable. The PCA of PANSS yielded negative and positive components perfectly stable over time and a disorganization component whose composition varied between admission and discharge. At admission, this component included the conceptual disorganization item negatively correlated with one of depression. At discharge, this disorganization component included two additional items, autistic preoccupation and mannerisms and one depression component appeared. The instability of the PCA of PANSS could express the role played by the phase of illness; in an acute phase, this disorganization component was constituted by more “positive” items such as grandiosity, unusual thought content and active social avoidance whereas in the postacute phase, it included items that reflected more the chronicity of the illness, such as mannerisms and autistic preoccupation. Moreover, the depressive item appeared, in the postacute phase, in a specific depressive component. This result could be due to the fact that depressive symptoms cannot be expressed when positive symptoms are very severe, which explains why no depressive components were shown during the acute phase.

Hallucinogen persisting perception disorder after psilocybin consumption: a case study

The recurrence of flashbacks without acute or chronic hallucinogen consumption has been recognized in the DSM IV criteria as the hallucinogen persisting perception disorder (HPPD). Perceptual disturbances may last for 5 years or more and represent a real psychosocial distress. We reported here a case of a 18-year-old young man presenting HPPD after a mixed intoxication with psylocibin and cannabis. This report shows symptomatic recurrences persisting more than 8 months. Various differential diagnoses were evoked and our therapeutic strategies were described.

Stability of positive and negative symptoms in schizophrenic patients: a 3-year follow-up study

The course of negative and positive symptoms was studied in neuroleptic-treated patients over a 3-year period, in consideration also of the initial phase of illness (post-acute or chronic). This study was carried out in a broadly defined schizophrenic sample, in order not to give preference to one diagnostic subgroup over another. Forty-six patients were evaluated every year for 3 years, 23 in the post-acute group and 23 in the chronic group. Aggravations of the Clinical Global Impression (CGI) and of the SANS total score were observed, regardless of the group (chronic or post-acute). This global aggravation confirmed Kraepelin's concept of dementia praecox; moreover, this aggravation was not due to an increase in the number of patients relapsing, or to an aggravation of akinesia. Three types of negative and positive symptom courses were observed: i) the mean sub-scores of positive symptoms, such as hallucinations, delusions, positive formal thought disorders, and of negative symptoms such as flattening affect, avolition/apathy and attentional impairment, did not vary significantly over time in either group; ii) the mean sub-scores of bizarre behavior and alogia fluctuated over time (p < 0.05) and only poverty of speech was perfectly stable among the items constituting alogia; iii) the mean subscores of anhedonia/asociality worsened significantly over time irrespective of the groups (p < 0.05), and among the items constituting anhedonia, recreational interest-activities and intimacy-closeness abilities worsened (p < 0.05 and p < 0.01, respectively). This aggravation was neither due to an increase in neuroleptic doses nor to the duration and chronicity of illness. However, negative symptoms, except anhedonia, can be reversible in some patients. The very strong stability of anhedonia, whatever the group, emphasize the importance of taking anhedonia into account in future diagnostic classifications.

Spanish validation of the self-evaluation of negative symptoms scale SNS in an adolescent population

BACKGROUND

Negative symptoms (NS) may be observed in the general population in an attenuated form and in high-risk mental states. However, they have been less studied in the general population than positive symptoms, in spite of their importance at the insidious onset of schizophrenia and their appearance before positive symptoms. This study aimed to analyze the empirical structure of the Spanish version of the Self-Evaluation of Negative Symptoms (SNS) Scale and find its psychometric properties and invariance of measurement across sex and age in a sample of adolescents.

METHODS

The sample consisted of 4521 adolescents (53.6% female) from 11 to 18 years of age.

RESULTS

Confirmatory Factor Analysis of the SNS confirmed an internal structure of five first-order factors by the characteristic dimensions of NS: avolition, social withdrawal, diminished emotional range, anhedonia, alogia, and one second-order factor which includes the total NS score. Multi-group confirmatory factor analysis showed that the scale was invariant across sex and age. Total scale reliability was adequate. A strong relationship was found between the SNS with depressive symptomatology, moderate with ideas of reference and low with aberrant salience.

CONCLUSION

The results back use of the Spanish version of the SNS scale for detection of NS in the general population of adolescents.

Corpus callosum microstructural and macrostructural abnormalities in schizophrenia according to the stage of disease

Corpus callosum (CC) volume and surface (macrostructural) studies remain controversial and have not considered the illness duration (ID) systematically. Regardless of ID, some CC macrostructural studies have shown no difference between SZ patients and healthy controls (HC), whereas others have reported macrostructural abnormalities in SZ. Conversely, CC microstructural studies are more in agreement with alterations in CC integrity regardless of the patients' ID, but the direction and degree of these abnormalities over time remain unknown. Moreover, no study has explored both the micro- and macrostructure of the CC in SZ by considering the stage of disease. Both CC micro- and macrostructural data were investigated in 43 SZ patients and compared between two patient groups (21 patients with a short ID and 22 with a long ID) and HC (23 participants) using diffusion tensor and structural imaging. CC microstructural alterations were detected in both SZ groups compared to the HC group, without differences between the SZ groups. In contrast, CC macrostructural alterations were only found in the long ID group. CC microstructural alterations might be detected in schizophrenia at an early stage, without an increase of magnitude thereafter, while CC macrostructural alterations might become apparent at later stages of the illness.

Specificity and sensitivity of the Self-assessment of Negative Symptoms (SNS) in patients with schizophrenia

OBJECTIVES

Negative symptoms can be present at any stage of schizophrenia but their evaluation remains challenging. Self-evaluations may be particularly useful in screening negative symptoms quickly and effectively. The purpose of this study was to determine the sensitivity, the specificity, and the threshold beyond which the negative symptoms are considered pathological in a comparative study between patients with schizophrenia and healthy subjects using the Self-assessment of Negative Symptoms (SNS).

METHODS

One hundred and nine patients with schizophrenia and schizoaffective disorders (DSM-5) and 99 healthy controls were included and evaluated with the SNS. AUROC analyses were performed to assess the discriminant performance of the SNS scale for screening negative symptoms in the whole sample of patients but also in 2 patient sub-samples without high scores of depression or negative symptoms.

RESULTS

The SNS (AUROC = 0.942 ± 0.046; p < 0.001) appears to be an appropriate screening tool for distinguishing between SZ and HC with a threshold value of 7, and the sensitivity and specificity were 92.7% (95CI = [86.1-96.8]) and 85.9% (95CI = [77.4-92.1]) respectively. A threshold at 7 was also observed in the samples without patients with high level of depressive or negative symptoms.

CONCLUSION

These results indicate that SNS might be a valuable tool for screening negative symptoms in clinical practice regardless the level of depressive and negative symptoms. Further studies using SNS in subjects at high risk for psychosis or with a first psychotic episode would be useful in the detection of negative symptoms.

A large European, multicenter, multinational validation study of the Brief Negative Symptom Scale

Negative symptoms represent an unmet need of treatment in schizophrenia. Although a consensus exists on negative symptom construct, and second generation assessment instruments reflecting the consensus are available, studies still rely upon old assessment instruments, that do not reflect recent conceptualizations and might limit progress in the search for effective treatments. This is often the case in the European context, where one of the challenges encountered in designing large studies is the availability of validated instruments in the many languages of the continent. To address this challenge and promote sound research on negative symptoms in Europe, the ECNP Schizophrenia Network coordinated a large multicenter, multinational validation study of the Brief Negative Symptom Scale (BNSS). Clinically-stable subjects with schizophrenia (SCZ, N = 249) were recruited from 10 European Countries. Apart from BNSS, subjects were administered the Positive and Negative Syndrome Scale (PANSS) and standardized instruments for depression, extrapyramidal symptoms and psychosocial functioning. Results showed an excellent internal consistency, convergent and discriminant validity of BNSS and replicated a 5 factor-model. A larger number of subjects with predominant negative symptoms, i.e. the target population for clinical trials, was identified by using the BNSS compared to the PANSS. Regression analysis showed that BNSS-avolition, a key negative symptom poorly assessed by PANSS, explained 23.9% of psychosocial functioning, while no combination of the PANSS core negative symptoms showed the same impact on functioning. The study demonstrated that BNSS has substantial advantages with respect to PANSS for the identification of the avolition domain and subjects with predominant negative symptoms.

Fronto-subcortical functional connectivity in patients with schizophrenia and bipolar disorder during a verbal fluency task

OBJECTIVES

Impairments in language production are common of schizophrenia (SZ) and bipolar disorder (BD). Identifying distinct functional connectivity (FC) patterns in SZ and BD may provide biomarkers for their diagnoses.

METHODS

Forty-nine participants (15 SZ, 14 BD and 20 healthy controls (HC)) underwent a verbal fluency task consisting of mentally generating verbs in French, alternated with periods of silence. Functional network allowed identifying activation clusters: the medio-frontal cluster (MFC), the left subcortical cluster (LSCC) and the left fronto-lateral cluster (LFLC). FC was calculated between the average blood oxygen level-dependent signal time series in each cluster. Analyses of covariance were performed to test group differences on FC among the three paired-seed regions.

RESULTS

SZ presented a significant reduced FC compared to HC within two paired-seed regions between the LFLC and the LSCC and between the MFC and the LSCC while BD were not significantly different from HC. SZ compared to BD exhibited a reduced FC within one paired-seed region between the MFC and the LSCC. There was no group effect between the MFC and the LFLC.

CONCLUSIONS

A specific medio-prefronto-striato-thalamic functional dysconnectivity may be implicated in the pathophysiology of schizophrenia. This reduced fronto-subcortical FC could be a functional brain biomarker of schizophrenia.

Social cognition in schizophrenia: Validation of an ecological fMRI task

Neuroimaging studies have revealed brain regions involved in social cognition, which reportedly show functional alterations in schizophrenia. However, the social neural network has not been investigated with regards to language perception and social interactions in daily life. Here we developed and validated an integrative fMRI task to explore the neural basis of social cognition with regards to language perception in schizophrenia. The task comprised listening to film extracts and inferring mental states to characters. We first identified the functional network activated during the task in 28 healthy controls (HC). Next, we evaluated the reproducibility of Blood-Oxygen-Level Dependent (BOLD) variations in 14 HC participants. Finally, we investigated network impairment in 20 patients with schizophrenia (SZ) compared to HC. The HC group exhibited bilateral activation in the superior and middle temporal gyri (including the poles and the temporo-parietal junction). Overall, our novel integrative task induced activation of a functional network with good reproducibility and involved in language conveying social information. Compared to the HC group, the SZ group showed decreased recruitment of the right temporo-parietal junction. These findings may be useful for testing the impact of remediation on the brain, particularly on the network of language conveying social information.

Dandy-Walker Malformation-Like Condition Revealed by Refractory Schizophrenia: A Case Report and Literature Review

INTRODUCTION

Dandy-Walker malformation is a rare congenital malformation involving cystic dilatation of the fourth ventricle, enlarged posterior fossa, complete or partial agenesis of the cerebellar vermis, elevated tentorium cerebelli, and hydrocephalus. Previous research highlighted a possible role for the cerebellum in schizophrenia as well as the contribution of underlying brain malformations to treatment resistance. Here, we present a case of a Dandy-Walker malformation-like condition revealed by a refractory schizophrenia in a 24-year-old male patient. We also conduct a literature review of all previously published case reports or case series of co-occurring posterior fossa abnormalities and schizophrenia or psychosis using a PubMed search query to better understand the potential link between these two disorders.

CASE PRESENTATION

A 9-month hospital stay was needed to address the treatment-resistant psychotic symptoms, and the patient continued to experience moderate symptoms despite the prescription of various antipsychotic and antidepressant medications. After an irregular initial medical follow-up, the patient is currently treated with 350 mg daily clozapine and 20 mg daily prazepam and still exhibits moderate anxiety without delirious thoughts, however allowing him to re-enroll at the university. Regarding the literature, 24 cases published between 1996 and 2017 were identified, reviewed and compared to the present case report.

DISCUSSION

This case report and literature review further illuminates the pathophysiology of psychotic disorders including the potential role of the cerebellum, reinforces the importance of a multidisciplinary approach for the neurological and psychiatric management of patients with schizophrenia, and highlights optimal pharmacological management strategies for treatment-resistant schizophrenia.

Auditory verbal hallucinations in schizophrenia: current perspectives in brain stimulation treatments

PURPOSE

This review reports the current perspectives of brain stimulation techniques in the treatment of auditory verbal hallucinations (AVH) in schizophrenia.

METHODS

A systematic search of the literature in the PubMed database revealed that the most studied techniques are noninvasive techniques (NIBS), including electroconvulsive therapy (ECT), transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS).

RESULTS

The results showed that ECT could have great clinical efficacy but is currently underused in practice perhaps due to the costs associated with its limited implementation and potential associated risks. tDCS is still poorly studied and does not demonstrate sufficiently homogeneous or conclusive results yet to prove its efficacy in the treatment of AVH. However, its safe and simple implementation allows us to recommend it to patients who are refractory to other stimulation techniques. Finally, rTMS seems to be the most efficacious NIBS to offer patients with persistent AVH as an add-on therapeutic strategy. Its implementation has a non negligible cost but can be performed by a single practitioner. Great evolution in these techniques with technological progress, robotics and computer science are currently being tested and will undoubtedly improve the clinical efficacy of these procedures, particularly towards more personalized treatments such as individual rTMS targets and intensities. There are also new techniques for deep brain stimulation based on focused ultrasound that could provide much insight into the treatment of AVH in schizophrenia.

CONCLUSION

This review suggests that add-on brain stimulation treatments could play a key role among the therapeutic strategies for auditory hallucinations reduction in schizophrenia.

Effects of low- and high-frequency repetitive transcranial magnetic stimulation on long-latency auditory evoked potentials

Long-latency auditory event potentials (LLAEPs) involving local and global auditory processes have been investigated to examine the impact of low-frequency (LF) and high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS) on the cortical excitability of the temporal cortex. We hypothesized that both stimulation frequencies have the same modulation effect, in accordance with clinical data showing a reduction in auditory verbal hallucinations (AVHs) after LF and HF temporal rTMS in patients with schizophrenia. With 30 right-handed healthy volunteer participants enrolled in a crossover trial, we analyzed LLAEPs before and after LF- and HF-rTMS of the left temporal cortex. While we observed no changes in latencies, we did observe a similar inhibitory action of both rTMS frequencies on LLAEP amplitudes. Analysis of surface potential maps and cortical generators revealed some differences regarding auditory processes: HF-rTMS produced earlier, more diffuse, and more right-lateralized effects than LF-rTMS. Beyond a local impact, rTMS exerted a remote modulation influence on the frontal cortex that might be involved in attentional processes. This association could explain the therapeutic effect of temporal HF-rTMS on AVH.

Abnormalities of fronto-subcortical pathways in schizophrenia and the differential impacts of antipsychotic treatment: a DTI-based tractography study

The fronto-striato-thalamic circuitry is a key network in patients with schizophrenia (SZPs). We use diffusion tensor imaging (DTI) to investigate the integrity of white matter (WM) pathways involved in this network in SZPs relative to healthy controls (HCs). We also evaluate the differential impact of chronic exposure to clozapine as well as other atypical and typical antipsychotics. 63 HCs and 41 SZPs were included. Of the SZPs, 16 were treated with clozapine (SZPsC), 17 with atypical antipsychotics (SZPsA), and 8 with typical antipsychotics (SZPsT). Three tracts were reconstructed in the left hemisphere using tractography: one fronto-subcortical tract, one prefronto-subcortical tract, and one prefronto-frontal tract. Diffusion parameters were individually extracted in each tract. SZPs exhibited lower integrity in both the fronto-subcortical and prefronto-subcortical tracts relative to HCs, and SZPsT showed altered integrity compared to SZPsC. There were no WM integrity differences in the prefronto-frontal tract between SZP groups or between SZPs and HCs. SZPs exhibit structural connectivity abnormalities in the prefronto-fronto-subcortical network that are specifically and differentially impacted by the type of antipsychotic treatment. Additional studies are needed to separate the contributions of clozapine-mediated neuroprotection, neurotoxicity related to typical antipsychotics, and the illness itself to observed differences.

Mobile Intensive Care Unit: A case management team dedicated to early psychosis in France

AIM

To present the activities of a Mobile Intensive Care Unit in France.

METHODS

We summarize participant recruitment as well as the diagnostic procedures and therapeutic interventions offered to individuals with an at-risk mental state or first-episode psychosis (FEP).

RESULTS

Since its inception in 2010, 266 individuals from 16 to 30 years old living in an area of 120 000 citizens have been recruited by the Mobile Intensive Care Unit. Patients are evaluated by clinical and neuropsychological assessments, and therapeutic interventions include medication, individual case management and both individual and group cognitive behavioural therapy. Diagnostic assessments are also provided for the patients outside of our geographic area.

CONCLUSIONS

The Mobile Intensive Care Unit is a functional unit enabling young adults with a high-risk mental state or FEP to receive high standard of care and mobile management over 2 years, aimed at diminishing the risk of transition to chronic disease and decreasing functional impairment.

[Physical activity in patients with schizophrenia: From neurobiology to clinical benefits]

Schizophrenia is a severe chronic mental disorder that mainly manifests by positive symptoms, negative symptoms, disorganized behavior and thought and cognitive impairments. Taken together, these symptoms have substantial impact on quality of life, well-being and functional outcome. Patients with schizophrenia have dramatically higher levels of cardiovascular and metabolic morbidity than the general population due to poor physical fitness and to sedentary lifestyle. They have a reduced life expectancy, and an excess mortality being two or three times more than that in the general population. Moreover, despite major therapeutic advances in the overall management of these patients, some symptomatic dimensions, and more specifically the negative and cognitive ones, remain to be resistant to the usual pharmacological approaches. Moreover, antipsychotics can also reinforce the global cardiovascular risk due to side effects and low neurometabolic tolerance. The benefits of physical activity on health are now well described in the general population and in many medical diseases. More recently, physical activity has also found its place as an adjuvant therapy in severe mental illnesses, particularly in schizophrenia. In the literature physical activity programs, in addition to pharmacological treatments, appear to be feasible in patients and improve both physical and mental health as well as functional outcome. Clinical benefits of physical activity would be underpinned by biological and cerebral mechanisms, which remain unclear. In this review, we propose to present a state of the art and to present an update of the interests of physical activity in the management of patients with schizophrenia. We emphasize the clinical benefits of physical activity regarding the different symptomatic dimensions and its impact specifically on cognitive deficits. Finally, we describe the various underlying pathophysiological mechanisms in particular in the neurobiological, cerebral and physiological fields. We then discuss the barriers, facilitators and motivating factors towards physical activity to enhance health promotion initiatives, to optimize resource allocation when delivering physical activity programs in clinical practice, and to maximize physical activity participation. Physical activity appears to be an original and novel adjunctive therapeutic approach in the management of patients with schizophrenia and would both reduce schizophrenic symptoms and act like pro-cognitive therapy, improve quality of life and long-term functioning in daily life and reduce cardiovascular comorbidities. However, efforts are still needed to increase the motivating factors and adherence towards physical activity participation for people with schizophrenia.

High-Frequency Neuronavigated rTMS in Auditory Verbal Hallucinations: A Pilot Double-Blind Controlled Study in Patients With Schizophrenia

INTRODUCTION

Despite extensive testing, the efficacy of low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) of temporo-parietal targets for the treatment of auditory verbal hallucinations (AVH) in patients with schizophrenia is still controversial, but promising results have been reported with both high-frequency and neuronavigated rTMS. Here, we report a double-blind sham-controlled study to assess the efficacy of high-frequency (20 Hz) rTMS applied over a precise anatomical site in the left temporal region using neuronavigation.

METHODS

Fifty-nine of 74 randomized patients with schizophrenia or schizoaffective disorders (DSM-IV R) were treated with rTMS or sham treatment and fully evaluated over 4 weeks. The rTMS target was determined by morphological MRI at the crossing between the projection of the ascending branch of the left lateral sulcus and the superior temporal sulcus (STS).

RESULTS

The primary outcome was response to treatment, defined as a 30% decrease of the Auditory Hallucinations Rating Scale (AHRS) frequency item, observed at 2 successive evaluations. While there was no difference in primary outcome between the treatment groups, the percentages of patients showing a decrease of more than 30% of AHRS score (secondary outcome) did differ between the active (34.6%) and sham groups (9.1%) (P = .016) at day 14.

DISCUSSION

This controlled study reports negative results on the primary outcome but demonstrates a transient effect of 20 Hz rTMS guided by neuronavigation and targeted on an accurate anatomical site for the treatment of AVHs in schizophrenia patients.

[Validation of the French version of the self-evaluation of negative symptoms (SNS)]

INTRODUCTION

Schizophrenia is a disorder affecting 1% of the population and is associated with severe functional impairment. Negative symptoms are responsible for the majority of this impairment, and many patients with schizophrenia have negative symptoms. However, their evaluation is still a challenge. Thus, standardized assessments are needed to facilitate identification of these symptoms. Many tools have been developed, but most are based on observer ratings. Self-evaluation can provide an additional outcome measure and allow patients to be more engaged in their treatment. The Self-evaluation of Negative Symptoms (SNS) has been developed recently. This is a remarkably understandable instrument for patients with schizophrenia as it allows them to readily complete it without assistance, providing information with respect to their own perception of negative symptoms. The SNS is a self-assessment that permits patients to evaluate themselves in 5 dimensions of negative symptoms. This validation study for the SNS revealed good psychometric properties alongside satisfactory acceptance by patients.

AIM

This study was to confirm the validation of the French version of the self-evaluation of negative symptoms (SNS).

METHODS

Patients with schizophrenia or schizoaffective disorder according to the DSM-IV-R, with a stable regimen of anti-psychotic drugs for the last two months, aged more than 18 years old were eligible for the study. Symptoms were rated using the SNS, the Scale for the Assessment of Negative Symptoms (SANS), the Calgary Depression Scale for Schizophrenics (CDSS), the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression and Parkinsonism. Patients were asked to fulfill the SNS twice, 6 weeks apart.

RESULTS

Sixty patients were evaluated. Cronbach's coefficient (α=0.8) showed good internal consistency. The SNS significantly correlated with the SANS (r=0.6), the negative sub-score of the BPRS (r=0.6) and the Clinician Global Impression on the severity of negative symptoms (r=0.7). SNS scores did not correlate with level of insight (r=0.08) or Brief Psychiatric Rating Scale positive sub-scores (r=0.2). SNS scores correlated with CDSS scores. However, we did not find correlation between the first item of the CDSS which evaluates depression and the "diminished emotional range" sub-score of SNS. The test-retest of SNS revealed no changes of scores at two evaluations 6 weeks apart.

CONCLUSION

The acceptance by patients of the SNS was excellent. The French version of the SNS demonstrated a good internal consistency, good convergent validity and good discriminant validity. The study demonstrates the ability of patients with schizophrenia to accurately report their own experiences. Self-assessments of negative symptoms should be more widely employed in clinical practice because they may allow patients with schizophrenia to develop appropriate coping strategies.

Impact of rTMS on functional connectivity within the language network in schizophrenia patients with auditory hallucinations

This exploratory study investigated the functional connectivity (FC) in the language network in schizophrenia patients (SZ) with auditory verbal hallucinations (AVHs), and the therapeutic efficacy of rTMS on it. Eleven SZ with AVHs and 10 healthy controls (HC) underwent two fMRI sessions using a speech listening paradigm. SZ received 20Hz rTMS following the first fMRI session. Compared to HC, SZ showed a reduced FC in the language network. While AVHs improved after 12days, no changes in FC were observed. This suggests the efficacy of high-frequency rTMS on AVH without any impact for rTMS on FC within the language network.

Abnormalities of language pathways in schizophrenia patients with and without a lifetime history of auditory verbal hallucinations: A DTI-based tractography study

OBJECTIVES

Auditory verbal hallucinations (AVHs) are frequently observed in patients with schizophrenia (SZ) and could be the result of white matter (WM) fibre abnormalities involved in speech production/comprehension and perception. We evaluated WM integrity changes in SZ with (SZ+) and without (SZ-) lifetime AVHs compared to healthy controls (HCs), using diffusion tensor imaging-based tractography, with a novel focus on the structural connectivity within both intra- and interhemispheric fasciculi.

METHODS

The study included 27 SZ+, 12 SZ- and 34 HCs. Fractional anisotropy (FA) and mean and radial diffusivities (MD and RD) were extracted in each participant in two left interhemispheric fasciculi and in the interhemispheric auditory pathway (IAP) to test integrity differences among groups.

RESULTS

SZ- and SZ + compared to HCs presented increased diffusivities and/or decreased FA in the interhemispheric fasciculi. Decreased FA was significant only between SZ + and HCs for the IAP.

CONCLUSIONS

In this first comparison of integrity changes within both intra- and interhemispheric fasciculi, abnormalities in the intrahemispheric fasciculi were observed in both SZ- and SZ+, but an alteration in the IAP was seen only in SZ+. These results suggest that the IAP may be more involved in patients with AVHs-proneness.

Relationships between corpus callosum and language lateralization in patients with schizophrenia and bipolar disorders

OBJECTIVES

The question of whether there is a continuum or a dichotomy among patients with schizophrenia (SZ) and bipolar disorders (BD) has not been clearly resolved and remains a challenge. Thus, the identification of specific biomarkers of these disorders might be helpful. The present study investigated the volume of the corpus callosum (CC) and functional lateralization for language as potential biomarkers and their relationships in SZ and BD.

METHODS

The study included 20 patients with SZ, 20 patients with BD and 40 healthy controls (HC). A functional lateralization index (FLI) was computed for each participant within the language comprehension network. For each participant, the volume of the total CC and those of three subregions were extracted. These variables and their anatomo-functional relationships were investigated.

RESULTS

In comparison to HC, SZ patients presented a decreased leftward lateralization for language, whereas this was not found in BD patients. However, as compared to SZ patients and HC, BD patients showed a reduction in CC volume associated with a lower leftward lateralization for language.

CONCLUSIONS

Our study revealed that SZ patients displayed a reduction of the leftward functional lateralization for language; however, no reduction of CC volume was observed, whereas BD patients presented a decreased volume of the CC associated with a lower leftward asymmetry for language. The results of our study detected distinct anomalies in both SZ and BD that may be considered as specific biomarkers of these disorders related to neurodevelopmental models.

Network modeling of resting state connectivity points towards the bottom up theories of schizophrenia

The dysconnectivity theory of schizophrenia proposes that schizophrenia symptoms arise from abnormalities in neuronal synchrony. Resting-state Functional Connectivity (FC) techniques allow us to highlight synchronization of large-scale networks, the Resting-state Networks (RNs). A large body of work suggests that disruption of RN synchronization could give rise to specific schizophrenia symptoms. The present study aimed to explore within- and between-network FC strength of 34 RNs in 29 patients suffering from schizophrenia, and their relationships with schizophrenia symptoms. Resting-state data were analyzed using independent component analysis and dual-regression techniques. Our results showed that both within-RN and between-RN FC were disrupted in patients with schizophrenia, with a global trend toward weaker FC. This decrease affected more particularly visual, auditory and crossmodal binding networks. These alterations were correlated with negative symptoms, positive symptoms and hallucinations, indicating abnormalities in visual processing and crossmodal binding in schizophrenia. Moreover, we stressed an anomalous synchronization between a visual network and a network thought to be engaged in mental imaging processes, correlated with delusions and hallucinations. Altogether, our results supported the assumption that some schizophrenia symptoms may be related to low-order sensory alterations impacting higher-order cognitive processes, i.e. the "bottom-up" hypothesis of schizophrenia symptoms.

Negative symptoms: History of the concept and their position in diagnosis of schizophrenia

Current conceptualizations of schizophrenia have been introduced over centuries and continue to progress in recent decades. Symptoms have been divided into several domains, contrasting negative and positive symptoms which are different in their nature, onset, progression and response to treatment. An account of the different historical changes of the concept – essentially nosographic – has led to models attempting to integrate findings for each dimension of the disorder. This paper reviews the history of negative symptoms in diagnosis and how different approaches have been utilised to consider negative symptoms in the concept of schizophrenia. The paper also bridges various international classifications which have evolved and modified the role of negative symptoms in their diagnostic criteria for schizophrenia, which highlights the challenge of defining this disease.

Current developments and challenges in the assessment of negative symptoms

Reliable and valid assessment of negative symptoms is crucial to further develop etiological models and improve treatments. Our understanding of the concept of negative symptoms has undergone significant advances since the introduction of quantitative assessments of negative symptoms in the 1980s. These include the conceptualization of cognitive dysfunction as separate from negative symptoms and the distinction of two main negative symptom factors (avolition and diminished expression). In this review we provide an overview of existing negative symptom scales, focusing on both observer-rated and self-rated measurement of negative symptoms. We also distinguish between measures that assess negative symptoms as part of a broader assessment of schizophrenia symptoms, those specifically developed for negative symptoms and those that assess specific domains of negative symptoms within and beyond the context of psychotic disorders. We critically discuss strengths and limitations of these measures in the light of some existing challenges, i.e. observed and subjective symptom experiences, the challenge of distinguishing between primary and secondary negative symptoms, and the overlap between negative symptoms and related factors (e.g. personality traits and premorbid functioning). This review is aimed to inform the ongoing development of negative symptom scales.