Predictors of community functioning in schizophrenia and substance use disorder patients.

Community functioning is a broad term that encompasses various 'real world' measures of disability among schizophrenia patients. It includes outcomes such as independent living, social competence and behavioural problems-all of which are priorities for treatment among schizophrenia patients, mental health care providers, and family members. An important goal for rehabilitation programs is to identify predictors of community functioning which, in turn, could be used as targets for intervention. The present case-control study examined socio-demographic and substance use disorder (SUD) variables as well as psychiatric, extrapyramidal, and cognitive symptoms as predictors of community functioning in schizophrenia patients with (DD patients; n=31) and without comorbid SUDs (SCZ patients; n=31), and non-psychosis substance abusers (SUD patients; n=39). Psychiatric and extrapyramidal symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia and the Extrapyramidal Symptoms Rating Scale. Cognition was evaluated using the Cambridge Neuropsychological Test Automated Battery (speed of processing, explicit and working memory). In SCZ patients, community functioning was predicted by explicit memory performance. In DD patients, community functioning was predicted by substance abuse, depression and speed of processing. In SUD patients, community functioning was predicted by substance abuse, positive symptoms and education. Our results suggest that cognition should be among the top treatment priorities in SCZ patients, whereas the key treatment targets in DD patients should be substance abuse and depression. Future studies will need to replicate the current findings, using prospective research designs.

Could the use of energy drinks induce manic or depressive relapse among abstinent substance use disorder patients with comorbid bipolar spectrum disorder?

OBJECTIVE: The potential harmful effects of excessive caffeine consumption remain largely unknown among psychiatric populations. Energy drinks have particularly high levels of caffeine content and have previously been shown to induce psychotic relapse. Clinical observations of three bipolar disorder patients with comorbid substance use disorder revealed an excessive consumption of energy drinks prior to manic or depressive relapse. BACKGROUND: Three patients with bipolar spectrum disorder and comorbid substance use disorder were assessed by a psychiatrist upon re-admission to a rehabilitation centre following manic or depressive relapse. The assessment was based on DSM-IV criteria and performed by a psychiatrist who specialized in bipolar spectrum disorder and comorbidities to determine the presence of manic or depressive relapse. Two patients were diagnosed with bipolar disorder type I, and the third with bipolar disorder type II. All three patients were diagnosed with comorbid substance use disorders and all three abused cocaine. RESULTS: In all three cases, relapse occurred following at least one week of excessive binging on energy drinks, with a maximum daily consumption of nine cans. Following cessation of energy drink consumption, two of the patients remained abstinent from drug use and maintained psychiatric stability. One patient relapsed three months post-treatment and resumed consuming cocaine and energy drinks. CONCLUSIONS: These clinical observations support other case reports that suggest the existence of a potential correlation between excessive energy drink consumption and relapse among psychiatric populations.

Is the Mood Disorder Questionnaire an appropriate screening tool in detecting bipolar spectrum disorder among substance use populations?

BACKGROUND: Bipolar spectrum disorder (BSD) has been shown to be difficult to assess in general and is further complicated by the presence of substance use disorder (SUD). OBJECTIVE: To review the specificity of the Mood Disorder Questionnaire (MDQ) in detecting BSD among substance abusers. METHOD: A retrospective chart review was conducted using 183 SUD patients who were screened using the MDQ and later assessed by a psychiatrist specializing in BSD. RESULTS: Among SUD patients scoring positive results on the MDQ for the presence of BSD, the BSD diagnosis could only be confirmed in 23% of the sample by an expert psychiatrist. CONCLUSIONS: The MDQ reports low specificity in detecting BSD among SUD populations. SCIENTIFIC SIGNIFICANCE: Physicians should question individuals on substance use behaviors if BSD is suspected due to high rates of comorbidity and diagnostic challenges.

Extrapyramidal symptoms in substance abusers with and without schizophrenia and in nonabusing patients with schizophrenia.

Extrapyramidal symptoms (EPS) such as parkinsonism, dystonia, dyskinesia, and akathisia are conditions of impaired motor function, which are associated with chronic antipsychotic treatment in schizophrenia. In addition, EPS is often exacerbated by psychoactive substance (PAS) abuse, which is frequently observed in this population. Few studies, however, have investigated the contribution of PAS abuse on EPS in PAS-abusers without comorbid psychosis. This study compared the occurrence of EPS in outpatient schizophrenia patients with (DD group; n= 36) and without PAS abuse (SCZ group; n = 41) as well as in nonschizophrenia PAS abusers undergoing detoxification [substance use disorder (SUD) group; n = 38]. Psychiatric symptoms were measured using the Positive and Negative Syndrome Scale and the Calgary Depression Scale for schizophrenia. Extrapyramidal symptoms were evaluated with the Extrapyramidal Symptoms Rating Scale and the Barnes Akathisia Scale. SUD diagnoses were complemented with urine drug screenings. We found that DD patients exhibited significantly more parkinsonism than SCZ patients. Our subanalyses revealed that cocaine and alcohol abuse/dependence was responsible for the increase in parkinsonism in DD patients. Additionally, we found that SUD individuals exhibited significantly more akathisia than SCZ patients. In these latter individuals, subanalyses revealed that alcohol and cannabis abuse/dependence was responsible for the increase in akathisia. Our results suggest that PAS abuse is a contributor to EPS in individuals with and without schizophrenia.

Antipsychotic agents for the treatment of substance use disorders in patients with and without comorbid psychosis.

Substance dependence has serious negative consequences upon society such as increased health care costs, loss of productivity, and rising crime rates. Although there is some preliminary evidence that atypical antipsychotic agents may be effective in treating substance dependence, results have been mixed, with some studies demonstrating positive and others negative or no effect. The present study was aimed at determining whether this disparity originates from that reviewers separately discussed trials in patients with (DD) and without (SD) comorbid psychosis. Using electronic databases, we screened the relevant literature, leaving only studies that used a randomized, double-blind, placebo-controlled or case-control design that had a duration of 4 weeks or longer. A total of 43 studies were identified; of these, 23 fell into the category of DD and 20 into the category of SD. Studies in the DD category suggest that atypical antipsychotic agents, especially clozapine, may decrease substance use in individuals with alcohol and drug (mostly cannabis) use disorders. Studies in the SD category suggest that atypical antipsychotic agents may be beneficial for the treatment of alcohol dependence, at least in some subpopulations of alcoholics. They also suggest that these agents are not effective at treating stimulant dependence and may aggravate the condition in some cases.

Sleep habits in middle-aged, non-hospitalized men and women with schizophrenia: a comparison with healthy controls.

Patients with schizophrenia may have sleep disorders even when clinically stable under antipsychotic treatments. To better understand this issue, we measured sleep characteristics between 1999 and 2003 in 150 outpatients diagnosed with Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) schizophrenia or schizoaffective disorder and 80 healthy controls using a sleep habits questionnaire. Comparisons between both groups were performed and multiple comparisons were Bonferroni corrected. Compared to healthy controls, patients with schizophrenia reported significantly increased sleep latency, time in bed, total sleep time and frequency of naps during weekdays and weekends along with normal sleep efficiency, sleep satisfaction, and feeling of restfulness in the morning. In conclusion, sleep-onset insomnia is a major, enduring disorder in middle-aged, non-hospitalized patients with schizophrenia that are otherwise clinically stable under antipsychotic and adjuvant medications. Noteworthy, these patients do not complain of sleep-maintenance insomnia but report increased sleep propensity and normal sleep satisfaction. These results may reflect circadian disturbances in schizophrenia, but objective laboratory investigations are needed to confirm subjective sleep reports.

Sex differences in memory processing in schizophrenia: an event-related potential (ERP) study.

Recently, research has begun to examine sex differences in cognitive functions in schizophrenia and whether such sex differences reflect normal, exaggerated, or reversed sexual dimorphism. This study examined this question by using event-related potentials (ERPs). ERPs were recorded in a recognition memory task in 18 patients and 18 matched control subjects. On an early frontal component, the results show an interaction between sex and pathological condition that results in an apparent reversed sexual dimorphism. On mid-latency components, patients show no sex difference on a frontal component, but a difference on the posterior component, whereas healthy subjects show a reverse pattern. Finally, late components show sex difference in the same direction as healthy subjects. These results indicate that the influence of sex on the cognitive impairment in schizophrenia is not homogenous across the information-processing cascade.

Pain perception in schizophrenia: no changes in diffuse noxious inhibitory controls (DNIC) but a lack of pain sensitization.

BACKGROUND: Pain is a dynamic phenomenon resulting from the activity of both excitatory (e.g. sensitization) and inhibitory endogenous modulation systems. Preliminary experimental studies have shown diminished pain sensitivity in schizophrenia patients. The objective of the study was to investigate the role of excitatory and inhibitory systems on pain perception in schizophrenia. METHODS: Participants were 23 patients with a schizophrenia-spectrum disorder (DSM-IV criteria) and 29 healthy volunteers, who did not differ in age, sex or ethnicity. Excitatory and inhibitory systems were elicited using a temporal summation test (Peltier thermode) administered before and after activation of the diffuse noxious inhibitory control (DNIC) by means of a cold-pressor test. RESULTS: Time was a significant predictor of pain scores in controls, but not in patients. That is, pain ratings increased during the tonic thermal stimulation among controls but not in schizophrenia patients. When correlation coefficients (between time and pain ratings) for patients and controls were compared, the correlation coefficient emerged as significantly weaker in the schizophrenia group (Z=12.04; p=0.0001), suggesting a lack of sensitization in schizophrenia. DNIC was similar in magnitude in both patients and controls. CONCLUSIONS: Diminished pain sensitivity in schizophrenia may be related to abnormal excitatory mechanisms, but not to DNIC. More studies are needed to better characterize the neurophysiological and neurochemical mechanisms involved in the lack of sensitization in schizophrenia.

Working memory and depressive symptoms in patients with schizophrenia and substance use disorders.

BACKGROUND: Substance abuse is highly prevalent in schizophrenia and it has been associated with negative consequences on the course of the pathology. Regarding cognition, the prevailing literature has produced mixed results. Some groups have reported greater cognitive impairments in dual diagnosis schizophrenia, while other groups have described the reverse. OBJECTIVE: The current cross-sectional study sought to investigate the potential differences in psychiatric symptoms and cognition between schizophrenia patients with and without substance use disorders. METHODS: Fifty-three schizophrenia patients were divided into two groups: with (n=30) and without (n=23) a substance use disorder (DSM-IV criteria). Psychiatric symptoms were measured with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS). Psychomotor speed and spatial working memory were measured using Cambridge Neuropsychological Tests Automated Battery (CANTAB). RESULTS: Patients in the dual diagnosis group displayed more severe depressive symptoms and poorer strategy during the working memory task. CONCLUSIONS: These results are in keeping with the prevailing literature describing negative consequences of substance abuse in schizophrenia. Substance abuse may exacerbate depressive symptoms and interfere with metacognition in schizophrenia.

Use of the process dissociation procedure to study the contextual effects on face recognition in schizophrenia: familiarity, associative recollection and discriminative recollection.

Contextual effects were explored in schizophrenia patients and paired comparison subjects during a long-term face recognition task. The objective was to investigate the contextual effects on face recognition by manipulating, in the same experiment, the perceptual context of the face (intrinsic vs. extrinsic) and the task context (inclusion vs. exclusion instructions). The situation was derived from the Jacoby's [Jacoby, L.L., 1991. A process dissociation framework: separating automatic from intentional uses of memory. Journal of Memory and Language 30, 513-541] process dissociation procedure. The results showed that schizophrenia patients (N=20) presented lower performances than healthy controls (N=20) in the inclusion but not in the exclusion task. This observation emphasizes the heterogeneity of recollection and suggests that the memory impairment in schizophrenia reflects an imbalance between two mechanisms. The first is a deficit in "associative recollection", i.e., the failure to use efficiently associative information. The other is an enhanced "discriminative recollection" that impedes their capacity to process information separately from its perceptual context. In addition, correlation with symptoms suggest that the former is expressed in the loosening of associations characteristic of disorganization symptoms, whereas the latter reflects the lack of flexibility or the contextualization bias related to psychotic symptoms, i.e., delusions and hallucinations.

The relationships between symptom dimensions and dysphoria in schizophrenia.

Previous studies have suggested that qualitatively distinct aspects of dysphoria (anxiety and depression) are related to specific dimension of schizophrenia symptomatology. Most of these studies used simple dimensions and dysphoria models, although finer distinctions could help defining specific relationships. This study examined the relationships of distinctive aspects of depression and anxiety (both state and trait) with symptom dimensions. Forty patients with a DSM-IV diagnosis of schizophrenia were assessed for symptoms (SAPS-SANS), trait and state anxiety (STAI) and depression (CDS). Symptoms ratings were summarized as dimensional scores according to a two-, three- or five-dimensional models proposed in the literature. The correlation analysis replicates previous observations that distinct aspects of dysphoria are associated with specific dimensions of schizophrenia, with the exception of disorganization. Moreover, controlling for intercorrelated variables revealed that schizophrenia and dysphoric symptoms might act in combination and/or through indirect links to contribute to illness expression. Our data further suggested that these associations may be best understood in terms of interactions between various processing biases alluded in the most recent cognitive accounts of schizophrenia symptoms.

Are there common mechanisms in sensation seeking and reality distortion in schizophrenia? A study using memory event-related potentials.

A growing literature suggests that the characteristics of sensation seeking and reality distortion expressed in schizophrenia share several mechanisms. In a previous study, the comparison of patients with high vs. low reality distortion using event-related potentials (ERPs) recorded in a recognition memory task for unfamiliar faces identified neural and cognitive anomalies specifically related to the expression of these symptoms. As a follow-up, this study investigated the ERP correlates of sensation seeking in schizophrenia using the same recognition memory protocol. ERPs have been recorded in controls (N=21) and schizophrenia patients separated into high (HSS; N=13) and low (LSS; N=17) scorers according to Zuckerman's Sensation Seeking Scale. The results show a reduced P2a that was found unrelated to reality distortion in the previous study of reality distortion. It identifies interference inhibition impairment as being specifically related to sensation seeking. On the other hand, HSS scorers display enhanced fronto-central and normal P600 effects also found in high reality distortion patients. These results indicate inappropriate context processing and mnemonic binding common to sensation seeking and reality distortion. LSS scorers also display a reduced temporal N300 similar to that found in low reality distortion patients. This anomaly could reflect the lower reactivity to emotionally significant stimuli that underlies anhedonia symptoms. Finally, the N400 effect and a late frontal effect are found in both HSS and LSS. Since they were unrelated to reality distortion, these indices have been related to basic aspects of schizophrenia, e.g., deficient knowledge integration, or other mechanisms, e.g. anxiety or impulsivity. In summary, the present study examines the strategy of investigating variables, such as temperamental characteristics, in addition to symptoms, to show how discrete impairments may contribute to the expression of the illness.

The cognitive and anatomo-functional basis of reality distortion in schizophrenia: a view from memory event-related potentials.

This study investigated the neural and cognitive correlates of reality distortion in schizophrenia by using event-related potentials (ERPs) recorded in a recognition memory task for face. This task has been chosen because previous studies have shown that it provides distinct indices related to specific cognitive processes and to the functioning of specific brain regions. ERPs have been recorded in controls and schizophrenia patients separated into high scorers (RD+) and low-scorers (RD-) according to their Reality Distortion score (hallucination and delusion SAPS subscales). The results indicate that RD+ presents abnormalities on various cognitive processes. First, RD+ are deficient at interference inhibition and knowledge integration (reduced P2a and N400 effect). The similar impairments found in RD- suggest that they represent basic traits of the illness. Second, RD+ showed inappropriate stimulus categorization and contextual integration (larger N300 and fronto-central effect). Third, RD+ showed a late index (P600 effect) not different from controls, but larger than in RD-. This result is consistent with a qualitative, rather than quantitative, impairment of mnemonic binding processes (inappropriate binding) in RD+. Since each of the ERP abnormalities observed represents associated with distinct brain dysfunction, the results are further discussed in regard of the respective contribution of the parietal, frontal and hippocampal structures to reality distortion symptoms.

Sensation-seeking, social anhedonia, and impulsivity in substance use disorder patients with and without schizophrenia and in non-abusing schizophrenia patients.

Substance use disorders (SUDs) are common in patients with schizophrenia and this comorbidity is associated with a poorer prognosis, relative to non-abusing patients. One hypothesis that has been advanced in the literature is that dual diagnosis (DD) patients may have a different personality profile than non-abusing schizophrenia patients. The present case-control study aimed to characterize levels of personality traits (sensation-seeking, social anhedonia, and impulsivity) in substance abuse/dependence patients with (DD group; n=31) and without schizophrenia (SUD group; n=39), relative to non-abusing schizophrenia patients (SCZ group; n=23), and healthy controls (n=25). Impulsivity was assessed using the Barratt Impulsivity Scale. Sensation-seeking was assessed using the Zuckerman Sensation Seeking Scale. Social anhedonia was assessed with the Chapman Social Anhedonia Scale. We found that sensation-seeking was significantly higher in DD and SUD, relative to SCZ patients. We found that social anhedonia was significantly elevated in DD and SCZ, relative to healthy controls. We found that impulsivity was significantly higher in DD, SCZ and SUD patients, compared to healthy controls. The results suggest that sensation-seeking is prominent in substance abuse/dependence (irrespective of schizophrenia), social anhedonia is prominent in schizophrenia (irrespective of substance abuse/dependence), and impulsivity is prominent in all three populations.

Contribution of orodental status to the intensity of orofacial tardive dyskinesia: an interdisciplinary and video-based assessment.

BACKGROUND: Tardive dyskinesia (TD) is a neurological motor complication eventually arising in one-third of patients chronically exposed to antipsychotic drugs. Some orodental peripheral factors have been reported to influence TD. OBJECTIVE: To measure orodental factors such as temporomandibular joint function, static occlusal contacts, and denture condition, and attempt correlations with orofacial TD intensity. METHODS: In this exploratory cross-sectional pilot study, 31 subjects between 30 and 75 years of age were divided in two groups displaying minimal to mild, or moderate to severe orofacial TD, respectively, and underwent a detailed oral, dental, and prosthetic evaluation to capture various aspects of oral health compared between the two groups. Blinded video-based TD ratings along a validated scale were obtained to compare dentulous and edentulous subjects, and contrast TD intensity in complete denture wearers with and without their own prostheses. RESULTS: None of the factors examined tightly correlated with orofacial TD intensity. However, edentulism was associated with a higher median orofacial TD rating compared to the dentulous group (p = 0.001). Further, a significant intra-subject difference was observed in the edentulous subjects rated with their own complete dentures in place or not (p = 0.028), the dentures attenuating the mean orofacial ratings by 21.8 ± 7.3%. CONCLUSION: Of all orodental factors considered, only edentulism and complete denture wearing influenced oral TD expression, calling for the close monitoring of the dental status in antipsychotic drug-exposed patients to prevent tooth loss. Further studies to measure the impact of an adequate prosthodontic rehabilitation in edentulous subjects with orofacial TD seem warranted.

Evolution of Substance use, Neurological and Psychiatric Symptoms in Schizophrenia and Substance use Disorder Patients: A 12-Week, Pilot, Case-Control Trial with Quetiapine.

Neurological and psychiatric symptoms are consequences of substance abuse in schizophrenia and non-schizophrenia patients. The present case-control study examined changes in substance abuse/dependence, and neurological and psychiatric symptoms in substance abusers with [dual diagnosis (DD) group, n = 26] and without schizophrenia [substance use disorder (SUD) group, n = 24] and in non-abusing schizophrenia patients (SCZ group, n = 23) undergoing 12-week treatment with the atypical antipsychotic, quetiapine. Neurological and psychiatric symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, the Extrapyramidal Symptoms Rating Scale, and the Barnes Akathisia Rating Scale. At endpoint, DD and SCZ patients were receiving significantly higher doses of quetiapine (mean = 554 and 478 mg/day, respectively), relative to SUD patients (mean = 150 mg/day). We found that SUD patients showed greater improvement in weekly dollars spent on alcohol and drugs and SUD severity, compared to DD patients. At endpoint, there was no significant difference in dollars spent, but DD patients still had a higher mean SUD severity. Interestingly, DD patients had significantly higher parkinsonism and depression than SCZ patients at baseline and endpoint. On the other hand, we found that SUD patients had significantly more akathisia at baseline, improved more than SCZ patients, and this was related to cannabis abuse/dependence. Finally, SUD patients improved more in Positive and Negative Syndrome Scale positive scores than DD and SCZ patients. Taken together, our results provide evidence for increased vulnerability to the adverse effects of alcohol and drugs in schizophrenia patients. They also suggest that substance abuse/withdrawal may mimic some symptoms of schizophrenia. Future studies will need to determine the role quetiapine played in these improvements.

Clinical evolution of substance use disorder patients during treatment with quetiapine: a 12-week, open-label, naturalistic trial.

OBJECTIVE: Substance use disorders (SUDs) are associated with a variety of psychiatric disorders and mood and behavioral instability. Growing evidence suggests that the atypical antipsychotic quetiapine may be useful in the treatment of SUDs. The primary objective of the current open-label trial was to examine the effects of quetiapine on SUD outcomes in patients entering detoxification. METHODS: Thirty-three nonpsychosis SUD patients participated. Patients received quetiapine for a 12-week beginning in detoxification. Craving, quantities used and psychiatric symptoms were evaluated on baseline and at end point. RESULTS: Out of 33 recruited patients, 26 completed > 9 weeks of treatment. Last observation carried forward (LOCF) analyses revealed that craving, SUD severity and quantities used improved during the study. Psychiatric and depressive symptoms also improved. CONCLUSIONS: Our results cannot be attributed per se to the pharmacological effects of quetiapine owing to the open-label design of the study, the small sample size involved and the fact that patients were involved in an intensive therapy program. Nevertheless, our results indicate that quetiapine may be helpful for the treatment of SUD patients entering detoxification. Controlled studies are warranted to determine whether these results are quetiapine-related.

Relationship between psychotic and obsessive compulsive symptoms in schizophrenia.

The presence of obsessive compulsive symptoms (OCSs) in schizophrenia was recognized as early as the first descriptions of the illness. Studies investigating the association between OCSs and schizophrenia have defined their co-occurrence in terms of co-morbidity and compared schizophrenia patients separated into groups according to whether they presented OCSs or not. However, most of these studies did not take both the complexity of the schizophrenia phenomenology and that of OCSs into account. The present research investigates the relationship between schizophrenia symptoms and OCSs using a correlational approach with a dimensional perspective in order to determine how the OCSs contribute to symptom expression in schizophrenia. Fifty nine schizophrenia patients were rated for schizophrenia symptoms (SAPS-SANS) and OCSs (Y-BOCS). Schizophrenia symptoms scores were collapsed into four dimensional scores and OCSs into for other dimensional scores. The latter were entered as explanatory variables to determine their associations with schizophrenia dimension scores using series of stepwise regression models. The results showed a strong positive relationship between Delusions and Obsessions consistent with the view that they reflect manifestations of the similar mechanisms. Similar results indicate an association between Auditory hallucinations and Compulsions also suggesting that they share common mechanisms. On the other hand, there were inverse relationships between Somatic Obsessions and Disorganization and between Hoarding/Collecting Compulsions and Delusions or Auditory hallucinations. These results may reflect that these OCSs have a protective effect against disorganization and psychotic symptoms respectively.

Temperament and executive dysfunctions in schizophrenia.

Recent studies suggest that both executive dysfunction and personality traits combine with symptoms to affect the social outcome of persons with schizophrenia. This study was designed to investigate how personality traits influence executive function in schizophrenia. Forty-four patients with schizophrenia and twenty-two healthy subjects were assessed for personality using the temperament and character inventory. Different aspects of executive function were assessed using the Auditory Digit Span (forward and backward) and the Wickens' test for proactive interference and release. The results showed that the influences of the various temperament dimensions on specific aspects of executive functions differ between patients and healthy subjects. On some dimensions, schizophrenia appears to reduce the cognitive differences related to temperament. On other dimensions, schizophrenia tends to reverse the cognitive differences related to temperament observed in healthy people. These results suggest that the temperamental profile of schizophrenia patients may well be of important prognostic value in the planning of cognitive enhancement therapy.