[French translation and validation of the Scale to assess Unawareness of Mental Disorder (SUMD) in patients with schizophrenics]. / Traduction et validation française de l'échelle d'évaluation de la conscience des troubles mentaux des patients schizophrènes: the Scale to assess Unawareness of Mental Disorder (SUMD).

BACKGROUND: The Scale to assess Unawareness of Mental Disorder (SUMD) is a semi-structured interview based on a dimensional and quantitative approach of insight. Different forms of insight are assessed: global insight into mental illness, insight into symptoms and insight into symptom aetiology (i.e. attribution). The SUMD divides the recognition of mental disorders into two concepts: awareness of, and attribution for mental disorders. Awareness relates to the subject's ability to recognize that the phenomenon in question is present, whereas attribution refers to explanations as to cause or source of these signs or symptoms. Thus, the scale distinguishes between the recognition of a symptom and its explanation. For example, the scale allows the investigator to distinguish between a patient's ability to recognize visual hallucinations as such (false perceptions), from his/her ability to explain their cause (e.g. due to mental illness or not). OBJECTIVE: The aim of this study was to translate the SUMD (version 3.1 revised) and test its convergent validity among 43 French adult inpatients diagnosed with schizophrenia according to DSM-IV-TR criteria. METHODS: Awareness of mental disorder was assessed using the SUMD and the Hamilton Rating Scale for Depression (HAMD) insight item (item 17) respectively, as done in the original English validation study. The SUMD was translated into French then back-translated into English. The back-translation was performed by both English and French native speakers who had no prior knowledge of the scale (the back translation was reviewed by one of the SUMD's authors, Dr Amador, for accuracy). The SUMD manual (v.2/14/99) was also translated into French. Concerning the SUMD directions followed in this study, the first three SUMD items, which are called general items: G1 "Awareness of mental disorder", G2 "Awareness of the achieved effects of medication" and G3 "Awareness of the social consequences of mental disorder" were systematically rated. However, symptom items (four through 20) are not always relevant for every patient. Indeed, for each symptom-item on the scale, it must first be ascertained that the patient has exhibited the particular symptom during the period under investigation. Therefore, for every patient, the symptom checklist was completed prior to filling out the scale, in order to determine which symptom-items were relevant. In addition, symptom attribution items are rated only if the subject received a score between 1 and 3 on the awareness item. Two periods of time of insight were assessed: "current" insight involved rating the highest level of awareness obtained at the time of the interview for the psychopathology present at anytime during the past 7 days. "Past" insight was defined as the present level of awareness during the period of time preceding the current period of investigation. RESULTS: The French translation of the SUMD achieved good convergent validity with the insight item of the Hamilton rating scale for depression. DISCUSSION: The SUMD has proven to be a reliable and valid instrument to assess insight into schizophrenia. The more psychometrically sound rating tools we have at our disposal, many of which have been published in non French journals, the more we will be able to sharpen our assessment of insight into schizophrenia. We are facing an epistemic paradox in which quantification helps description, i.e. we need to have access to different rating tools to measure insight in order to improve our knowledge of the causes, course and treatment of poor insight into mental disorders.

Medications and verbal memory impairment in schizophrenia: the role of anticholinergic drugs.

BACKGROUND: We wished to assess the effect of three types of medication on verbal memory impairments in schizophrenia. METHOD: Forty-eight patients with schizophrenia and 40 healthy control subjects underwent a battery of verbal memory tasks, including free recall, recognition and short-term memory span. All the patients were on antipsychotic medication. In addition, 24 were taking anticholinergic drugs (benztropine) and 30 were taking benzodiazepines. A subsample of 39 had clinical ratings for depressive symptoms. Regression analyses were conducted on the memory measures in this subsample, with negative symptoms, depression, type of antipsychotic medication (conventional v. atypical), benzodiazepines and anticholinergic drugs as predictors. RESULTS: Type of antipsychotic medication made no significant contribution to memory deficits and benzodiazepine use made very little contribution. However, anticholinergic medication was a predictor of memory impairment, especially with regard to semantic organization. Complementary analyses revealed that patients taking any type of drug with anticholinergic activity (benztropine and/or antipsychotic agents) were significantly impaired relative to the other patients on measures reflecting free recall efficiency and semantic organization. CONCLUSIONS: Drugs with anticholinergic activity are the major pharmacological agents that contribute to the verbal memory deficit observed in patients with schizophrenia. These drugs appear to act by impeding semantic organization at encoding.

Perceptual asymmetries in schizophrenia: subtype differences in left hemisphere dominance for dichotic fused words.

OBJECTIVE: Dichotic listening techniques have been used to study hemispheric dominance for language in schizophrenia. The authors' goal was to compare subjects with paranoid and undifferentiated subtypes of schizophrenia. METHOD: The Fused Rhymed Words Test was used to compare perceptual asymmetries in 16 patients with paranoid schizophrenia, 28 patients with undifferentiated schizophrenia, and 29 healthy comparison subjects. RESULTS: Patients with paranoid schizophrenia had the largest left hemisphere advantage and patients with undifferentiated schizophrenia had the smallest. The asymmetry of healthy subjects was intermediate. Hemisphere advantage varied as a function of gender only in the patients with undifferentiated schizophrenia. CONCLUSIONS: The findings support the hypotheses that undifferentiated schizophrenia is associated with underactivation of left hemisphere resources for verbal processing and that paranoid schizophrenia is characterized by preserved left hemisphere processing.

Event-related brain potentials (ERPs) in schizophrenia for tonal and phonetic oddball tasks.

BACKGROUND: Prior studies using simple target detection ("oddball") tasks with pure tones have reported asymmetric reduction of the P3 event-related potential (ERP). This study investigated the time course and topography of ERPs recorded during both tonal and phonetic oddball tasks. METHODS: Event-related potentials of 66 patients (14 unmedicated) diagnosed with schizophrenia (n = 46) or schizoaffective disorder (n = 20) and 32 healthy adults were recorded from 30 scalp electrodes during two oddball tasks using consonant-vowel syllables or complex tones. Overlapping ERP components were identified and measured by covariance-based principal components analysis. RESULTS: Schizophrenic patients showed marked, task-independent reductions of early negative potentials (N1, N2) but not reduced P3 amplitude or abnormal P3 asymmetry. Task-related hemispheric asymmetries of the N2/P3 complex were similar in healthy adults and schizophrenic patients. Poorer task performance in patients was related to ERP amplitudes, but could not account for reductions of early negativities. CONCLUSIONS: The findings suggest that both patients and control subjects activated lateralized cortical networks required for pitch (right frontotemporal) and phoneme (left parietotemporal) discrimination. Task-independent reductions of negativities between 80 and 280 msec after stimulus onset suggest a deficit of automatic stimulus classification in schizophrenia, which may be partly compensated by later effortful processing.

Clinical and cognitive factors associated with verbal memory task performance in patients with schizophrenia.

OBJECTIVE: The authors have previously shown the role of depression, slowing of processing speed, and selective attention deficit in verbal memory task performance in schizophrenia. They wished to determine the specific contribution of each of these factors to various types of memory impairment. METHOD: The negative symptom score from the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale score, a measure of processing speed, and a measure of selective attention were entered as predictors in regression analyses. Furthermore, analyses of covariance were conducted on the memory measures to test the significance of the differences between schizophrenic patients and healthy comparison subjects after control for processing speed and selective attention. RESULTS: Depression was associated only with deep encoding reflected by semantic clustering. Selective attention was associated only with superficial encoding reflected by serial recall. Slowing of processing speed was associated with both deep and superficial encoding. Negative symptoms were not associated with memory impairment except for the avolition item from the Scale for the Assessment of Negative Symptoms. Processing speed accounted for all the group differences on the memory measures that reflected superficial encoding. In addition, a subgroup of patients with no or minor depression was not significantly impaired on deep encoding relative to the healthy comparison group. CONCLUSIONS: The authors suggest that verbal memory impairment in schizophrenia is a consequence of depression and slowness, rather than a primary feature of the disease.

Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features.

OBJECTIVE: Deficits in insight have been found in one study to be more common and severe in patients with schizophrenia than in patients with schizoaffective and major depression with and without psychosis but not more severe than they are in patients with bipolar disorder. The goals of this study were to replicate this finding independently and to clarify whether patients with schizophrenia differ from patients with bipolar disorder in a larger study group. METHOD: Using the Scale to Assess Unawareness of Mental Disorder, the authors evaluated 29 inpatients with schizophrenia, 24 with schizoaffective disorder, and 183 with mood disorders with psychotic features (153 with bipolar disorder and 30 with unipolar depression). RESULTS: Patients with schizophrenia had poorer insight than patients with schizoaffective disorder and patients with psychotic unipolar depression but did not differ from patients with bipolar disorder. CONCLUSIONS: The lack of significant differences between patients with schizophrenia and patients with bipolar disorder was not a result of low statistical power. This replication and more detailed examination of diagnostic group differences in insight have clinical, theoretical, and nosological implications.

Cognitive-behavioral therapy in schizophrenia.

The authors review the literature on cognitive-behavioral approaches to the treatment of schizophrenia. They begin by providing a historical context to explain the recent resurgence of interest in this area. Next, they provide an overview of studies of cognitive-behavioral interventions that target poor insight, medication nonadherence, and refractory symptoms. Insight and nonadherence are emphasized because these are particularly common and problematic areas that present major stumbling blocks in the treatment of patients suffering from schizophrenia that are not yet sufficiently addressed by the interventions clinicians currently have in their treatment arsenal. The authors conclude that support exists for the efficacy of interventions derived from cognitive-behavioral approaches in improving some aspects of insight into illness, increasing adherence to medication, ameliorating the severity of symptoms, and mitigating other negative consequences of schizophrenia. Finally, the authors offer guidelines for future work in this area and emphasize the importance of identifying patients who are most likely to benefit from the use of cognitive-behavioral approaches.

Defending the unabomber: anosognosia in schizophrenia.

The use of recent psychiatric research in the defense of the 'Unabomber' (United States vs. Theodore Kaczynski) is a compelling example of how the gap between research and practice can have profound consequences on the practice of forensic psychiatry, psychology and the judicial process. In this case, educating the lawyers and the court about the research on poor insight in schizophrenia changed the defense strategy and ultimately the course of the trial.

Positive symptomatology and source-monitoring failure in schizophrenia--an analysis of symptom-specific effects.

Recent research has suggested that certain positive symptoms in patients with schizophrenia are linked to self monitoring/reality-monitoring deficits. We wished to investigate the association between such deficits and three specific symptoms: hallucinations, delusions and thought disorganisation. Forty patients with schizophrenia and 40 normal controls were administered a source-monitoring task. Twenty-four items were produced, either verbally by the experimenter, or verbally by the subject, or presented as pictures. Then, subjects were read a recognition list including the produced target items mixed with distractors. They were required to recognise the target items and to remember their source of production. The pattern of memory deficits has previously been reported (Brébion, G., Smith, M., Gorman, J., Amador, X., 1997. Discrimination accuracy and decision biases in different types of reality monitoring in schizophrenia. Journal of Nervous and Mental Disease 185, 247-253). The current analyses focussed on the false recognition of distractors, and on the errors in the source attribution of the recognised target items. Results showed that higher hallucination scores were associated with an increased tendency towards false recognition of non-produced items. In addition, hallucinators were more prone than control subjects to misattribute to another source the items they had produced themselves. Furthermore, hallucinators and delusional patients were more prone than the other patients to report that spoken items had been presented as pictures. This latter finding suggests that both hallucinations and delusions are associated with confusion between imagined and perceived pictures. Our previous report stated that only one of the three investigated types of response bias was associated with global positive symptomatology. However, this finer-grained analysis revealed that the three of them were in fact associated with hallucinations and/or delusions. On the other hand, thought disorganisation appeared to be independent from these mechanisms.

Depression, psychomotor retardation, negative symptoms, and memory in schizophrenia.

OBJECTIVE: The purpose of this study was to examine the relations between depression, psychomotor retardation, and negative symptoms in schizophrenia as well as the specific contribution of each of these factors to memory impairment. BACKGROUND: It has been suggested that depression overlaps with negative symptomatology in schizophrenia. The relation between psychomotor retardation and negative symptomatology has been unclear. METHOD: The Hamilton Depression Rating Scale, The Positive and Negative Symptom Scale for Schizophrenia, and Scale for the Assessment of Negative Symptoms were used to assess depressive and negative symptomatology in a sample of patients with schizophrenia. Verbal memory performance was assessed by a free recall test. Two indices of processing speed were measured. Correlations among variables were computed. RESULTS: Depression score was correlated with the avolition item from the Scale for the Assessment of Negative Symptoms and with both measures of processing speed. Negative symptomatology was unrelated to processing speed. Memory performance was correlated with depression score, slowing of processing speed, and avolition. Its correlation with depression score and processing speed remained significant when the other factors were partialled out. CONCLUSIONS: Memory performance in schizophrenia may be affected by lack of motivation, psychomotor retardation, and depression. It is suggested that negative symptoms could be split between a volitional component linked to depression and cognitive efficiency and an emotional component unrelated to them.

Relation of familial schizophrenia to negative symptoms but not to the deficit syndrome.

OBJECTIVE: Although a family history of schizophrenia has been associated with negative symptoms, family history is inconsistently related to the presence of the deficit syndrome. METHOD: The authors assessed family history and the deficit syndrome in 99 patients with DSM-III-R-diagnosed schizophrenia who were assessed during clinical treatment. Of these 99 patients, 45 were assessed both while antipsychotic free and during antipsychotic treatment to index their treatment response. RESULTS: Patients with (N=39) and without (N=60) a family history of schizophrenia had similar proportions of the deficit syndrome. Yet family history and deficit syndrome categorizations identified a group with greater negative symptoms on the Positive and Negative Syndrome Scale. Those with a family history had greater emotional withdrawal, poor rapport, and lack of spontaneity. Groups with and without the deficit syndrome similarly differed in these symptoms but also in affective blunting, motor retardation, and passive or apathetic social withdrawal. The study involving antipsychotic-free and antipsychotic treatment phases showed main medication effects explaining positive, psychopathology, depression, and activation symptoms but not negative symptoms. Only patients without a family history had improved negative symptoms with antipsychotic treatment. CONCLUSIONS: Patients with a family history of schizophrenia had greater and more treatment-resistant negative symptoms than those without a family history. They were not more likely to have the deficit syndrome. The group with a family history had more pathology only in negative symptoms related to psychosocial function. The stable negative symptoms specifically related to the genetic vulnerability to inherit schizophrenia might be those associated with psychosocial functioning.

Memory and schizophrenia: differential link of processing speed and selective attention with two levels of encoding.

The purpose of this study was to investigate how underlying cognitive deficits such as a defect in processing speed or in selective attention contributed to different types of memory impairment observed in schizophrenia (superficial vs deep encoding). 49 schizophrenic patients and 40 normal controls were administered a verbal memory task. Superficial encoding was assessed by the ability to recall items in their serial order. Deep encoding was assessed by the ability to organise words into semantic categories. Two measures of processing speed (Digit Symbol Substitution Test and Stroop colour time) and one measure of selective attention (Stroop test) were used. Regression analyses were carried out. In the patient group, processing speed contributed to both superficial and deep encoding, and to a global verbal memory score. Selective attention only contributed to the superficial encoding processes. Thus, slowing of processing speed in schizophrenia seems to be more crucial for memory performance, since it affects memory in a pervasive way.

Reliability of the life chart schedule for assessment of the long-term course of schizophrenia.

We report on the inter-rater reliability of the Life Chart Schedule (LCS). The LCS is designed to assess the long-term course of schizophrenia in four key domains (symptoms, treatment, residence, and work) over two time periods (past two years, entire period of illness). The subjects were 27 consecutive admissions to a schizophrenia research unit. The LCS was filled out by pairs of raters, blinded to each others' ratings, using the same data (interview with subject and chart). Reliability was examined for 45 LCS ratings selected from all four domains and both time periods. Selected ratings pertained to the duration of specified experiences, the quality of these experiences, and the long-term time trend. The kappa statistic and the intra-class correlation coefficient (ICC) were used to determine inter-rater reliability for continuous and categorical ratings, respectively. LCS ratings proved reliable in all four key domains and both time periods. The reliability was fair to excellent for ratings of duration of experience (ICC ranged from 0.53 to 0.99), quality of experience (kappa ranged from 0.46 to 0. 92) and long-term time trends (kappa ranged from 0.66 to 0.94). The LCS can be used to obtain reliable ratings of the long-term course of schizophrenia in multiple domains.

Brain event-related potentials (ERPs) in schizophrenia during a word recognition memory task.

Impairments of recognition memory for words and attenuation of the ERP 'old-new' effect have been found in patients with left medial temporal lobe damage. If left temporal lobe dysfunction in schizophrenia involves medial structures (e.g. hippocampus), then schizophrenic patients might show similar abnormalities of verbal recognition memory. This study recorded ERPs from 30 electrode sites while subjects were engaged in a continuous word recognition memory task. Results are reported for 24 patients having a diagnosis of schizophrenia (n = 16) or schizoaffective disorder (n = 8) and 19 age-matched healthy controls. Both patients and controls showed the expected 'old-new' effect, with greater late positivity to correctly recognized old words at posterior sites, and there was also no significant difference between groups in P3 amplitude. However, accuracy of word recognition memory was poorer in patients than controls, and patients showed markedly smaller N2 amplitude. Reduced amplitudes of N2 and N2-P3 were associated with poorer performance, with highest correlations over the left inferior parietal (N2) and left medial parietal (N2-P3) region. Moreover, patients failed to show significantly greater left than right hemisphere amplitude of N2-P3 at posterior sites, which was seen for healthy controls. These findings suggest that impaired word recognition in schizophrenia may arise from a left lateralized deficit at an early stage of processing, beginning at 200-300 ms after word onset.

Suicidal behavior in schizophrenia: characteristics of individuals who had and had not attempted suicide.

OBJECTIVE: This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt. METHOD: Participants were interviewed with the Diagnostic Interview for Genetic Studies. RESULTS: Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed. CONCLUSIONS: Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.

Stability of the diagnosis of deficit syndrome in schizophrenia.

OBJECTIVE: Primary, enduring negative symptoms have been distinguished from negative symptoms more generally and are used to define the deficit syndrome of schizophrenia. Although the validity of the deficit syndrome has been demonstrated by using brain imaging, neuropsychological, illness outcome, and developmental history data, the stability of this diagnostic category has not been tested prospectively by using direct patient assessments. METHOD: Forty-three outpatients with schizophrenia and schizoaffective disorder were categorized into deficit and nondeficit groups an average of 3.8 years after having been previously categorized. RESULTS: There was 83% agreement between initial and blind follow-up designations of deficit status and 88% agreement on the nondeficit categorization. CONCLUSIONS: These results provide evidence for the long-term stability of the deficit syndrome in patients with schizophrenia and the reliability of the deficit/nondeficit categorization when diagnosed by those with appropriate training. Furthermore, they validate the method of categorizing deficit patients by using cross-sectional and retrospective data.

Left temporal lobe dysfunction in schizophrenia: event-related potential and behavioral evidence from phonetic and tonal dichotic listening tasks.

BACKGROUND: Asymmetric reduction of the P3 event-related potential (ERP) has provided evidence of left temporal lobe dysfunction in schizophrenia. Prior studies have been limited by reliance on simple target detection (oddball) tasks with pure tones. This study investigated the time course and topography of ERPs to binaural syllables or complex tones in dichotic listening tasks. METHODS: Event-related potentials of 26 patients meeting criteria for schizophrenia (n = 19) or schizoaffective disorder (n = 7) and 26 healthy controls were recorded from 30 scalp electrodes during 2 dichotic tasks in which different syllables or complex tones were simultaneously presented to each ear. A principal components analysis was used to derive factor scores corresponding to overlapping components in ERP waveforms--N1, N2, P3, and a late-positive potential. RESULTS: Healthy controls showed a right ear advantage for perceiving dichotic syllables, which was associated with greater N2 amplitude at left than right temporoparietal sites. Patients with schizophrenia did not show either this perceptual or N2 asymmetry. Patients also had smaller late-positive potential amplitude when compared with controls for both syllables and complex tones, with greatest decrement over left temporal sites. CONCLUSIONS: A right ear advantage in healthy adults for perceiving consonant-vowels was associated with a left-lateralized ERP component peaking at 200 milliseconds after syllable onset (N2). Patients with schizophrenia failed to show either of these task-dependent asymmetries, which may indicate a dysfunction of left temporal regions involved in phonetic classification. A task-independent asymmetric reduction of a later positive potential in patients with schizophrenia resembled left temporal P3 reductions reported for auditory oddball tasks.

Opposite links of positive and negative symptomatology with memory errors in schizophrenia.

We wished to confirm and extend a previous correlational study of our group, suggesting that positive symptoms in schizophrenia were linked to an increase in certain types of memory errors, and negative symptoms to a decrease in other types of errors. A post-hoc analysis was conducted in 33 schizophrenic patients and 40 normal control subjects on memory errors collected in a free recall task and two types of recognition tasks. The memory errors were intrusions and list errors in free recall, and decision bias towards false alarms in recognition, all assumed to reflect a source-monitoring failure. In a first analysis, the patient sample was split along the median for positive symptoms as rated by the Scale for the Assessment of Positive Symptoms (SAPS). In a second analysis, it was split along the median for negative symptoms as rated by the Scale for the Assessment of Negative Symptoms (SANS). Patients with high ratings of positive symptoms made more memory errors (intrusions, list errors, false alarms) than those with low ratings, supporting the hypothesis of a link between positive symptomatology and source-monitoring failure. On the other hand, patients with high ratings of negative symptoms made fewer of these errors than the other patients. Fewer errors were specifically associated with more affective flattening, alogia and anhedonia, whereas avolition was entirely unrelated to them.

Word recognition, discrimination accuracy, and decision bias in schizophrenia: association with positive symptomatology and depressive symptomatology.

The purpose of this experiment was to replicate and extend to a memory task Bentall and Slade's (1985) finding that hallucinations in schizophrenic patients were linked to a liberal decision bias. A word recognition task was administered to 40 schizophrenic patients and 40 normal controls that yielded two indices of performance: an index of discrimination accuracy (Pr) and one of decision bias (Br). Patients obtained a lower Pr than controls, whereas Br was similar in both groups. In patients, Br was selectively correlated with positive symptomatology: the more the positive symptoms, the more liberal the bias. In particular, there was a specific correlation between decision bias and hallucinations. Conversely, Pr was inversely correlated with severity of depression, but not with either positive or negative symptoms. Thus, positive symptomatology may be linked more to difficulties in distinguishing between representations of internal versus external events than to deficits in encoding external events.

Summer birth and the deficit syndrome of schizophrenia.

OBJECTIVE: Patients with the deficit syndrome differ from other patients with schizophrenia relative to physiological correlates, course of illness, and response to treatment. Because of the abnormal seasonality of birth among persons with schizophrenia, the authors examined the relation between this risk factor and the deficit syndrome. METHOD: Findings in two clinical groups suggested an increase in summer births among deficit syndrome patients. The association between summer birth and the deficit syndrome was then examined in a catchment area study of first-admission patients with psychosis. RESULTS: In the catchment area sample, summer birth was also significantly associated with the deficit syndrome; negative symptoms broadly defined were not. CONCLUSIONS: These findings add to the increasing evidence that 1) patients with the deficit syndrome have a disease with an etiopathophysiology separate from that of other patients with what is now called schizophrenia and 2) the correlates of broadly defined negative symptoms are different from those for the deficit syndrome. The previously reported association between winter birth and schizophrenia appears to apply to nondeficit schizophrenia only.