The impact of emotion awareness and regulation on psychotic symptoms during daily functioning.

Emotion regulation (ER) difficulties are ubiquitous among individuals with schizophrenia and have been hypothesized to contribute to stress sensitivity and exacerbation of psychotic symptoms in this population. However, the evidence supporting this link is equivocal, potentially due to previous studies' reliance on retrospective assessments of ER and psychosis, as well as lack of consideration of putative moderators such as emotion awareness. To address these limitations, we employed experience sampling method using mobile electronic devices to investigate the links between momentary in vivo use of ER strategies (mER), emotion awareness, and psychotic symptoms during daily functioning. Fifty-four individuals with schizophrenia completed assessment of mER and psychotic symptoms, along with traditional retrospective measures of ER and symptoms. Use of mER suppression predicted significant increases in momentary experiences of thought insertion, mind reading, auditory and visual hallucinations. Use of mER reappraisal predicted significant increases in momentary experiences of suspiciousness, thought insertion, and mind reading. Emotion awareness, driven primarily by difficulties identifying feelings, moderated the impact of ER on psychotic symptoms. There were no associations between retrospective measures of ER and symptoms. Our results indicate that, among individuals with schizophrenia, emotion awareness significantly impacts the relationship between use of ER and exacerbations in psychotic symptoms during the course of daily functioning. Our results highlight the need to incorporate emotion awareness and regulation difficulties into the development of treatment models and interventions for psychosis. In addition, our results underscore the need to employ in vivo, high time-resolution assessment methods to study dynamic clinical phenomena such as ER and psychotic symptoms.

The Impact of Hypomania on Aerobic Capacity and Cardiopulmonary Functioning-A Case Report.

Background: Hypomanic episodes are characterized by increased goal-directed behavior and psychomotor agitation. While the affective, cognitive, and behavioral manifestations of such episodes are well-documented, their physiological influence on aerobic capacity and cardiopulmonary functioning are unknown. Methods: We describe a case report of an individual with schizophrenia who experienced a hypomanic episode while serving as a control participant (wait list) in a single-blind, randomized clinical trial examining the impact of aerobic exercise (AE) on neurocognition in people schizophrenia. As part of the trial, participants completed two scheduled clinical assessments and cardiopulmonary exercise tests (VO2max) at baseline and 12 weeks later at end of study. All participants received standard psychiatric care during the trial. Following a baseline assessment in which he displayed no evidence of mood lability, the subject returned on Week-12 for his scheduled follow-up assessment displaying symptoms of hypomania. He was able to complete the follow-up assessment, as well as third assessment 2 weeks later (Week-14) when his hypomanic symptoms ebbed. Results: While not engaging in AE, the subject's aerobic capacity, as indexed by VO2max, increased by 33% from baseline to Week-12. In comparison, participants engaged in the aerobic exercise training increased their aerobic capacity on average by 18%. In contrast, participants in the control group displayed a small decline (-0.5%) in their VO2max scores. Moreover, the subject's aerobic capacity increased even further by Week-14 (49% increase from baseline), despite the ebbing of his hypomania symptoms at that time. These changes were accompanied by increases in markers of aerobic fitness including peak heart rate, respiratory exchange rate, peak minute ventilation, watts, and peak systolic blood pressure. Resting systolic and diastolic blood pressure, and peak diastolic blood pressure remained unchanged. Conclusions: Our findings suggest that hypomania produce substantial increase in aerobic capacity and that such elevations may remain sustained following the ebbing of hypomanic symptoms. Such elevations may be attributed to increased mobility and goal-directed behavior associated with hypomania, as individuals in hypomanic states may ambulate more frequently, for longer duration, and/or at higher intensity. Our results provide a first and unique view into the impact of hypomania on aerobic capacity and cardiopulmonary functioning.

Autonomic Regulation and Auditory Hallucinations in Individuals With Schizophrenia: An Experience Sampling Study.

Auditory Hallucinations (AH) cause substantial suffering and dysfunction, yet remain poorly understood and modeled. Previous reports have linked AH to increases in negative emotions, suggesting a role for the autonomic nervous system (ANS) in underlying this link. Employing an Experience Sampling Method (ESM) approach, 40 individuals with schizophrenia completed a 36-hour ambulatory assessment of AH and cardiac autonomic regulation. Participants carried mobile electronic devices that prompted them to report 10 times/d the severity of their momentary AH, along with a Holter monitor that continuously recorded their cardiac autonomic regulation. The clocks of the devices and monitors were synchronized, allowing for high time-resolution temporal linking of the AH and concurrent autonomic data. Power spectral analysis was used to determine the relative vagal (parasympathetic) contribution to autonomic regulation during 5 minutes prior to each experience sample. The participants also completed interview-based measures of AH (SAPS; PSYRATS). The ESM-measured severity of AH was significantly correlated with the overall SAPS-indexed AH severity, along with the PSYRATS-indexed AH frequency, duration, loudness, degree of negative content, and associated distress. A mixed-effect regression model indicated that momentary increases in autonomic arousal, characterized by decreases in vagal input, significantly predicted increases in ESM-measured AH severity. Vagal input averaged over the 36-hour assessment displayed a small but significant inverse correlation with the SAPS-indexed AH. The results provide preliminary support for a link between ANS regulation and AH. The findings also underscore the highly dynamic nature of AH and the need to utilize high time-resolution methodologies to investigate AH.

Aerobic Exercise in People with Schizophrenia: Neural and Neurocognitive Benefits.

Schizophrenia is characterized by extensive neurocognitive deficits, which are linked to greater disability, poorer functional outcome, and have been suggested to impact daily functioning more than clinical symptoms. Aerobic exercise (AE) has emerged as a potential intervention. This review examines the impact of AE on brain structure and function along with neurocognitive performance in individuals with schizophrenia. Preliminary evidence indicates that AE can increase hippocampal volume and cortical thickness, in addition to exerting a neuroprotective effect against hippocampal volume decrease and cortical thinning. There is also evidence that AE is able to significantly increase serum brain-derived neurotrophic factor (BDNF) levels, which are implicated in neurogenesis, neuroplasticity, and cognitive improvement. Finally, evidence suggests that AE plays a significant role in improving overall cognition, including improvements in processing speed, working memory, and visual learning. The authors discuss the implications of the findings and provide recommendations for future research and areas of inquiry.

Use of Active-Play Video Games to Enhance Aerobic Fitness in Schizophrenia: Feasibility, Safety, and Adherence.

OBJECTIVE: Active-play video games have been used to enhance aerobic fitness in various clinical populations, but their use among individuals with schizophrenia has been limited. METHODS: Feasibility, acceptability, safety, and adherence data were obtained for use of aerobic exercise (AE) equipment by 16 individuals with schizophrenia during a 12-week AE program consisting of three one-hour exercise sessions per week. Equipment included exercise video games for Xbox 360 with Kinect motion sensing devices and traditional exercise equipment. RESULTS: Most participants (81%) completed the training, attending an average of 79% of sessions. The proportion of time spent playing Xbox (39%) exceeded time spent on any other type of equipment. When using Xbox, participants played 2.24±1.59 games per session and reported high acceptability and enjoyment ratings, with no adverse events. CONCLUSIONS: Measures of feasibility, acceptability, adherence, and safety support the integration of active-play video games into AE training for people with schizophrenia.

Depressed mood in individuals with schizophrenia: A comparison of retrospective and real-time measures.

Depressed mood is prevalent among individuals with schizophrenia, leading to difficulties in functioning. Typically, depressed mood is evaluated using retrospective assessments during which individuals are asked to recall their mood during the past week or month. However, as individuals with schizophrenia may display memory difficulties, the results of such assessments may be biased, potentially leading to inaccurate clinical characterizations and/or suboptimal treatment. Our aim was to assess the potential impact of long-term memory on depressed mood in individuals with schizophrenia. Employing an Experience Sampling Method (ESM) approach, 51 individuals with schizophrenia and 22 healthy controls rated their momentary emotions up to 10 times/day over a two-day period, along with retrospective measures of depressed mood, long-term memory, quality of life, social functioning, and symptoms. ESM assessment of real-time depressed mood demonstrated discriminant and convergent validity. Among the schizophrenia group, there was a significant correlation between the real-time and retrospective measures of depressed mood. However, once variance due to long-term memory was controlled, the relationship between the real-time and retrospective measure was no longer significant. The findings suggest that a real-time measure of depressed mood may allow overcoming some of the limitations associated with long-term memory difficulties common among individuals with schizophrenia.

The Impact of Aerobic Exercise on Brain-Derived Neurotrophic Factor and Neurocognition in Individuals With Schizophrenia: A Single-Blind, Randomized Clinical Trial.

Individuals with schizophrenia display substantial neurocognitive deficits for which available treatments offer only limited benefits. Yet, findings from studies of animals, clinical and nonclinical populations have linked neurocognitive improvements to increases in aerobic fitness (AF) via aerobic exercise training (AE). Such improvements have been attributed to up-regulation of brain-derived neurotrophic factor (BDNF). However, the impact of AE on neurocognition, and the putative role of BDNF, have not been investigated in schizophrenia. Employing a proof-of-concept, single-blind, randomized clinical trial design, 33 individuals with schizophrenia were randomized to receive standard psychiatric treatment (n = 17; "treatment as usual"; TAU) or attend a 12-week AE program (n = 16) utilizing active-play video games (Xbox 360 Kinect) and traditional AE equipment. Participants completed assessments of AF (indexed by VO2 peak ml/kg/min), neurocognition (MATRICS Consensus Cognitive Battery), and serum-BDNF before and after and 12-week period. Twenty-six participants (79%) completed the study. At follow-up, the AE participants improved their AF by 18.0% vs a -0.5% decline in the TAU group (P = .002) and improved their neurocognition by 15.1% vs -2.0% decline in the TAU group (P = .031). Hierarchical multiple regression analyses indicated that enhancement in AF and increases in BDNF predicted 25.4% and 14.6% of the neurocognitive improvement variance, respectively. The results indicate AE is effective in enhancing neurocognitive functioning in people with schizophrenia and provide preliminary support for the impact of AE-related BDNF up-regulation on neurocognition in this population. Poor AF represents a modifiable risk factor for neurocognitive dysfunction in schizophrenia for which AE training offer a safe, nonstigmatizing, and side-effect-free intervention.

Aerobic fitness and body mass index in individuals with schizophrenia: Implications for neurocognition and daily functioning.

Previous reports indicate that among healthy individuals low aerobic fitness (AF) and high body-mass index (BMI) predict poor neurocognition and daily-functioning. It is unknown whether these associations extend to disorders characterized by poor neurocognition, such as schizophrenia. Therefore, we compared AF and BMI in individuals with schizophrenia and non-clinical controls, and then within the schizophrenia group we examined the links between AF, BMI, neurocognition and daily-functioning. Thirty-two individuals with schizophrenia and 64 gender- and age-matched controls completed assessments of AF (indexed by VO2max) and BMI. The former also completed measures of neurocognition, daily-functioning and physical activity. The schizophrenia group displayed significantly lower AF and higher BMI. In the schizophrenia group, AF was significantly correlated with overall neurocognition (r=0.57), along with executive functioning, working memory, social cognition, and processing speed. A hierarchical regression analysis indicated that AF accounted for 22% of the neurocognition variance. Furthermore, AF was significantly correlated with overall daily-functioning (r=0.46). In contrast, BMI displayed significant inverse correlations with neurocognition, but no associations to daily-functioning. AF was significantly correlated physical activity. The authors discuss the potential use of AF-enhancing interventions to improve neurocognitive and daily-functioning in schizophrenia, along with putative neurobiological mechanisms underlying these links, including Brain-Derived Neurotrophic Factor.

Use of mobile assessment technologies in inpatient psychiatric settings.

Mobile electronic devices (i.e., PDAs, cellphones) have been used successfully as part of research studies of individuals with severe mental illness living in the community. More recently, efforts have been made to incorporate such technologies into outpatient treatments. However, few attempts have been made to date to employ such mobile devices among hospitalized psychiatric patients. In this article, we evaluate the potential use of such devices in inpatient psychiatric settings using 33 hospitalized patients with schizophrenia. Employing an Experience Sampling Method approach, we provide support for the feasibility of using such devices, along with examples of potentially clinically-relevant information that can be obtained using such technologies, including assessment of fluctuations in the severity of psychotic symptoms and negative mood in relation to social context, unit location, and time of day. Following these examples, we discuss issues related to the potential use of mobile electronic devices by patients hospitalized at inpatient psychiatric settings including issues related to patients' compliance, assessment schedules, questionnaire development, confidentiality issues, as well as selection of appropriate software/hardware. Finally, we delineate some issues and areas of inquiry requiring additional research and development.

Emotional granularity and social functioning in individuals with schizophrenia: an experience sampling study.

Previous research has shown that healthy individuals who fail to differentiate among emotional states (i.e., those with low emotional granularity; EG) have poorer social functioning (SF) than those with high EG. It is unknown, however, whether these associations extend to clinical disorders characterized by impaired SF, such as schizophrenia. In the present study, we compared SF and EG in individuals with schizophrenia and healthy controls, and then, within the schizophrenia group, we examined the links between EG and SF. Employing an Experience Sampling Method approach, 77 individuals with schizophrenia and 27 healthy controls rated their momentary emotions (sadness, anxiety, anger, and happiness) up to 10 times/day over a two-day period using mobile electronic devices. For each participant, we then calculated the within-subject average correlations among the momentary emotion ratings, producing two EG indices - EGIall for all emotions and EGIneg for negative ones. A subsample of participants with schizophrenia also completed self-report, interview, and ability-based measures of SF. Compared to healthy controls, individuals with schizophrenia displayed significantly poorer SF and lower EGIall, but comparable EGIneg. Within the schizophrenia group, hierarchical multiple regression analyses indicated that EGIall, but not EGIneg, significantly predicted social dysfunction after controlling for emotional awareness, symptoms, and emotional intensity and variability. Our findings indicate that individuals with schizophrenia have a relatively intact ability to differentiate among negative emotions in everyday life. However, they experience significant difficulties differentiating between positive and negative emotions, and this may contribute to their social difficulties.

Emotion awareness and regulation in individuals with schizophrenia: Implications for social functioning.

Successful social functioning requires adaptive forms of emotion awareness and regulation. However, despite well-documented deficits in social functioning in individuals with schizophrenia, little is known about emotion awareness and regulation in this population. Therefore, we compared emotion awareness and regulation in individuals with schizophrenia and healthy controls, and then, within the schizophrenia group, we examined their impact on social functioning. Forty-four individuals with schizophrenia and 20 healthy controls completed measures of emotion awareness, emotion regulation, and social functioning, in addition to control measures, including neurocognitive functioning. Compared to controls, individuals with schizophrenia displayed significant deficits describing and identifying their emotions and used significantly less reappraisal and more suppression to regulate their emotions. Among the schizophrenia group, better social functioning was associated with the ability to identify, and in particular to describe emotions, better emotion management, as well as greater use of reappraisal and less use of suppression. A hierarchical multiple regression analysis indicated that, after controlling for age and neurocognition, difficulties describing feelings accounted for 35% of the social functioning variance. The present study highlights the importance of emotion awareness and regulation in schizophrenia, pointing to their substantial influence on social functioning above and beyond the impact of neurocognitive functioning.

Risperidone associated weight, leptin, and anthropometric changes in children and adolescents with psychotic disorders in early treatment.

OBJECTIVE: To document prospective weight and anthropometric changes in children and adolescents during the first 12 weeks of treatment with risperidone and evaluate metabolic outcomes including plasma leptin levels. METHOD: Eight patients with psychotic disorders (ages 11-17) who had started risperidone (mean: 1.80 mg/day; sd = 1.04) in the prior 4 weeks participated in this observational study. Fasting morning blood samples were obtained at baseline and week 8 to assess glucose, leptin, cortisol, insulin, and triglycerides. Measures of body mass index (BMI), weight, waist and hip circumference, blood pressure, and heart rate were obtained weekly. RESULTS: Participants increased in mean weight (4.16 kg; sd = 4.36; p = 0.03) and BMI (1.47 kg/m(2); sd = 1.53; p = 0.03) with five out of eight gaining at least 7% of baseline body weight. They had a 4.03 cm (sd = 3.82; p = 0.02) increase in waist circumference and a 5.17 cm (sd = 3.68; p = 0.01) increase in hip circumference. Leptin trended higher, but did not reach statistical significance. There were no significant changes in glucose, insulin, cortisol, blood pressure, or heart rate. CONCLUSION: Subjects experienced significant increases in weight, BMI, hip and waist circumference during the first 3 months of treatment. Better powered research with more advanced anthropometric assessment is warranted to further elucidate mechanisms of antipsychotic associated weight gain in youth.

Effectiveness of medications used to attenuate antipsychotic-related weight gain and metabolic abnormalities: a systematic review and meta-analysis.

Antipsychotic-related weight gain and metabolic effects are a critical outcome for patients requiring these medications. A literature search using MEDLINE, Web of Science, PsycNET, and EMBASE for randomized, open and double-blind, placebo-controlled trials of medications targeting antipsychotic-induced weight gain was performed. Primary outcome measures were change and endpoint values in body weight and body mass index (BMI). Secondary outcomes included >or=7% weight gain, all-cause discontinuation, change in waist circumference, glucose and lipid metabolism parameters, and psychiatric symptoms. Sensitivity analyses were conducted to explain heterogeneity of the results. Across 32 studies including 1482 subjects, 15 different medications were tested: amantadine, dextroamphetamine, d-fenfluramine, famotidine, fluoxetine, fluvoxamine, metformin, nizatidine, orlistat, phenylpropanolamine, reboxetine, rosiglitazone, sibutramine, topiramate, and metformin+sibutramine. Compared with placebo, metformin had the greatest weight loss (N=7, n=334, -2.94 kg (confidence interval (CI:-4.89,-0.99)), followed by d-fenfluramine (N=1, n=16, -2.60 kg (CI:-5.14,-0.06)), sibutramine (N=2, n=55, -2.56 kg (CI:-3.91,-1.22)), topiramate (N=2, n=133, -2.52 kg (CI:-4.87,-0.16)), and reboxetine (N=2, n=79, -1.90 kg (CI:-3.07,-0.72)). Weight loss remained significant with metformin initiation after weight gain had occurred, but not when started concomitantly with antipsychotics. Nausea rates were not higher with any treatment compared with placebo. In all, 5 of 15 psychopharmacologic interventions aimed at ameliorating antipsychotic-induced weight gain outperformed placebo. Results were most robust for metformin, although these were modest and heterogeneous. Only one (negative) combination treatment study was available and head-to-head studies are absent. None of the agents were able to entirely reverse weight gain because of antipsychotics. At present, no treatment has sufficient evidence to recommend broad clinical usage. Antipsychotics with no or minimal cardiometabolic liability, as well as interventions that prevent or normalize adverse antipsychotic cardiometabolic effects are needed.