Electroretinogram and cue-elicited craving in withdrawn cocaine-dependent patients: a replication.

BACKGROUND: We previously reported that cocaine-dependent patients with a reduced blue cone b wave electroretinogram (ERG) responses had significantly more cue-elicited craving. METHODS: A new series of 21 recently withdrawn cocaine-dependent patients completed a craving questionnaire at baseline and following cue exposure; an ERG was also performed. RESULTS: Cocaine-dependent patients with a blunted ERG blue cone response (<0.5 microV) showed greater increases in craving following cue exposure. When subjects were included from our preliminary study (N = 14), these differences became highly significant. CONCLUSIONS: Patients with a reduced ERG response may represent a subgroup more vulnerable to cocaine craving and future relapse.

The efficacy and safety of clozapine versus chlorpromazine in geriatric schizophrenia.

BACKGROUND: There has been an absence of controlled studies focusing specifically on neuroleptic treatment in the elderly schizophrenic population. Therefore, we conducted a 12-week double-blind comparison study to assess the efficacy and tolerability of clozapine and chlorpromazine in a group of elderly inpatients with chronic schizophrenia. METHOD: Forty-two elderly DSM-IV schizophrenic veterans were randomly assigned to clozapine or chlorpromazine and assessed for efficacy at baseline and at termination with the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impressions scale (CGI). Side effects were also monitored. Medications were titrated, on the basis of clinical response and side effects, to a maximum dose of 300 mg/day of clozapine or 600 mg/day of chlorpromazine. RESULTS: The results suggest that both the chlorpromazine and clozapine groups improved their PANSS scores at termination compared with baseline, but the difference between the 2 groups was not statistically significant. The mean CGI scores reflecting severity of illness also demonstrated improvement in both groups over time. Both groups had similar incidences of side effects. One patient in each group had a life-threatening side effect. More patients taking clozapine had tachycardia and weight gain, while more chlorpromazine patients noted sedation. CONCLUSION: We concluded that both clozapine and chlorpromazine are effective treatments for psychosis and behavioral disturbances in geriatric schizophrenia. Both agents had similar incidences of side effects. With careful monitoring and titration of dosage, both clozapine and chlorpromazine were fairly well tolerated in this population.

Obsessions and compulsions as a distinct cluster of symptoms in schizophrenia: a neuropsychological study.

Using neurocognitive testing, the present study assessed whether obsessions and compulsions could represent a distinct cluster of symptoms in schizophrenia. We formulated our hypothesis based on data from nonschizophrenic patients, expecting to find that schizophrenic patients with obsessive-compulsive (OC) symptoms would experience more difficulties in the same cognitive areas as nonschizophrenic patients with obsessive-compulsive disorder (OCD). Patients had separate psychiatric and cognitive evaluations. The OC and non-OC schizophrenic subjects did not differ significantly on the positive and negative symptom scores. However, compared with non-OC schizophrenic patients, those with OC symptoms performed worse on cognitive areas thought to be impaired (i.e., visual-spatial skills, delayed nonverbal memory, and cognitive shifting abilities). In addition, the severity of OC scores correlated with poor performance in these areas of cognition. Our results support our hypothesis, specifically that OC symptoms may constitute a distinct cluster separate from psychosis in schizophrenia and raise the possibility of a distinct subtype of schizophrenia. The theoretical and clinical implications of these findings are discussed.

Regional cerebral blood flow changes associated with risperidone treatment in elderly schizophrenia patients: a pilot study.

Although there is evidence that some schizophrenia patients may have altered regional cerebral blood flow patterns, few studies have addressed the relationship between cortical activity and changes in psychiatric symptoms following treatment, particularly in the elderly. We took advantage of an existing safety and tolerance study of risperidone in the elderly and examined the possible relationship between changes in psychiatric symptoms following risperidone and changes in relative cortical perfusion in a group of 6 elderly schizophrenia patients. All subjects were at least 65 years old and diagnosed with schizophrenia according to DSM-III-R criteria. The patients were assessed using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and Mini-Mental Status Examination (MMSE) and had single photon emission computed tomography (SPECT) studies before and at least 3 weeks after change of their previous neuroleptic to risperidone. The frontal/total cortex and temporal/total cortex counts in the slice ratios, and 99mTechnitium-hexamethylpropylene amine oxime (99mTc-HMPAO) percentage uptake in the whole cortical area in the slice were used for data analysis. With risperidone, patients (age 66-81) scored better on the PANSS, particularly in the positive symptom subtests. The changes in positive symptom scores correlated directly with those in frontal and temporal relative activity and 99mTc-HMPAO percentage uptake in the whole cortical area in the slice. Our findings suggest that the improvement in psychotic symptoms after risperidone is associated with a decrease in frontal and temporal activity and a reduction in 99mTc-HMPAO percentage uptake in the entire cortical area in the slice and agree with data from younger populations. Comparative studies assessing the therapeutic impact of neuroleptics on cortical activity in different age groups could be helpful in examining both the mechanisms of action of various drugs and the links between symptoms and specific brain areas.

Treatment of obsessive-compulsive symptoms in schizophrenic patients with clomipramine.

Recent studies show that obsessive-compulsive symptoms may occur in many patients with schizophrenia and may predict a poor prognosis. Pilot studies have shown that some schizophrenic patients may improve if a serotonin reuptake blocker is added to their neuroleptic. We have performed a pilot, double-blind, crossover study of clomipramine (CMI) or placebo, added to maintenance psychotropic medication. Six schizophrenic patients with obsessive-compulsive symptoms were studied in a double-blind CMI versus placebo crossover protocol. The patients met DSM-III-R criteria for chronic schizophrenia, experienced obsessive-compulsive symptoms, and had been previously stabilized on their psychiatric medication. The patients were rated at baseline and longitudinally through the study with the Positive and Negative Symptom Scale for Schizophrenia (PANSS) and the Yale Brown Obsessive-Compulsive Scale (YBOCS). An analysis of covariance was used to compare the drug versus placebo effect at the final visit with the baseline rating as a covariate. Ratings on both the YBOCS and the PANSS showed that patients improved significantly more on CMI than on placebo. No patients experienced an exacerbation of psychotic symptoms. Preliminary findings from this double-blind, crossover, pilot study of CMI and placebo, designed to assess the effect of CMI in the treatment of schizophrenic patients with obsessive symptoms, suggest that CMI is superior to placebo in the treatment of obsessions and compulsions and improves overall schizophrenic symptoms. Further studies with larger samples and longer follow-up period are necessary to confirm these preliminary findings.

Severity of symptoms in chronically institutionalized geriatric schizophrenic patients.

OBJECTIVE: The goal of this study was to characterize the symptoms of geriatric, chronically ill, institutionalized schizophrenic patients and investigate age-related differences in schizophrenic symptoms and cognitive performance from early adulthood to late senescence. METHOD: The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitive performance, respectively, of 393 institutionalized schizophrenic patients stratified into seven groups designated by 10-year age intervals from 25 years to over 85 years. RESULTS: In the comparisons of the seven age groups, significant differences between groups in positive and negative subscale scores on the Positive and Negative Syndrome Scale and in Mini-Mental State scores were revealed. Significant correlations between Mini-Mental State scores and Positive and Negative Syndrome Scale negative symptom scores, but not positive symptom scores, were found for all age groups, except for the youngest patients studied. Current treatment with neuroleptics and prior treatment with ECT, insulin coma, or leukotomy could not account for the poor cognitive performance of the older schizophrenic patients. CONCLUSIONS: The older schizophrenic patients continued to experience psychotic and nonpsychotic symptoms in senescence. Their positive symptoms were moderately less severe and their negative symptoms and cognitive impairment were significantly more severe than those of the younger patients. Somatic treatment appeared not to be responsible for the severe cognitive impairment and negative symptoms of the older patients. These data are relevant to chronically hospitalized geriatric schizophrenic patients but not necessarily to all geriatric schizophrenic patients.

Lateralized visual-field inattention in schizophrenia.

Numerous studies have shown impaired verbal functioning in schizophrenic patients as compared with normals. The verbal deficits are generally attributed to damage of the left cerebral hemisphere. This attribution is based on literature which suggests that verbal processing is primarily mediated by the left hemisphere in right-handed humans. This study explored left-hemispheric integrity directly by assessing sustained attention in both the left and right hemispheres of 40 schizophrenic patients with the Weintraub Cancellation Tasks. Patients made significantly more errors of omission on the right visual field than on the left. These results are consistent with cognitive research in schizophrenia by demonstrating selective left-hemispheric impairment relative to right-hemispheric functioning.

Diagnostic issues in chronic schizophrenia: kraepelinian schizophrenia, undifferentiated schizophrenia, and state-independent negative symptoms.

Data are presented concerning three recent clinical distinctions in schizophrenia: kraepelinian versus non-kraepelinian patients; mixed versus simple undifferentiated subtypes; and state-dependent versus state-independent negative symptoms. Schizophrenic patients who have been ill and dependent on others for the past 5 years ('kraepelinians') were compared to other chronic schizophrenics. The kraepelinian patients met the criteria for schizophrenia by more diagnostic systems than other patients, were less responsive to haloperidol, had more severe negative symptoms and formal thought disorder, and had similarly severe positive symptoms. They also had cerebral ventricles that demonstrated more left-to-right asymmetry and a greater family history of schizophrenia spectrum disorders. Mixed undifferentiated schizophrenic patients, who met criteria for more than one schizophrenic subtype, were compared to simple undifferentiated schizophrenic patients, who met criteria for no subtype. The mixed group was characterized by more severe positive and negative symptoms and formal thought disorder, worse social functioning, and a worse response to haloperidol. In a subgroup of patients who were studied once while in a state of exacerbation and once while in a state of relative remission, the negative symptoms of inattention and affective flattening were state-dependent, while anhedonia-asociality was state-independent.

Changes in plasma homovanillic acid concentrations in schizophrenic patients following neuroleptic discontinuation.

Changes in plasma levels of the dopamine metabolite homovanillic acid have been reported to correlate with changes in the severity of schizophrenic symptoms during neuroleptic administration and after neuroleptic discontinuation. This study examined the effects of discontinuation of neuroleptic treatment on plasma homovanillic acid levels in 23 patients with chronic schizophrenia. It was hypothesized that clinical decompensation would be associated with increased plasma homovanillic acid levels. Plasma homovanillic acid was measured during administration of neuroleptic medication and during a subsequent 6-week drug-free period. Nine patients decompensated during the drug-free period and 14 patients did not. Following drug discontinuation, plasma homovanillic acid concentrations were higher in schizophrenic patients who decompensated than in those who did not. Furthermore, peak plasma homovanillic acid elevation after discontinuation of neuroleptic medication was significantly correlated with peak Brief Psychiatric Rating Scale increase. The data suggest that, in some schizophrenic patients, symptomatic decompensation after discontinuation of neuroleptic treatment is associated with increases in dopamine turnover.

Premorbid sociosexual functioning and long-term outcome in schizophrenia.

Chronic schizophrenic patients with the most severe social deterioration have been shown to differ from other chronic schizophrenic patients with respect to measures of left-to-right ventricular asymmetry, negative symptoms, and response to haloperidol treatment. In the current study, the authors investigated the social antecedents of these characteristics of very poor outcome schizophrenia in 69 chronic schizophrenic patients. Poor premorbid sociosexual functioning was associated with more severe left-to-right ventricular asymmetry, greater severity of negative symptoms, fewer positive symptoms, and worse current social functioning. These data suggest that factors associated with severe social deterioration in the end stage of schizophrenia are also associated with premorbid sociosexual impairment.

Memory impairment in schizophrenic patients with tardive dyskinesia.

Memory functioning was contrasted in 40 schizophrenic patients with and without tardive dyskinesia (TD). Visual and verbal memory tests were used to investigate specific types of impairments. The presence of TD was ascertained using the Abnormal Involuntary Movement Scale (AIMS). TD patients scored significantly lower than non-TD patients on two measures of visual learning, though no differences were found for verbal learning or immediate recall. These results are consistent with previous reports that schizophrenic patients with TD demonstrate impaired cognitive functioning. They also raise the possibility that the neurochemical and structural changes underlying TD may produce specific deficits in memory for visual materials. In addition, a significant relationship was found between total score on the Brief Psychiatric Rating Scale (BPRS) and performance on all of the test measures included in the cognitive test battery. This demonstrates the importance of attending to the overall level of schizophrenic symptomatology when evaluating results from experimental learning tasks.

Effects of debrisoquin and haloperidol on plasma homovanillic acid concentration in schizophrenic patients.

Plasma levels of the dopamine metabolite homovanillic acid (pHVA) may potentially reflect upon central dopamine activity. This study examines the effects of debrisoquin, haloperidol, and the two drugs combined on pHVA concentrations of schizophrenic patients. Debrisoquin is a drug that suppresses the peripheral formation of homovanillic acid without affecting the central formation. Acute haloperidol administration consistently increased pHVA concentrations in patients pretreated or not pretreated with debrisoquin, suggesting that this increment reflects haloperidol's central and not peripheral effects.

Familial schizophrenia and treatment response.

Thirty-nine patients with chronic schizophrenia for whom hospitalization was clinically indicated received haloperidol for 4 to 6 weeks in a standardized dose schedule. Responders were compared with nonresponders for family history, baseline symptom factors, and ventricle-brain ratio (VBR). The lifetime risk for schizophrenia spectrum disorders was higher among first-degree relatives of nonresponders than among first-degree relatives of responders. Treatment responders had higher baseline scores on the factors of activation and hostile-suspiciousness, but the groups did not differ in any other baseline symptom factor or in VBR. The authors suggest that there is an association between failure to respond to drugs and genetic loading for schizophrenia spectrum disorders.

Characteristics of very poor outcome schizophrenia.

The authors compared 21 "Kraepelinian" schizophrenic patients who had been ill and dependent on others for the past 5 years with 76 chronic schizophrenic patients in remission or with exacerbations requiring hospitalization. The Kraepelinian patients met the criteria for schizophrenia by more diagnostic systems than the exacerbated patients, were less responsive to haloperidol, had more severe negative symptoms, and had similarly severe positive symptoms. They had cerebral ventricles that were more asymmetrical and a greater family history of schizophrenia spectrum disorders than the other chronic patients. These data suggest that patients with 5 years of illness and complete dependency on others may represent a subgroup of schizophrenia.

L-dopa challenge and relapse in schizophrenia.

Neuroleptic administration has been shown to be superior to placebo in prolonging schizophrenic remission. However, individual patients are able to maintain long periods of remission in the absence of neuroleptic treatment, while others relapse soon after neuroleptic withdrawal. This study attempted to predict time to relapse in 28 schizophrenic patients withdrawn from neuroleptics and challenged with L-dopa for 7 days, then followed until relapse. Time to relapse correlated significantly with L-dopa-induced increase in BPRS score (p = .006). Five of six patients who responded to L-dopa relapsed within 4 weeks after L-dopa administration, while only four of 22 who did not respond relapsed in a comparable period.