Insight into illness in schizophrenia

Lack of insight of patients with schizophrenia into various aspects of their illness and treatment is an important clinical issue. Poor insight has been reported to be associated with neurocognitive deficits, particularly in the frontal and parietal functions. The aim of this study was to examine relationships between insight and cognitive and emotional function in patients with schizophrenia. Thirty-five male forensic patients suffering from chronic schizophrenia participated. The Scale for the Assessment of Unawareness of Mental Disorder was used to assess insight. Neuropsychological function was assessed with a comprehensive battery of tests. Clinical state was also assessed. Of 35 patients, 18 (51%) believed that they had a mental disorder. A similar proportion reported awareness of a need for medication and correctly attributed symptoms to illness. Measures of insight showed significant associations with visual object learning, verbal working memory, and identification of facial emotions but not with measures of frontal lobe function. Poorer insight was associated with a higher occurrence of violent events. Our findings support an association between poor insight and cognitive impairment in patients with chronic schizophrenia but suggest that the relationship may not specifically involve frontal lobe dysfunction.     

Clinical and neuropsychological correlates of insight in schizophrenia and bipolar I disorder: does diagnosis matter?

BACKGROUND: Lack of insight is a well-recognized feature of schizophrenia and is associated with symptom severity and cognitive impairments. However, the diagnostic specificity of insight variables and their correlates is not known. To assess this specificity, we compared awareness of illness and neuropsychological function between patients with chronic schizophrenia and bipolar I disorder. METHOD: We assessed insight, level of psychopathology, and cognitive performance on a neuropsychological test battery in 37 patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition bipolar I disorder, 32 patients with schizophrenia, and 31 healthy subjects for comparison. RESULTS: There was no significant difference between the 2 diagnostic groups on general illness awareness. However, patients with bipolar disorder had better awareness of their symptoms and their pathologic nature compared to patients with schizophrenia. Similar patterns of association emerged between insight and clinical variables. General unawareness was associated with clinical severity, especially of the affective type, and working memory deficits (Wechsler Adult Intelligence Scale digit span) in both diagnostic groups. The contribution of other cognitive deficits to insight differed across the groups. Misattribution differed from the other aspects of insight in its relative independence of clinical and neurocognitive correlates. Both patient groups were neurocognitively impaired, with the schizophrenia group performing significantly worse on conceptual ability, verbal learning, visuospatial processing, and motor speed. CONCLUSIONS: The results suggest that differences in general insight in major mental disorders may be explained by symptom severity and working memory function rather than the specific diagnosis. Subcomponents of insight are influenced by different factors emphasizing the need to consider insight as multidimensional.     

Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests

The present study seeks to elucidate the relationship between unawareness of illness in schizophrenia and frontal lobe dysfunction, in addition to investigating the relationship between lack of insight and sociodemographic and clinical variables. Twenty-one medicated schizophrenic patients, recruited from in- and out-patient wards at Ulleval Hospital, underwent the Scale to Assess Unawareness of Mental Disorder (SUMD), neuropsychological testing, psychiatric symptom ratings and neuroimaging procedures (CT). Also, 21 matched normal controls were neuropsychologically tested. CT data were assessed blindly by two experienced neuroradiologists, according to the degree of ventricular enlargement and/or sulcal widening, and an assessment of localisation of atrophy was made. Unawareness of illness was correlated with neuropsychological measures related to executive functioning, but not with other neuropsychological measures. Five patients showed slight frontal atrophy, while two showed moderate frontal atrophy. The remaining 13 patients did not show signs of frontal lobe atrophy. Frontal lobe atrophy documented by structural brain measures was associated with poor insight in schizophrenia. Furthermore, Anergia (BPRS), GAF score and 'undifferentiated' sub-diagnosis correlated with SUMD scores. Unawareness of illness in schizophrenia may be related to frontal lobe deficit. Also, awareness of illness may not be related to general psychopathology, but rather to specific aspects.     

Insight,global neuropsychological functioning,and symptomatology in chronic schizophrenia

It is proposed that poor insight in schizophrenia may be explained by neuropsychological dysfunction and linked to the negative syndrome, which in turn may be related to structural neurological impairment. This study tested the hypothesis that poor insight is related to global neuropsychological impairment and negative symptoms in 89 patients with chronic schizophrenia. No significant association was found between total insight and cognitive impairment. When the dimensions of insight-treatment compliance, awareness of illness, and symptom attribution-were analyzed separately, symptom misattribution was modestly correlated with frontal impairment. However, in subsequent multiple regression analyses, cognitive impairment failed to be a significant predictor of this or any other dimension of insight. Symptoms, particularly positive ones, accounted for approximately one quarter of the variance in symptom misattribution and the total insight score. These results suggest that neuropsychological functioning cannot account for the variance in insight, and that only one quarter of the variance in symptom misattribution can be explained by symptomatology. Future research could also address the role of psychosocial factors in modulating the expression of insight.     

Relationship between insight, cognitive function, social function and symptomatology in schizophrenia

OBJECTIVE: To examine the nature and clinical correlates of insight in first-episode schizophrenia, and how these differ from findings in established schizophrenia. METHOD: Insight (and insight dimensions), clinical symptoms, neurocognitive function and social function were assessed in 94 patients with first-episode schizophrenia or schizophreniform disorder according to DSM-IV criteria. RESULTS: Greater global insight was associated with more severe depression. Poor overall insight was associated significantly with more severe negative and disorganisation symptoms as well as poor working memory, and at a trend level with lower current IQ. Patients with poor insight perceived themselves to have a better level of independent performance at daily living activities. CONCLUSION: In first-episode psychosis, the clinical correlates of poor insight are similar to those reported for established schizophrenia. Those patients with greater insight may be at risk of depression. The complex relationships between insight, positive and negative symptoms, neurocognitive dysfunction and social function may reflect the multidimensional nature of insight.     

The relationship between insight and symptoms in schizophrenia

We examined the relationship between insight and the positive, negative, active, dysphoric, and autistic dimensions of symptoms in patients with a diagnosis of schizophrenia. Ninety-six patients with a diagnosis of schizophrenia were assessed using the Scale to Assess Unawareness of Mental Disorder, Revised Version (SUMD-R) and the Positive and Negative Syndrome Scale (PANSS). The PANSS data were analyzed based on a five-factor model defined by White et al (1997). The percentage of patients having a lack of awareness was 32.7% for illness, 58.2% for symptoms, 18.4% for treatment response, and 41.8% for social consequences. Lack of awareness of symptoms was significantly correlated with all five symptom factors. Lack of awareness of the illness and its social consequences was only correlated with the positive dimension. Lack of awareness of achieved effects of medication was correlated with the autistic preoccupation factor. There was no correlation between current misattributions for symptoms and PANSS factors. We conclude that poor insight is a common feature of schizophrenia and has a complex relationship to other symptoms of the illness. Our results suggest that (1) unawareness of symptoms is related to severity of illness; (2) insight into illness and its social consequences is more closely tied to positive symptoms than other aspects of insight; and (3) insight into the effects of medication is more closely related to cognitive impairment. Treatment studies that measure insight could answer the question of whether these deficits in awareness improve along with positive and cognitive symptoms.     

Frontal lobe dysfunctions in schizophrenia--II. Impairments of psychological and brain functions

In Part I of this paper (Levin, 1984), it was proposed that the phenomena of eye movement impairments in schizophrenia are consistent with a dysfunction of frontal eye field mechanisms of ocular-motor control. In Part II, a frontal lobe dysfunction in schizophrenia is also proposed on the basis of clinical, psychological, neurochemical, and neuropathological grounds. There are striking similarities between the clinical frontal syndrome and negative symptom schizophrenia. Parallels between experimental studies of disturbances in attention and information processing, in humans and animals with frontal lobe lesions on the one hand, and in schizophrenics on the other, are noteworthy. The evidence for seemingly disparate dysfunctions in schizophrenia of eye movements, psychomotility, cognition, arousal, motivation and affect, is consistent with a disruption of frontal lobe mechanisms of stimulus-response and drive-response modulation. Studies on the neurochemistry and neuroanatomy of schizophrenia provide further evidence for a frontal lobe dysfunction in a subgroup of schizophrenic patients, particularly those with negative symptoms.     

Laterality and frontality of cerebral blood flow and metabolism in schizophrenia: relationship to symptom specificity

Two of the hypotheses on regional brain dysfunction in schizophrenia that have received some support in studies of cerebral blood flow (CBF) and cerebral metabolic rate (CMR) are: (1) left hemispheric dysfunction and overactivation (laterality) and (2) frontal lobe deactivation or failure to activate (frontality). Although these hypotheses are not mutually exclusive, their relative importance for providing clues to neural underpinnings of symptoms specific to schizophrenia depends on their ability to predict variation in symptomatology. A potentially efficient strategy for such study is to start with physiological parameters of laterality and frontality, and correlate them with measures of severity of clinical symptoms specific to schizophrenia. For two schizophrenic samples reported earlier, we derived laterality (left-right hemispheres) and frontality (frontal-posterior regions) measures of CBF (Study 1) and CMR (Study 2), and correlated them with symptom specificity, defined as the difference in severity of symptoms specific and nonspecific to schizophrenia assessed by the Brief Psychiatric Rating Scale. In both studies, low but significant positive correlations were obtained between the specificity score and laterality for CBF in Study 1 and for CMR in Study 2, but not frontality. The results suggest that in these samples disturbances in lateralized activity are more prominently associated with the phenomenology of schizophrenia than disturbed frontal lobe activity.     

Hypofrontality and negative symptoms in schizophrenia: synthesis of anatomic and neuropsychological knowledge and ecological perspectives]

Cognitive deficits in schizophrenia have been observed with neuropsychological tests of executive function, traditionally considered sensitive to frontal lobe damage. These impairments affect planning abilities, as well as the aptitude to initiate and regulate a goal-directed behaviour. On the other hand, negative symptoms of schizophrenia are widely suspected to reflect a frontal lobe dysfunction. Based on a review of a hundred papers, the present article analyses the anatomical and neuropsychological evidence of disturbed frontal lobe functioning in patients with negative schizophrenic symptoms. The phenomenological similarity of some schizophrenic symptoms to the clinical features of patients with prefrontal injury inspired the hypothesis of damaged frontal lobe in the former disorder. The morphological findings of neuroimaging studies brought inconsistent conclusions, with some researchers noting no differences between patients and control subjects while others observing reduced prefrontal volumes in schizophrenia. The functional neuroimaging demonstrated a reduced frontal blood flow relative to the general cerebral perfusion in patients with schizophrenia. Even though the overall neuroimaging literature provides reliable evidence of frontal impairment in schizophrenia, the average magnitude of the difference between patients and healthy controls is insufficient to defend the hypothesis of frontal lobe dysfunction, as far as brain volume, resting metabolism or blood flow are concerned. The only measure, which clearly distinguishes between the patients' and controls' distributions, is the functional neuroimaging of the frontal lobe while subjects are performing an experimentally controlled task. Schizophrenic patients fail to activate their frontal cortex when the task requires it. Analysing executive abilities in relation to symptom expression leads to recognising the fact that frontal dysfunction is a characteristic of only a sub-syndrome of schizophrenia. The factor analysis of the clinical features consistently reveals three syndromes in schizophrenia, termed disorganisation, positive and negative syndromes. The substantial body of evidence that patients exhibit more than one syndrome indicates these are dimensions within a single illness rather than discrete diseases. Liddle labelled the negative syndrome as "psychomotor poverty" and associated it with malfunction of the neuronal projections from dorsal prefrontal cortex to thalamus via striatum, connections involved in the initiation of mental activity. His hypothesis was supported by the work of other, independent research groups. The patients with negative symptoms, in contrast with the nonnegative symptom group, tend to demonstrate reduced neuronal activation of the frontal cortex during executive task realisation. The nonnegative patients are indistinguishable from the healthy control subjects in this region. Neuropsychological studies reveal that severity of psychomotor poverty is associated with slowing of mental processing and deficits in tasks that require planning abilities. These frontal functions are identified with the selection, the initiation and monitoring of a wide variety of behavioural processes. It was hypothesised that executive dysfunction will appear through different patterns across symptom subtypes, but few studies sought to validate this assumption. Finally, researchers make little effort to develop theoretical conceptualisations of the aetiology of negative schizophrenic symptoms, despite the growing body of evidence on its resemblance to the dorsolateral frontal lobe syndrome. Frith proposes that defects in the initiation of spontaneous action underlie these clinical phenomena, but his definition is not specific enough to be confronted to existing literature, neither has been empirically tested. Disturbed executive functioning has detrimental impact on the quality of daily living in patients with schizophrenia. Indirect observation of the latter accounts for defective long-term adaptation, which has been correlated to severity of negative symptoms and, although not consistently, to executive deficit as assessed by neuropsychological testing. Unfortunately, this area of research lacks ecologically valid studies. Measuring executive dysfunction as it occurs in the natural setting of the patient and validating dissocialbility of frontal deficits with respect to the schizophrenic symptomatology could lead to greater individualization of treatment plans and therefore to more efficient therapy outcome.     

Frontal Systems Behavior Scale in schizophrenia: relationships with psychiatric symptomatology,cognition and adaptive function

Schizophrenia patients often exhibit impairments in executive functioning on formal testing and exhibit behaviors consistent with executive/frontal impairment in daily life. The Frontal Systems Behavior Scale (FrSBe) assesses behaviors associated with frontal lobe damage including executive dysfunction, apathy and disinhibition. We examined the reliability and validity of the FrSBe in 131 schizophrenia outpatients. Subjects were rated on the FrSBe and received symptom, cognitive and functional assessments. Statistical tests were corrected for multiple comparisons. The FrSBe was found to have good internal consistency and test-retest reliability. All three dimensions of the FrSBe (i.e. executive dysfunction, apathy and disinhibition) were significantly correlated with poor adaptive functioning as measured by the Social and Occupational Functioning Scale and the Functional Needs Assessment. In addition, differential relationships were found for apathy and disinhibition with symptoms as rated from the Brief Psychiatric Rating Scale and with cognitive variables including Trails B and verbal fluency scores. A multivariate analysis of variance examined differences on the FrSBe between patients and a group of 51 education-matched controls. Patients had significantly greater impairment on the FrSBe than controls. These differences were found for all FrSBe subscales. Results support the use of the FrSBe to characterize goal-directed behavior in schizophrenia patients.     

Volumetric analysis of frontal lobe regions in schizophrenia: relation to cognitive function and symptomatology.

BACKGROUND: The purpose of this study was to examine the structure of dorsolateral, medial, and orbital regions of the frontal lobe in schizophrenia, and to determine whether their volumetric measurements were related to cognitive function and symptomatology. METHODS: High resolution magnetic resonance imaging scans of the brains of 14 schizophrenic patients and 14 closely matched healthy controls were acquired. Volumes of gray and white matter of the left and right dorsolateral, medial, and orbital prefrontal brain regions were measured. Tests of verbal and visual memory and executive functions were used to assess cognitive function. The SANS and SAPS were used to obtain symptom ratings in patients. RESULTS: Data of 13 schizophrenic patients were analyzed. Patients showed a general, though not significant, decrease in volumes of frontal regions as compared to controls. In patients, but not in controls, smaller left and right prefrontal gray matter volumes were significantly correlated with impaired performance on immediate recall in verbal and visual memory and semantic fluency. Furthermore, in patients, smaller total orbitofrontal gray matter volume was significantly correlated with more severe negative symptomatology (rs = -.76, p = .006). CONCLUSIONS: These findings suggest that in schizophrenia, deficits in verbal and visual memory and semantic fluency and negative symptoms may be related to (subtle) abnormalities in frontal lobe structure.     

Is insight in schizophrenia multidimensional? Internal structure and associations of the Greek version of the Schedule for the Assessment of Insight—Expanded

Despite the general agreement that insight is a multidimensional phenomenon, the studies on the factorial structure of the scales for its assessment have yielded rather inconsistent results. The present study aimed to assess the internal structure of the Schedule for the Assessment of Insight (SAI-E). Seventy-two chronic patients with schizophrenia were assessed with SAI-E. Hierarchical cluster analysis and multidimensional scaling (MDS) were used to identify insight components and assess their inter-relationships. The associations of the extracted components with demographic, clinical and cognitive characteristics were also examined. The SAI-E demonstrated good psychometric properties. Three subscales of SAI-E were identified measuring awareness of illness, relabeling of symptoms, and treatment compliance. Moreover, the MDS disclosed two underlying dimensions – degree of ‘specificity’ and ‘spontaneity’ – within the insight construct. Treatment compliance was more strongly correlated with symptom relabeling than illness awareness. Excitement symptoms, global functioning and general intelligence were correlated with all the components of insight. Depressive symptoms were more strongly correlated with illness awareness. Impaired relabeling ability was linked to cognitive rigidity and greater severity of disorganization and positive symptoms. Education and severity of negative symptoms specifically affect treatment compliance. Our results support the hypothesis that insight is a multidimensional construct.     

Insight, symptoms, and neurocognition in schizophrenia and schizoaffective disorder

There are conflicting reports in the literature regarding the relationships among impaired insight, symptoms, and neurocognition in schizophrenia. The inconsistent findings likely reflect the multidimensionality of insight in this population, along with variations in study design. We examined 46 individuals with chronic schizophrenia or schizoaffective disorder who were recently discharged from an inpatient unit. Insight was operationalized as awareness of having a mental disorder and awareness and attribution of both current and past symptoms. Positive, negative, disorganized, and depression symptoms were rated, and a neurocognition battery, including measures of visual processing, memory, visuo-spatial ability, and executive functions, was administered. Poor awareness of symptoms was moderately associated with core schizophrenia symptoms, and higher levels of depression were strongly associated with good awareness. Symptom misattribution, more so than symptom unawareness, was associated with deficits in frontal lobe functioning. Finally, different patterns of associations between symptoms, neurocognition, and insight were noted for current symptoms versus past symptoms. The data suggest that insight deficits in schizophrenia are multidimensional, and that investigators should pay careful attention to the choice of measures as well as to phase of illness characteristics in future studies.     

Insight in schizophrenia: a meta-analysis

There has been an increase in the study of insight in schizophrenia in the last 20 years. Insight is operationally defined according to five dimensions which include: the patient's awareness of mental disorder, awareness of the social consequences of disorder, awareness of the need for treatment, awareness of symptoms and attribution of symptoms to disorder. Despite the development of psychometrically sound measurement tools, the results from previous studies have been inconclusive regarding the nature of the relationship between insight and symptomatology. A meta-analysis of 40 published English-language studies was conducted to determine the magnitude and direction of the relationship, or effect size, between insight and symptom domains in schizophrenia and to determine moderator variables that were associated with the variations in effect sizes across studies. Results indicated that there was a small negative relationship between insight and global, positive and negative symptoms. There was also a small positive relationship between insight and depressive symptoms in schizophrenia. Acute patient status and mean age of onset of the disorder moderated the relationship between insight and symptom clusters. The possible reasons for the effect sizes being modest, the examination of the role of moderator variables and directions for future research are provided.     

Dissociating self-reported cognitive complaint from clinical insight in schizophrenia

Whereas new pharmacological treatments are developed for cognitive impairments in schizophrenia, self-assessment of cognitive dysfunctioning besides their objective validity could be of interest in evaluating patients' motivation to engage in rehabilitation program. Nevertheless insight into symptoms is severely impaired in schizophrenia and is negatively linked with poor compliance. But it is yet unknown if patients with poor insight into their symptoms could have some insight into their cognitive impairments. The aim of this study was to explore the relationships existing between the cognitive complaint and the level of awareness of the disease in patients with schizophrenia. A total of 101 patients with DSM-IV schizophrenia or schizoaffective disorder and 60 control participants were recruited. Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) and cognitive complaint intensity was assessed with the Scale to Investigate Cognition in Schizophrenia (SSTICS). Participants with schizophrenia displayed the same level of cognitive complaint when compared to healthy controls. Strong correlations were observed between SSTICS total score and duration of illness, levels of depression and state anxiety. Patients with a good insight into the therapeutic effects achieved with medication expressed a more important cognitive complaint. No correlations were found between the four others SUMD insight dimensions and total SSTICS score. The partial overlap of insight into illness and cognitive complaint suggests that insight is modular in schizophrenia. Assessment of cognitive complaint and awareness of illness need to be assessed before engagement in rehabilitation program.     

Negative schizophrenic symptoms and the frontal lobe syndrome: one and the same?

The negative symptoms of schizophrenia have been considered to be a psychiatric form of the frontal lobe syndrome. However, no studies have compared these two disorders at the clinical level. In this study, 12 negative symptom schizophrenic patients and 11 patients with behavioural variant frontotemporal dementia (bv-FTD) were rated for negative symptoms and for occurrence of frontal lobe behaviours in everyday life. They were also rated for speech disorder and were given a series of executive tests. Both patient groups showed positive ratings on negative symptoms and frontal lobe behaviours in daily life; however, the schizophrenic patients had higher negative symptom scores and the bv-FTD patients had higher carer ratings on frontal behaviours in daily life. Both groups were impaired on the executive tests, but the bv-FTD patients showed significantly greater impairment on verbal fluency and a test requiring inhibition of prepotent responses. A minority of the bv-FTD patients unexpectedly showed speech abnormalities typically associated with schizophrenia. The findings indicate that the negative syndrome in schizophrenia and the frontal lobe syndrome resemble each other clinically in important respects. Some of the differences may be attributable to the additional presence of disinhibition in the frontal lobe syndrome.     

Cognitive correlates of the negative, disorganized, and psychotic symptom dimensions of schizophrenia

Knowledge of the relationship between specific cognitive abnormalities and the clinical symptoms of schizophrenia could give insight into the nature of their underlying pathophysiology. Composite scores were generated for negative, disorganized, and psychotic symptom ratings in 134 patients with schizophrenia (DSM-IV criteria). Partial correlations (each composite corrected for the others) were computed with neuropsychological measures. Negative symptoms were related to poor performance on tests of verbal learning and memory, verbal fluency, visual memory, and visual-motor sequencing. Disorganized symptoms were correlated with lower verbal IQ and poor concept attainment. Psychotic symptoms had no significant relationship with cognitive deficit.     

Quantitative magnetic resonance spectroscopy of schizophrenia: relationship between decreased N-acetylaspartate and frontal lobe dysfunction

Numerous studies using proton magnetic resonance spectroscopy (1H-MRS) have detected signal changes in schizophrenia. However, most studies investigated relative concentrations such as N-acetylaspartate/creatine plus phosphocreatine (NAA/Cre) and choline-containing compounds/creatine plus phosphocreatine (Cho/Cre), and individual metabolite concentrations have not been clarified. Using absolute quantification measurement of 1H-MRS, the aim of the present paper was to demonstrate the changes in metabolite concentrations in the frontal lobe of patients with chronic schizophrenia. The 1H-MRS was performed in the left frontal lobe in 14 patients with schizophrenia and in 13 healthy comparison subjects. Individual MRS peak concentration was quantified based on a frequency-domain fitting program: LCModel. The scores on the Positive and Negative Symptoms Scale and Wisconsin Card Sorting Test were used for clinical assessment. The NAA concentration was reduced in schizophrenic patients (average, 7.94 mmol/L, t=2.28, P<0.05) compared with healthy subjects (average=8.45 mmol/L) while choline, creatine or NAA/Cre ratio did not show any differences. The reduction in NAA concentration had a significant correlation with the severity of negative symptoms (r=-0.536, P<0.05) and poor performance in Wisconsin Card Sorting Test (r=-0.544, P<0.05). Using quantitative MRS, decreased NAA concentration was confirmed in the left frontal lobe of schizophrenic patients and was demonstrated to be correlated with negative symptoms and cognitive dysfunction in schizophrenia.     

Social cognition in schizophrenia: similarities and differences of emotional perception from patients with focal frontal lesions

The structural and functional abnormalities of the frontal lobes, the region implicated in social information processing, have been suspected to underlie social cognitive impairments in schizophrenia. However, multiple structures, including the limbic/paralimbic areas that are also important for social cognition, have been reported to be abnormal in schizophrenia. The aim of this study is to investigate the extent to which the frontal lobe dysfunction accounts for social cognitive impairments in schizophrenia by comparing with patients who have focal frontal lobe injuries. Social cognitive abilities, focusing on affective aspects, were examined by an emotion intensity recognition task, which is sensitive to the amygdala function, and the emotion attribution tasks, which rely mainly on the frontal lobe function. Individuals with schizophrenia were impaired on the emotion intensity recognition task as well as on the emotion attribution tasks as compared with healthy subjects. By contrast, the frontal lobe-damaged group was defective in the emotion attribution tasks but not in the emotion intensity recognition task. Our results indicated that social cognitive impairments observed in schizophrenia can be accounted for partly by their frontal lobe pathology. Other aspects of social cognitive impairments could also be associated with the extra-frontal pathology, such as the amygdala.     

Akinesia, tardive dysmentia, and frontal lobe disorder in schizophrenia

Two iatrogenic effects of antipsychotic medications other than tardive dyskinesia have been recently described in schizophrenic populations: akinesia and tardive dysmentia. These effects involve activational, cognitive, and affective rather than motor changes, and closely resemble two most common prefrontal syndromes: dorsolateral and fronto-orbital/mediobasal. It is possible that the widely reported "frontal lobe dysfunction" in some chronic schizophrenic patients at least in part reflects iatrogenic changes in the mesolimbic/mesocortical dopamine system, which projects extensively into prefrontal areas. The degree of iatrogenic versus genuine contribution to the frontal lobe dysfunction in schizophrenia needs to be ascertained further, and the heterogeneity of known frontal lobe syndromes must be taken into account in describing schizophrenic populations. The mechanisms of noniatrogenic contributions to the frontal lobe dysfunction in schizophrenia may reflect a variety of anatomical sources and require further examination.