精神分裂症神经系统软体征的系统综述

目的收集国内外2000年-2014年公开发表的关于精神分裂症神经系统软体征(neurological soft signs,NSS)的文献,综述精神分裂症NSS主要研究领域的最新研究成果,为今后研究精神分裂症NSS提供新的视角和相关理论依据。方法计算机检索Pub Med、Embase、中国知网以及万方数据库,检索精神分裂症神经系统软体征的相关文献。由2位评价员按纳入与排除标准筛选文献,评价纳入研究质量并提取原始资料后,综述精神分裂症神经系统软体征的主要研究成果。结果共检索到相关文献407篇,最终纳入25篇。结果显示精神分裂症NSS与精神分裂症阴性症状以及患者认知功能存在一定的相关性,NSS也渐渐显示出潜在的脑区皮层相关性,同时被认为是潜在的精神分裂症内表型之一。结论神经系统软体征对精神分裂症病理机制的确定具有一定的理论意义,同时对精神分裂症临床工作的完善具有指导作用;建议今后的研究对协变量做出更好的控制,拓展被试样本的年龄跨度,增加纵向研究和遗传学证据。     

La stimulation magnétique transcrânienne répétée : vers un nouvel outil thérapeutique en psychiatrie

Transcranial magnetic stimulation (TMS) is a technique used for investigation of the tics, when repeatedly applied, has a therapeutic potential, notably in psychiatry. The physiological and neuroendocrine effects induced by repeated TMS treatment in an animal model are similar to those caused by antidepressants in man. In particular, TMS appears to modify the release of neuromediators (serotonin, dopamine) involved in depressive states. Because of these properties, repeated TMS has been proposed as a potential treatment for depression. Several randomized studies have now evaluated its effects in this regard and for the most part show statistically significant results, although the findings are sometimes modest at the clinical level. However, the therapeutic effects depend on various parameters which are generally not taken into account, such as cortical excitability and regional cerebral metabolism, Apart from depression, the trials focus on a limited number of disorders. In schizophrenia, the use of TMS has permitted abnormalities in cortical excitability to be demonstated and an improvement of the symptomatology, e.g. by suppressing the perception of auditory hallucinations. Parkinson?s disease, nervous twitch and Gilles de la Tourette syndome, obsessive-compulsive disorders and mania have also been the focus of promising albeit preliminary trials. Wider randomized studies should now assess the different parameters involved in the therapeutic effects, so that the treatment procedure can be optimized and the physiopathology of various neuropsychiatric disorders better understood.     

Conscience de soi et conscience de la maladie dans la schizophrénie : relations avec l’anxiété et la dépression

Elevated rates of suicide in schizophrenia lead us to think that a lot of patients can’t cope with such a frightening, disorganizing or apragmatic experience. In contrast, we insist about the frequency of unawareness of illness as a characteristic of the schizophrenic patient, with paradoxically litlle or no effect on suicidal behaviour. Our study tended to precise the links between awareness of illness, anxiety and depression. We also rated self-consciousness, to see if this tendency could be correlated with other variables, and confirm if possible the hypothesis that awareness of illness relies on a broader tendency for self consciousness.In our population of 46 schizophrenic or schizoaffective inpatients, we failed to show any correlation between awareness of illness, anxiety or depression. Moreover, awareness of illness is not correlated with self-consciousness. On the other hand, anxiety and depression are correlated with self-consciousness. A tendency for high self reflection is frequently observed in autistic attitudes but also when the patient is in relation with others. Some patients sometimes feels like if a an “active” and a “reflexive” self were simultaneously present when they speak to others or even when they are doing daily life activities. The consequences are a loss of spontaneity, apragmatism, anxiety and depression. Those data are discussed in regard to phenomenological studies of Bin Kimura and to mescaline experiences described by the writer H. Michaux.     

Le repérage de l’affect dans l’entretien clinique avec le patient souffrant de schizophrénie : proposition méthodologique

The authors take up the question of expression of affect in clinical interview with schizophrenic patient from analysis of interactions; they underline that verbal interaction enable privileged investigation of affect rationality. They propose a reflection about a model of analysis and formalisation; this one may initiate the construction of a model which emphasizes the types of conversational shapes underlying therapeutic strategies of change. The emotive dimension, as it is studied in psychanalytic theories can be questionned by cognitive and conversational theories. Indeed, cognitive and conversational enlightenment are used to bring out marks of affect expression, on the one hand, about syntactic and semantic structure of utterances, on the other hand, about shapes of conversational structures. So, this article presents a method which permits to study structure of conversations as ground of accomplishment of affect expression in interaction. From an illustration, the authors explain how some clinician's interventions are a prop of exploration of affect in conversation. The studied conversational sequence invite to think that some modalities of interaction organize connection of subject with his own affects, updating it in therapeutic relation. The authors brings out the idea that conversational relation facilitate the creation of a specific psychic space permitting mutual prop between intersubjective ties and intrapsychic.     

Cognitive remediation program for individuals living with schizophrenia (Recos): preliminary results

Background

Nowadays, cognitive remediation is widely accepted as an effective treatment for patients with schizophrenia. In French-speaking countries, techniques used in cognitive remediation for patients with schizophrenia have been applied from those used for patients with cerebral injury. As cognitive impairment is a core feature of schizophrenia, the Département de psychiatrie du CHUV in Lausanne (DP-CHUV) intended to develop a cognitive remediation program for patients with a schizophrenia spectrum disease (Recos–Vianin, 2007). Numerous studies show that the specific cognitive deficits greatly differ from one patient to another. Consequently, Recos aims at providing individualized cognitive remediation therapy. In this feasibility trial, we measured the benefits of this individualized therapy for patients with schizophrenia. Before treatment, the patients were evaluated with a large battery of cognitive tests in order to determine which of the five specific training modules – Verbal memory, visuospatial memory and attention, working memory, selective attention, reasoning – could provide the best benefit depending on their deficit.

Objectives

The study was designed to evaluate the benefits of the Recos program by comparing cognitive functioning before and after treatment.

Method

Twenty-eight patients with schizophrenia spectrum disorders (schizophrenia [n = 18], schizoaffective disorder [n = 5], schizotypal disorder [n = 4], schizophreniform disorder [n = 1], DSM-IV-TR) participated in between one and three of the cognitive modules. The choice of the training module was based on the results of the cognitive tests obtained during the first evaluation. The patients participated in 20 training sessions per module (one session per week). At the end of the training period, the cognitive functioning of each patient was reevaluated by using the same neuropsychological battery.

Results

The results showed a greater improvement in the cognitive functions, which were specifically trained, compared to the cognitive functions, which were not trained. However, an improvement was also observed in both types of cognitive functions, suggesting an indirect cognitive gain.

Conclusion

In our view, the great heterogeneity of the observed cognitive deficits in schizophrenia necessitates a detailed neuropsychological investigation as well as an individualized cognitive remediation therapy. These preliminary results need to be confirmed with a more extended sample of patients.     

Neurological soft signs and gray matter changes: a longitudinal analysis in first-episode schizophrenia

Neurological soft signs (NSS) - i.e. discrete deficits of sensory and motor function - are frequently found in schizophrenia and vary with psychopathological symptoms in the course of the disorder. Hence, persistence of NSS herald chronicity in first episode schizophrenia. To investigate the cerebral correlates of persisting NSS over time, 20 patients with first-episode schizophrenia underwent T1 magnetic resonance imaging (MRI) after remission of the acute symptoms and after 1 year of follow-up. NSS were rated on the Heidelberg Scale. Twenty age- and gender-matched control subjects were scanned once. Longitudinal gray matter (GM) changes were measured by using tensor based morphometry (TBM). At follow-up, patients demonstrated significantly decreased NSS scores. For further analysis, the patient sample was dichotomized into patients with decreasing NSS scores and patients with persistently increased scores, respectively. While patients with decreasing NSS exhibited only localized changes within the left frontal lobe, cerebellum, and cingulate gyrus, patients with persistently increased scores showed pronounced GM reductions of the sub-lobar claustrum, cingulate gyrus, cerebellum, frontal lobe, and middle frontal gyrus. Results were confirmed after correction for multiple comparisons. These findings support the hypothesis that persisting NSS refer to progressive cerebral changes in first-episode schizophrenia. Since NSS can be assessed in any clinical environment, this association facilitates the prospect that NSS can help to establish prognosis in first-episode patients with schizophrenia.     

Neurological soft signs and cognition in the late course of chronic schizophrenia: a longitudinal study

European Archives of Psychiatry and Clinical Neuroscience - Neurological soft signs (NSS) are minor (‘soft’) neurological abnormalities in sensory and motor performances, which are...     

Ocular myasthenia: diagnosis and treatment

Myasthenia gravis is a rare, auto-immune disorder of the neuromuscular junction. Onset signs frequently involve ocular muscles, accounting for ptosis and/or diplopia in more than 75% of cases. Among the cases with purely ocular muscle involvement, less than one half will never progress towards a more general form of myasthenia. However, even if they do not share the potentially life-threatening course of generalized myasthenia, purely ocular forms are often responsible for severe impairment in everyday life. The diagnosis is essentially based on fluctuations in the time and topography of the ocular muscle weakness. It still remains uneasy, as investigations such as electromyography, search for antiacetycholine receptor antibodies (positive in 50% of cases of purely ocular myasthenia), and edrophonium chloride test sometimes yield false negative results. Whereas some patients get better while on anticholinesterasic drugs alone, most of them will experience insufficient improvement and need steroids and/or immunosuppressant drugs. There is no indication for plasma exchanges, intravenous immunoglobulin or thymectomy (except in the presence of thymoma). This treatment could well decrease the risk of an evolution towards generalized myasthenia. The reasons underlying the vulnerability of ocular motor muscles in myasthenia are complex and several factors (linked to immunology, anatomy and function) may combine to bring about their specific involvement. In the future, randomized, controlled trials will be necessary, in order to determine a more rational approach of the treatment of ocular myasthenia, which currently lies mostly on retrospective data and the expertise of reference centers implicated in the management of the disease.     

The psychopathology of schizophrenia and the presence of neurological soft signs: a review

PURPOSE OF REVIEW: The symptoms of schizophrenia cluster in at least three subtypes: positive, negative, and disorganized. The study of these subtypes and their phenotypic markers may help our understanding of the pathophysiology of schizophrenia. Among the markers of schizophrenia are minor neurological signs, which are abnormalities in sensory and motor performance elicited by clinical examination. Evidence on whether neurological abnormalities are associated with a specific symptom subtype is considered. As recent studies have often evaluated individuals at their first psychotic episode who are antipsychotic na?ve, a review would help to clarify whether neurological soft signs are part of a neurodysfunction that underlies schizophrenia rather than the consequence of degenerative processes or of long-term pharmacological treatment. RECENT FINDINGS: A consistent association seems to emerge between an excess of neurological soft signs and severe negative symptoms. Signs associated with negative symptoms remain stable over time, and may characterize a subgroup of patients with poor illness course and outcome. Some signs, such as motor dysfunction, may be associated with a worse profile of positive symptoms, and may improve as symptoms improve. Too few studies have evaluated the association between neurological soft signs and disorganization symptoms to suggest or disconfirm any relationship. SUMMARY: Finding an association between neurological soft signs and one (or more) dimension(s) of schizophrenia in never treated patients may explain which neurological dysfunction is an intrinsic characteristic of the illness. The comparability of future studies can be improved by using the same structured rating scale for neurological soft signs and psychopathology, and by a better characterization of patient samples.     

Insight et neuro-imagerie : l’apport de l’étude des réseaux du repos

Insight, in the field of psychiatry, can be seen as a complex phenomenon involving the ability to recognize one's own mental illness and the need for a treatment, but also to attribute a cause to various symptoms and life events. Patients with schizophrenia appear to have a lack of insight, leading to a poor outcome. Several theoretical models postulate a link between insight on the one hand, and cognitive (executive and autobiographical) dysfunctions on the other hand. In the past decade, large amounts of work have been dedicated to a particular network: the Default-Mode Network. This network seems to support the spontaneous mental activity of a subject at rest. In particular, its activation seems to be elicited by thoughts dealing with self-awareness. In a functional Magnetic Resonance Imaging study, we highlighted several network alterations in patients with schizophrenia, and one of these seems to have a relationship with insight. In the light of these results and the existing literature, we propose a conceptual framework of lack insight in schizophrenia with implications for future research.     

Le comportement d’observance des patients atteints de schizophrénie : impact du diagnostic et du traitement. Analyse phénoménologique de trois attitudes

The aim of this study is to analyze the different characteristics of three patient clusters defined according to their relationship toward their disease. Based on the 40 patients collected data, we were able to identify three patient groups: 23 patients were qualified as “active” as they showed a more collaborative participation in career venues and higher acceptance of comprehensive treatment plans (57.5 %). Seven patients were qualified as “passive” as they had less autonomy and therefore were less concerned with the treatment modalities (17.5 %). Ten patients were qualified “ambivalent” as they had a more conflicted understanding and insight of their disease, of their careers and their family dynamics (25 %). “Active” patients had a higher level of understanding of their diagnosis, were more aware of prescribed treatments and of the negative consequences of poor compliance. “Passive” patients were more willing to learn about their diagnosis, while having a significantly lower baseline knowledge of it, were more often prescribed an atypical neuroleptic and reported higher satisfaction with their medical treatment. “Ambivalent” patients had a higher propensity for disagreeing with the negative consequences of their disease, were more often prescribed two classic neuroleptics, reported higher rate of self-discontinuation of treatment and were overall less satisfied with their treatment. It appears that the disagreement with the understanding of the disease and its seriousness has a major impact on the acceptance of the treatment modalities and leads to reduced adherence to treatment plan.     

Dyskinesia and soft neurological signs in schizophrenia: a comparative study

Objective. Several neurological abnormalities can be found at a greater frequency in patients with schizophrenia, including neurological soft signs (NSS) and signs of the “pyramidal” and “extrapyramidal” systems. We aimed to explore the frequency of movement disorders in patients with antipsychotic naïve schizophrenia and to compare and contrast with antipsychotic-treated patients and healthy controls. Methods. Twenty-two antipsychotic naive schizophrenic patients, 22 antipsychotic treated patients and 22 healthy control subjects were assessed by Neurological Evaluation (NES), Abnormal Involuntary Movements (AIMS), and Positive and Negative Syndrome (PANSS) Scales. Results. The NES scores of the never-medicated schizophrenic group were significantly higher than those of normal controls but did not differ significantly from the medicated group. Dyskinesia rates in the both schizophrenic groups were higher than in healthy controls. Medicated and non-medicated schizophrenic patient scores did not differ in AIMS with regard to facial and oral movements, but medicated patients scored higher than non-medicated subjects with respect to extremity movements. Conclusion. Our data suggest that: soft neurological signs and abnormal involuntary movements in the facial region are more prevalent in patients with schizophrenia, whether they are medicated or antipsychotic naïve. On the contrary, abnormal involuntary movements in the trunk and the extremities seem to be associated with medication.     

Stratégies de résolution de problèmes et attention sélective dans la schizophrénie : critères typologiques et multidimensionnels de la Positive and Negative Syndrome Scale (PANSS)

Introduction

The Positive and Negative Syndrome Scale (PANSS) is one of the most widespread diagnostic scales of psychoses, in particular for Schizophrenia. The scale distinguishes between positive and negative subtypes. A consequent number of researches explored the cognitive dysfunction in schizophrenia by distinguishing these negative and positive subtypes. However, findings are inconsistent. On the other hand, multidimensional diagnostic criteria show the specificity of cognitive disorders within the different spheres of schizophrenia.

Literature findings

Studies show that principal components analyze applied to PANSS's 30 items attain from three to nine components. Therefore, psychotic, negative and disorganized dimensions were regularly obtained. Every one of these dimensions has specific neuropsychological and cognitive correlations.

Objectives

Our purpose was to explore cognitive disorders related to the negative and positive subtypes as defined by typological criteria and negative, disorganised and psychotic dimensions defined by multidimensional criteria. Our particular interest was selective attention and problem-solving abilities.

Materials and methods

Our sample incorporated 42 subjects responding to D.S.M.-IV criteria for schizophrenia (APA, 1994). The mean age was 40.58 ± 7.95 years, the mean years of education were 9.88 ± 2.74, the mean duration of illness was 12.26 ± 6.49 years and the number of hospitalisations was 4.41 ± 2.27. Clinical assessment was reached by using the Positive and Negative Symptoms Scale (PANSS). In order to define schizophrenic dimensions, the principal components analysis was performed with Varimax rotation. To assess problem-solving and selective attention, subjects were asked to complete the Wisconsin Card Sorting Test, the Parlor Game, the Stroop test and the Word Recognition Scale (ADAS-cog). Statistical significance was based on non-parametric measures: the Kruskal-Wallis test and the Spearman correlation test.

Results

Typological diagnostic criteria based on PANNS show no cognitive differences between positive, negative and mixed sub-types in selective attention and problem-solving ability. On the other hand, the principal component analysis applied to PANSS shows three components ; negative, psychotic and disorganisation. Clinical assessment: the negative component included blunted affect, lack of spontaneity and active social avoidance, the psychotic component included delusions, hallucinatory behaviour, grandiosity, suspiciousness and unusual thought content, and finally the disorganisation component comprised conceptual disorganisation, difficulty in abstract thinking, disorientation and poor attention. Cognitive assessment: the disorganisation dimension was associated with low performances in the Stroop test and in the Word Recognition Scale. Negative dimensions were correlated to low performances in the indicators of the Wisconsin Card Sorting Test (number of errors, number of perseverant errors, number of failures to maintain the set, number of trials to achieve the task and number of achieved categories) and the Parlor Game. However, no significant correlation was found between psychotic dimensions and cognitive dysfunctions.

Conclusion

Our study contributes to the comprehension of specific patterns of cognitive disorders of schizophrenics by using multidimensional criteria. Results are detailed and discussed.     

SSRIs and pregnancy: a review of the literature

Objective

A review of the consequences of maternal depression on fetal and infant development and the risk and benefits of SSRI use.

Method

We have reviewed the literature published on PubMed between January 1980 and February 2009 using the following keywords: SSRI, depression, pregnancy, abnormality, teratogenic effect.

Results

Pregnancies complicated by the onset or recurrence of a major depressive disorder constitute a complex medical situation. The management of such situations is based on the principle of avoiding, as far as possible, the exposure of the developing foetus to both the maternal illness and the potential teratogenic effects of psychotropic drugs. Epidemiological studies show that maternal depression is a very frequent disease: 10 to 16% of pregnant women fulfill major depressive disorder diagnostic criteria and 15% suffer from postpartum depression. The consequences of such exposure on fetal and infant development are so harmful that a pharmacological treatment is highly recommended. Nowadays, the information available on the safety of SSRI use in pregnancy is abundant and these molecules are probably the most studied drugs in pregnant women. Their beneficial effects largely prevail over their potential fetal/neonatal risks and it is unlikely that any marked teratogenic effect occurs, with the possible exception of an increased risk for cardiovascular defects after maternal use of paroxetine. However, transient neonatal symptoms are common after SSRI use in late pregnancy. These include transient autonomic, gastrointestinal, somatic, and clinical respiratory manifestations in the immediate neonatal period.

Conclusion

Treatment of maternal depression during pregnancy and immediate neonatal period is uniformly recommended despite the potential side effects on the fetus and newborn. With a possible exception for paroxetine, maternal treatment with SSRIs during pregnancy is not associated with significantly increased risks of congenital defects.     

Menopause and cognitive impairment: A narrative review of current knowledge

A severe impairment of cognitive function characterizes dementia. Mild cognitive impairment represents a transition between normal cognition and dementia. The frequency of cognitive changes is higher in women than in men. Based on this fact, hormonal factors likely contribute to cognitive decline. In this sense, cognitive complaints are more common near menopause, a phase marked by a decrease in hormone levels, especially estrogen. Additionally, a tendency toward worsened cognitive performance has been reported in women during menopause. Vasomotor symptoms (hot flashes, sweating, and dizziness), vaginal dryness, irritability and forgetfulness are common and associated with a progressive decrease in ovarian function and a subsequent reduction in the serum estrogen concentration. Hormone therapy (HT), based on estrogen with or without progestogen, is the treatment of choice to relieve menopausal symptoms. The studies conducted to date have reported conflicting results regarding the effects of HT on cognition. This article reviews the main aspects of menopause and cognition, including the neuroprotective role of estrogen and the relationship between menopausal symptoms and cognitive function. We present and discuss the findings of the central observational and interventional studies on HT and cognition.