Smoking and schizophrenia: epidemiological and clinical features

FREQUENCY: The prevalence of cigarette smoking is significantly higher among patients with schizophrenia (60-90%) than in the general population (23-30%). While tobacco smoking decreases in the general population (from 45% in the 1960's to 23-30% in the 2000's), smoking in patients with schizophrenia remains high. Patients with schizophrenia smoke more cigarettes than control subjects. Patients smoke more deeply, thereby increasing their exposure to the harmful elements in tobacco smoke. IMPACT OF SMOKING IN SCHIZOPHRENIC PATIENTS: As in the general population, smoking contributes to the reduced life expectancy in patients with schizophrenia. Patients with schizophrenia are at increased risk for cardiovascular disease due to high rates of cigarette smoking. In the Department of Mental Health of the commonwealth of Massachusetts, cardiovascular disease was the factor the most strongly associated with excess mortality. Cardiac deaths were elevated more than six-fold. Weight gain, insulin resistance, metabolic syndrome and diabetes mellitus are frequent in patients with schizophrenia, and may worsen the risk of cardiovascular diseases. It has been reported that the risk for lung cancer in patients with schizophrenia is lower than that of the general population, despite increased smoking. However, in a study conducted in Finland, a slightly increased cancer risk was found in patients with schizophrenia. Half of the excess cases were attributable to lung cancer. IMPROVEMENT OF COGNITIVE DEFICITS: Patients with schizophrenia may use nicotine to reduce cognitive deficits and negative symptoms or neuroleptic side effects. Smoking may transiently alleviate negative symptoms in schizophrenic patients by increasing dopaminergic and glutamatergic neurotransmission in the prefrontal cortex. In patients with schizophrenia, nicotine improves some cognitive deficits: (1) sensory gating deficits and abnormalities in smooth pursuit eye movements associated with schizophrenia are transiently normalized with the administration of nicotine ; (2) high-dose nicotine transiently normalizes the abnormality in P50 inhibition in patients with schizophrenia and in their relatives; (3) in tasks that tax working memory and selective attention, nicotine may improve performance in schizophrenia patients by enhancing activation of and functional connectivity between brain regions that mediate task performance (Jacobsen et al. 2004; Paktar et al.2002); (4) cigarette smoking may selectively enhance visuospatial working memory and attentional deficits in smokers with schizophrenia. However, Harris et al., found that nicotine affects only the attention without effects of nicotine on learning, memory or visuospatial/constructional abilities. In addition, smoking could facilitate disinhibition in schizophrenic patients.     

A rare and not very studied disorder: childhood-onset schizophrenia. A case report

SUMMARY: Childhood-onset schizophrenia is rare: its prevalence is about 50 times lower than the one observed in adulthood. It is also frequently unrecognized, notably because its clinical aspect varies with age. The authors report the case of a prepubertal girl who developed a typical clinical picture of schizophrenia (paranoid subtype) by age 9. CASE REPORT: The patient was 10 years old when she was hospitalized for a relapse of a suspected childhood-onset schizophrenia. Several significant mental disorders were found in her family history: her mother was treated for mood disorders (including dysthymia and major depression with postpartum onset), while her father and a aunt exhibited schizophrenic disorders. In addition, prenatal and perinatal events (including probable prenatal maternal infection and obstetric complications) were reported by her mother. Demonstrable impairments were already present in her premorbid development: from the age of 3.5, she showed significant manifestations of behavioural inhibition and separation anxiety, severe difficulties in social adaptation, and language abnormalities (qualified by her general practitioner as selective mutism). At the age of 9, when her mother was hospitalized for a diabetes mellitus, she suddenly showed auditory and visual hallucinations associated with delusions. Their content included filiation, somatic, and persecutory themes. Grossly disorganized behaviour (and more particularly catatonic motor behaviours including catatonic rigidity and negativism and bizarre postures) was also observed. Negative symptoms (eg anhedonia, affective flattening, and alogia) were noted. Her IQ scores were 74 in the verbal subtests and 53 in the performance subtests. Because the diagnostic of childhood-onset schizophrenia was suspected, a neuroleptic treatment, haloperidol 3 mg/day, was tried. After a partial remission during a few months period (characterized by a decrease in delusions, anxiety and sleep difficulties), she showed a relapse leading to her hospitalization. At the time of her admission, she showed severe manifestations of separation anxiety including agitation, anger, crying, and insomnia, for which she received a short-lived treatment by lorazepam. When sedation was obtained, the clinical picture proved similar to the one previously observed: hallucinations, delusions, grossly disorganized behaviour, and thought disorder were noted. As soon as the diagnostic of childhood-onset schizophrenia was confirmed, she was administered a new antipsychotic agent, amisulpride, at dose of 600 mg/day. This treatment was going on during several weeks with no significant clinical effect. Because the early onset of the disorder, the family history of schizophrenia, and the lack of effectiveness of the two previously administered antipsychotic agents, a treatment with clozapine was started at the dose of 12,5 mg/day. From the outset of this treatment, clinically significant reductions in hallucinations and disorganized behaviours were noted. Dose was then progressively increased until 200 mg/day, resulting in significant improvement in cognitive and motor functioning. The patient is now in an educational institute. Her adaptation is considered satisfactory, in spite of regular exacerbations of delusions in response to stressful life events. Treatment with clozapine is going on, without any significant undesirable clinical effects. DISCUSSION: If an abrupt onset is rarely observed in prepubertal children, all the authors report that patients with very early onset schizophrenia show to have demonstrable impairments in their premorbid language as well as in their motor and social development. In addition, several studies suggest that more pronounced early developmental abnormalities are usually associated with a poor outcome in schizophrenia. The clinical picture also agrees with recent studies showing that in children paranoid subtype is as frequent as seen in adult disorders. If genetic factors play a significant role in the pathogenesis of schizophrenia, the notion that such factors may be more salient in very early onset and more severe cases is now usually accepted. However, a number of environmental factors, including prenatal maternal infections and perinatal complications, may also be implicated in the pathogenesis of schizophrenia, in addition to genetic factors. Because a significant relationship between stressful life events and exacerbations in positive symptoms was found in the case reported, the authors examine the role of such stress factors in the pathogenesis of schizophrenia and in the course of illness. A brief review of studies that have examined the effects of antipsychotic agents in children with schizophrenia underscores the paucity of data available to guide clinicians in this area. However, these data suggest that children who receive conventional neuroleptics experience significant adverse effects, primarily sedation and extrapyramidal symptoms. In addition, they suggest that new antipsychotic agents, such as clozapine, may be more effective than conventional neuroleptics, particularly in negative symptoms. Lastly, the authors emphasize the poor outcome usually reported in childhood-onset schizophrenia, highlighting the need of a long-term pharmacological and behavioural treatment. CONCLUSION: This case report, such as others, supports the hypo-thesis that there is a clinical continuity between early and later onset schizophrenia. It also suggests that very early onset schizophrenia is a more severe form of the disorder and may be secondary to greater familial vulnerability. Consequently, systematic studies of these patients may be particularly informative and may provide important informations for understanding the etiologic processes involved in the pathogenesis of schizophrenia.     

Present data and treatment schedule of aripiprazole in the treatment of schizophrenia

Among the second generation antipsychotics, aripiprazole presents a new pharmacological profile, basically differentiated by a partial agonist effect on the D2 and D3 dopaminergic receptors. Five short-term efficacy studies, conducted on 1648 patients presenting with schizophrenia or acute relapse of schizoaffective disorders, demonstrated the greater efficacy of aripiprazole than the placebo and comparable efficacy to that of haloperidol and risperidone. The short-term tolerance profile was characterised by a lesser incidence of the extrapyramidal side effects and drowsiness than with haloperidol. Two thousand six hundred and eighty five patients were followed-up over a period of 26 to 52 weeks in five clinical trials versus a placebo and haloperidol, olanzapine, quetiapine and risperiodone: demonstrated efficacy in maintaining the response to treatment and on the delay before relapse was comparable to the other antipsychotics. The classical side effects of antipsychotics decreased in the long-term. Versus olanzapine, a glucid and lipid profile, clearly in favour of aripiprazole, was completed by a lesser incidence of hyperprolactinaemia. Aripiprazole is effective on all the dimensions of schizophrenia: the positive and negative and depressive and anxious symptomatology. It appears to be of interest, notably on the cognitive dimension, which should motivate more in-depth exploration of its place in the treatment in the early stages of schizophrenia. Its therapeutic schedule and the methods of initiation are an essential criterion to the success of treatment, notably during the substitution of other antipsychotics. The clinical and pharmacological originality of aripiprazole would justify the terminology of a "third generation antipsychotic".     

精神分裂症首次发病患者及其健康同胞认知功能的比较研究

目的 比较精神分裂症首次发病患者与健康同胞及正常对照认知功能的差异,探讨精神分裂症在认知功能领域的内表型.方法 采用目前常用的范畴流畅测验(CFT)、数字符号编码测验(DSCT)、连线测验(TMT)、韦克斯勒记忆量表第3版(WMS-Ⅲ)空间广度测验(WMS-ⅢSST)、霍普金斯词汇学习测验-修订版(HVLT-R)、简易视觉空间记忆测验-修订版(BVMT-R)、定步调听觉连续加法测验(PASAT)和威斯康星卡片分类测验-64(WCST-64)对92例精神分裂症首次发病患者(患者组)、56例健康同胞(同胞组)和62名健康对照者(对照组)的认知功能进行检测.结果 (1)患者组所有神经心理测验成绩均差于对照组,差异有统计学意义(P＜0.01).(2)同胞组的CFT、DSCT、TMT、HVLT-R即刻记忆和延迟记忆、BVMT-R即刻记忆、PASAT、WCST-64持续错误数、持续反应数和完成分类数的测验成绩差于对照组,差异有统计学意义(P＜0.05).(3)患者组与同胞组的CFT、WCST-64中的持续错误数、持续反应数和完成分类数测验成绩分别为(18.40±12.12)分比( 18.86±5.19)分、(16.48±8.19)分比(14.80±5.86)分、(18.76±10.91)分比(16.86 ±7.73)分、(1.33±2.81)分比(1.63±1.36)分,2组比较差异无统计学意义(P＞0.05),其他神经心理测验成绩比较,患者组差于同胞组,差异有统计学意义(P＜0.05).结论 精神分裂症首次发病患者存在处理速度、工作记忆、言语记忆、空间记忆、注意警觉和执行功能广泛性的认知功能损害,精神分裂症健康同胞存在处理速度、言语记忆、视觉记忆、注意警觉、执行功能的认知缺陷;语义流畅性功能和执行功能可能是精神分裂症的潜在内表型.     

Disability in chronic daily headache: state of the art and future directions

Aim of this literature review is to summarize the most relevant research findings on disability in subjects with chronic daily headache (CDH) and chronic migraine (CM) measured with the MIDAS and the HIT-6, and to address issues for further research in the field. Research strategy aimed to find papers published after 2001 that focused on disability in patients with CDH, CM and transformed migraine. Both, general population surveys or clinical series were included if they reported total scores, or distribution of the different disability levels, derived from the MIDAS and/or from the HIT-6. Fifteen papers were selected. Studies demonstrated that these subjects report a remarkable impact on functioning, with high disability scores, and reduced ability in work and non-work activities. Modern definitions of disability conceptualize it as the result of the interaction between a health condition and environmental factors. Research strategies should therefore recognize that disability may represent a global evaluation which should be added to more specific endpoints, using instruments that measure disability in a multi-dimensional way, such as the WHO-DAS II.

     

Perturbed consciousness in schizophrenia: an evaluation of C.D. Frith's model

INTRODUCTION: While many neurocognitive models of schizophrenia coexist, a lot of attention has been centered on C.D. Frith's model over the past few years, especially in regard to its parsimony. BACKGROUND: The aim of this paper is to examine its validity. The model relies on the assumption that there are two main components: self-monitoring and monitoring. The first permits one to keep consciousness of personal goals and intentions with metarepresentations. Losing consciousness of personal goals would be the source of schizophrenics' avolition and losing consciousness of personal intentions would generate reference ideas. The second component refers to the so-called "theory of mind", which is the monitoring of others' mental content (knowledge and intentions). Disturbing monitoring would cause schizophrenics persecution disillusions, third order persecutions or speech content disorders. LITERATURE FINDINGS: After reviewing the empirical and theoretical bases of Frith's model, strengths and weaknesses are highlighted, in particular by contrasting Hardy-Baylé's and Abu-Akel's theoretical proposals. For explaining the monitoring impairments of schizophrenics, Hardy-Baylé's model emphasizes the executive functioning defect, while Abu-Akel's model proposes a "hyper theory of mind" where too many hypotheses would lead to misattributions. In addition, several criticisms of Frith's model are examined, particularly those voiced by phenomenologists who underline its reductionism presupposition and argue that the underlying cognitive conception of the "theory of mind" neglects the fundamental intersubjectivity issue. In addition, Gallagher points out that monitoring is a tautological concept and that intention is not like thinking inherent to behaviour. CONCLUSION: Frith's model validity is finally discussed at large in the light of these criticisms and competing models, and it is concluded that the self-monitoring part of the model needs to be redefined and that the measurement of the "theory of mind" has to be standardized.     

2-COM: presentation of an instrument facilitating communication between physicians and carers in daily practice

Communication between the patient and the professional carer lies at the heart of all decisions regarding diagnosis and treatment. However, patients and doctors often have divergent views on care needs; 2-COM (for 2-communication) is a simple patient-completed self-report instrument designed in order to facilitate patient-professional carer communication. Aims - To present 2-COM and to examine whether providing patients with an opportunity to identify and discuss their needs would improve communication and induce changes in care. Methods - The 2-COM is a simple list of 20 common problems, or areas of perceived need, that might be experienced by patients with severe mental illness. The list includes problems with housing, relationships, money, lack of activities, psychological distress, sexuality, symptoms and treatment side effects; 2-COM has shown adequate test-retest reliability and is well accepted by patients as a valued aid to communication with their doctor; 134 patients in a clinical diagnosis of schizophrenia or schizoaffective disorder were recruited at seven European centres: Maastricht, Oviedo, Gijon, Hamburg, Copenhagen, Milan and Nice. The assessment took place over 3 out patient clinic visits; at visit 1, the clinician recorded a list of all current interventions, including medication and non-medical treatments, together with demographic information and an assessment of current level of functioning, using the Global Assessment of Functioning scale. Prior to the second visit, patients were randomised to receive either 2-COM or "standard care" - a routine appointment without 2-COM. Immediately after the interview, all patients, whether they had completed 2-COM or not, completed a confidential questionnaire in which they could indicate the perceived quality of communication. Similarly, clinicians completed a repeat of the list of all current interventions, together with an assessment of any changes to the treatment plan implemented after the interview with the patient. Four to six weeks after clinic visit 2, patients attended the clinic for a third, "routine" clinical interview. Both patients and clinicians then completed the same set of post-interview assessments as at visit 2. The 2-COM induced a stable improvement of patient-reported quality of patient-doctor communication (B=0.33, P=0.031), and induced changes in management immediately after the intervention. Treatment change was more likely in patients with more reported needs at the 2-COM and needs most likely to induce treatment changes. In conclusion, the study showed that 2-COM is a useful instrument to expose and subsequently bridge, patient-professional carer discordance on patient needs.     

Working memory in schizophrenia: a review

INTRODUCTION: Working memory refers to a limited capacity system for temporary storage and processing of information that is known to depend on the integrity of the prefrontal cortex. It has been classically described as composed of a "central executive" that performs control, selection and planning functions, and two "slave" systems: on the one hand, the phonological loop that holds verbal, speech-based representations, and on the other hand, the visuospatial sketchpad that manipulates spatial and object visual representations. LITERATURE FINDINGS: Studies in schizophrenia have used different tasks that tap different processes within the working memory. Despite the variety of measures, there is solid neuropsychological evidence that patients with schizophrenia demonstrate deficits in all subsystems of working memory. Several studies have shown no correlations between working memory deficits and age, gender, premorbid IQ, duration of disease or positive syndrome, but a correlation has been found with a low-educational level, and negative and disorganization symptoms. Neuroimaging studies have provided evidence of an involvement of the dorsolateral-prefrontal cortex during working memory performance. Many studies have demonstrated a functional deficit in this area. However, several recent studies have reported either equal or increased activation of the dorsolateral-prefrontal cortex in schizophrenia during working memory performance. Working memory deficits are present early in the course of schizophrenia and they have been shown to be consistently associated with reduced levels of elementary social skills and learning capacity. Unaffected relatives of individuals with schizophrenia and individuals diagnosed with schizotypal personality demonstrate deficits in tasks designed to measure working memory function. Working memory dysfunctions might be suitable candidate markers for vulnerability. Certain executive sub-processes seem to be the most heritable component of the working memory. Working memory deficits in schizophrenia may benefit from specific stimulation of receptors such as the dopaminergic D1 receptor, adrenergic alpha-2A receptor or nicotinic receptors. Few studies on the effect of antipsychotic medication on working memory in schizophrenia have been carried out and their results are highly variable. Atypical antipsychotic drugs, notably risperidone, have appeared to improve performance in working memory tasks. Cognitive exercises can improve working memory with a six-month persistent effect.     

Qualifying language disorders of schizophrenia through the speech therapists' assessment

This study investigates a comprehensive assessment of language disorders in order to identify impaired and unaffected language abilities of individuals with schizophrenia. Furthermore, the purpose of this study was to demonstrate the importance of the role of speech therapists in the treatment of schizophrenia. Speech therapy is especially thought to treat language disorders. However, to date, speech therapists have not been solicited in the treatment of schizophrenia, despite growing evidence supporting that schizophrenia is characterized by cognitive disorders such as impairments in memory, attention, executive functioning and language. In this article, we discuss the fact that elements of language and cognition are interactively affected and that cognition influences language. We then demonstrate that language impairments can be treated in the same way as neurological language impairments (cerebrovascular disease, brain injury), in order to reduce their functional outcome. Schizophrenia affects the pragmatic component of language with a major negative outcome in daily living skills [Champagne M, Stip E, Joanette Y. Social cognition deficit in schizophrenia: accounting for pragmatic deficits in communication abilities? Curr Psychiatry Rev:2006;(2):309-315]. The results of our comprehensive assessment also provide a basis for the design of a care plan. For this, subjects with schizophrenia were examined for language comprehension and language production with a focus on pragmatic abilities. In neurology, standardized tests are available that have been designed specifically to assess language functions. However, no such tests are available in psychiatry, so we gathered assessments widely used in neurology and examined the more relevant skills. In this article, each test we chose is described and particular attention is paid to the information they provided on impaired language abilities in schizophrenia. In this manner, we provide an accurate characterization of schizophrenia-associated language impairments and offer a solid foundation for rehabilitation. Current research makes connections between schizophrenia and other neurological disorders concerning language. Nevertheless, further studies are needed to explore these connections to complete our investigations. The strategies we designed are aimed at enabling a subject with schizophrenia to improve his/her language skills. We support the idea that such improvement could be reached by speech therapy. We conclude that speech therapists can play an important role in the non pharmacological treatment of schizophrenia, by selecting appropriate interventions that capitalize on spared abilities to compensate for impaired abilities.     

Inhibition of return in schizophrenia: a review

INTRODUCTION: Most visual environments contain more information than the human brain can process in real time. To overcome this limitation, the attention system acts as a filter by selectively orienting attention to specific regions of the visual field. This ability to orient attention can be reflected in covert shift processes of attention. LITERATURE FINDINGS: In a typical covert orienting task, subjects have to maintain fixation on a central cross and respond as quickly as possible to a target, which appears in a peripheral box following a cue that summons attention to the direction where the target is going to appear (valid cueing) or to the contralateral direction (invalid cueing). When the cues are nonpredictive, the response characteristics critically depend on stimulus-onset asynchrony (SOA). With short SOAs (<300ms), valid cues result in a reaction time advantage over invalid trials, which is due to a reflexive shift of attention towards the source of stimulation. In contrast, with longer SOAs, valid cues result in longer reaction times to the subsequent target. DISCUSSION: This phenomenon is known as the inhibition of return and is mostly thought to reflect an inhibitory mechanism protecting the organism from redirecting attention to previously scanned insignificant locations. Many studies have reported blunted or delayed inhibition of return in patients with schizophrenia. However, some authors reported normal amounts of inhibition of return. This can be partly explained by the use of manipulations of the covert orienting of the attention paradigm that is known to enhance the course of inhibition of return. CONCLUSION: The deficit of inhibition of return seems to be time-stable and to be unrelated to psychopathology or length of illness. The contribution of neuroleptic medication to this deficit cannot be determined. Recent data suggest a deficit of inhibition of return in two human models of psychosis (dimethyltryptamine and ketamine). Further studies should clarify whether blunted inhibition of return might represent a trait marker of schizophrenia.     

Cognitive functioning in community dwelling older adults with chronic partial epilepsy

PURPOSE: To examine cognitive functioning in community-dwelling older adults with chronic partial epilepsy and demographically matched healthy older adults. METHODS: Standardized measures of neurocognitive function were collected as part of an ongoing study investigating health-related quality-of-life issues in older adults with epilepsy. Cognitive tests consisted of the Mattis Dementia Rating Scale (subscales include attention, initiation/perseveration, construction, conceptualization, memory), Logical Memory subtest from the WMS-III (immediate and delayed recall scores), and word fluency. Mood was measured with the Geriatric Depression Scale. Older adults with epilepsy (n=25) and healthy older adults (n=27) completed testing. All participants were at least 60 years old, living independently in the community, and had no history of drug/alcohol abuse or life-threatening medical conditions. All older adults with epilepsy had been diagnosed as having medically intractable partial complex seizures, including those with histories of secondary generalization. RESULTS: Older adults with epilepsy demonstrated impairments across all cognitive measures compared with the healthy controls. Seizure onset (age) and seizure duration (years) were not statistically associated with neurocognitive function or self-reported mood. Older adults with epilepsy who were receiving antiepileptic drug (AED) polytherapy (n=11) displayed worse performance on the attention, initiation/perseveration, and memory subscales of the DRS and Logical Memory delayed recall score compared with those older adults with epilepsy receiving monotherapy (n=14). The number of AEDs taken was not associated with seizure frequency. CONCLUSIONS: Negative effects on cognitive function are experienced by older adults with chronic partial epilepsy. AED polytherapy may increase the risk for negative cognitive dysfunction.     

Cognitive behavior therapy for schizophrenia and psychosis: current status and future directions

Cognitive behavior therapy (CBT) is an empirically based psychological treatment, which has a strong evidence base in a range of psychological disorders and, more recently, has also been applied to more serious disorders such as schizophrenia and psychoses (CBTp). This review outlines the background to this development and the theoretical bases to CBTp. There is good evidence from a considerable number of clinical trials that CBTp has a consistent clinical benefit when used in addition to standard care. There is, however, some variation in the outcomes of these clinical trials which may be due, in part, to the variation in methodological rigor of the trials. There is evidence that smaller, albeit still significant, effect sizes are found in methodologically more robust clinical trials. This is consistent with results found in other branches of medicine and healthcare. The different clinical strategies and outcomes found with various phases of the illness are outlined. There are considerable clinical and research challenges posed by issues of: 1) risk; 2) treating serious comorbidity; and, 3) treating conditions that limit recovery. These clinical problems are being addressed by a second wave of clinical developments. Lastly, the perennial problem of dissemination and translation of research into clinical practice is discussed.     

Cognitive performance and functional competence as predictors of community independence in schizophrenia

Measures of functional competence have been introduced to supplement standard cognitive and neuropsychological evaluations in schizophrenia research and practice. Functional competence comprises skills and abilities that are more relevant to daily life and community adjustment. However, it is unclear whether relevance translates into significantly enhanced prediction of real-world outcomes. The aim of this study was to assess the specific contribution of functional competence in predicting a key aspect of real-world outcome in schizophrenia: community independence. Demographic, clinical, cognitive, and functional competence data were obtained from 127 patients with schizophrenia or schizoaffective disorder and used to predict community independence concurrently and longitudinally after 10 months. Hierarchical regression analyses indicated that demographic, clinical, and cognitive predictors accounted jointly for 35%-38% of the variance in community independence across assessment points. Functional competence data failed to add significantly to this validity. Considered separately from demographic and clinical predictors, cognitive and functional competence data accounted for significant amounts of outcome variance. However, the addition of functional competence to standard cognitive test data yielded a significant increase in validity only for concurrent and not for longitudinal prediction of community independence. The specific real-world validity of functional competence is modest, yielding information that is largely redundant with standard cognitive performance.     

Cognitive functioning in the schizophrenia prodrome

In the last decade, there has been an increasing interest in cognitive alterations during the early course of schizophrenia. From a clinical perspective, a better understanding of cognitive functioning in putative at-risk states for schizophrenia is essential for developing optimal early intervention models. Two approaches have more recently been combined to assess the entire course of the initial schizophrenia prodrome: the predictive "basic symptom at-risk" (BS) and the ultra high-risk (UHR) criteria. Basic symptoms are considered to be present during the entire disease progression, including the initial prodrome, while the onset of symptoms captured by the UHR criteria expresses further disease progression toward frank psychosis. The present study investigated the cognitive functioning in 93 subjects who met either BS or UHR criteria and thus were assumed to be at different points on the putative trajectory to psychosis. We compared them with 43 patients with a first episode of psychosis and to 49 help-seeking patient controls. All groups performed significantly below normative values. Both at-risk groups performed at intermediate levels between the first-episode (FE) group and normative values. The UHR group demonstrated intermediate performance between the FE and BS groups. Overall, auditory working memory, verbal fluency/processing speed, and declarative verbal memory were impaired the most. Our results suggest that cognitive impairments may still be modest in the early stages of the initial schizophrenia prodrome and thus support current efforts to intervene in the early course of impending schizophrenia because early intervention may prevent or delay the onset of frank psychosis and thus prevent further cognitive damage.     

Schizophrenia and culture: reality and perspectives based on the Tunisian experience

Despite notable advances in the field, schizophrenia is still considered a major public health problem on international level. The combination of frequency, chronicity and severity make it, for some authors, the "cancer of mental disorders". However, according to the many cross-cultural studies, in particular, the two mammoth research projects of the WHO (IPSS and DOSMED, it is now irrefutable that the course and outcome of schizophrenia are better in patients from developing countries. The reasons for better outcome and more favorable course of schizophrenia in developing countries are still far from clear and remain speculative. AIM OF THE STUDY: We have carried out a study among a population of schizophrenic patients admitted to our hospital during the past year, to question the issues of outcome, course and prognosis in Tunisia, which is an emerging country, ranking half-way between the most and the least developed countries. RESULTS: It appears that the outcome of schizophrenia is similar to that of developed countries. A community survey reported an annual prevalence of 5.7 and an incidence of 3. 266 patients with schizophrenia were admitted between August 2003 and 2004, representing 40% of the whole hospitalized population; 80% were former patients who had been hospitalized an average of 8 times. One patient out of five will be readmitted at least once within the same year. Only 16.5% were married, and 10% had a regular job, in spite of a high level of education. A chronic course without remission is not unusual and long stay patients now account for a fourth of the hospital population. COMMENTS: It seems clearly and paradoxically that the course and outcome of schizophrenia is deteriorating and getting closer to what is observed in the industrialized societies. The same trend was observed in the western countries during the last centuries, leading some authors to claim that schizophrenia is a modern disease, which appeared in the XIX(e) century and spread in the XX(e). Besides, other than the controversy regarding the recent evolution of its incidence, it seems that we are not witnessing the anticipated decrease in incidence that comes with the therapeutic progress and the decline in fertility among individuals with schizophrenia. DISCUSSION: We shall discuss three hypotheses to try to explain the aggravation of schizophrenia along with the economic development: the heterogeneity of the disease with two clinical presentations: a benign form (good prognosis), more frequent in developing countries, and a severe form, observed mainly in developed societies. The progress in medicine and gynecology-obstetrics, which contributes to the survival of patients with serious schizophrenia and the vulnerable newborn exposed to multiple assaults and risk factors related to birth. The progress in psychiatry that is selecting the more serious subtypes of schizophrenia, which are overrepresented today. Research issues pertaining to course and outcome of schizophrenia are still unresolved. It is likely that prognosis of schizophrenia varies according to the economic development rather than to the culture. This observation could open new research and prevention perspectives.     

The subjective quality of life of patients with schizophrenia: influence of psychopathology and patients' expectations. A comparative study

Most studies on the quality of life (Qol) of patients with schizophrenia deal with objective living conditions and how they are perceived by hospitalized patients. The few studies that compare Qol for patients treated in part time services with the Qol of ambulatory patients do not show any significant difference in terms of subjective Qol. Some stu-dies evaluate the influence of psychopathology and needs (or expectations) on the subjective Qol in these groups of patients. Available data indicate that the general well-being is influenced by psychopathology (positive, negative or depressive symptoms) and unmet needs in ambulatory patients. They also show that subjective Qol in certain life domains (social relations, family relations, leisure, health, law and security) is influenced by negative symptoms, anxiety and depression in patients treated in part-time services. The aim of this study is to compare the objective and subjective Qol of patients with schizophrenia treated in part time services (day hospital and day care center) to the Qol of out-patients treated on a purely ambulatory basis (out patient clinic). We studied the Qol of 2 groups of 30 patients with schizophrenia (ICD 10 criteria) treated in various centers. The first group was made of ambulatory patients, the second one was constituted of patients treated in a day hospital or a day care center. Patients were matched for age, duration of illness, number of hospitalizations. The instruments used for rating were the following: Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), Positive And Negative Symptoms Scale (PANSS), Drug Attitude Inventory (DAI-10). The Qol was measured with a french version of the Lancashire Quality Of Life Profile (LQOLP) (Salomé, Germain, Petitjean, Demant and Boyer, 2000). This instrument measures the objective Qol as well as the subjective Qol. It does possess satisfying psychometric properties and offers the possibility to establish Qol profiles. All Qol ratings were carried out by a clinician who was not involved in the treatment of the patients. When the 2 groups are compared our results indicate that ambulatory patients are less symptomatic, have a better level of functioning and a better objective Qol in such domains as: finances, living situation, family relations and health. There is no significant difference in terms of anxiety and depression as measured by the respective items of the PANSS. Patients treated in part-time services present higher scores of positive symptoms. Our results indicate that there is no significant difference for subjective Qol variables between the two groups, except for general well-being, that tends to be higher in ambulatory patients. When exploring the influence of clinical data on the Qol in each group, we find negative correlations in ambulatory patients between various domains of subjective Qol and illness severity (law and security, family relations, social relations, general well-being), global functioning (family relations, social relation, health) and positive symptoms (living conditions, law and security, family relations, social relations, health). In this same group, the subjective Qol for family relations is significantly correlated with several expectations in terms of Qol improvement (leisure, social relations, family relations, transport, work). In these patients, the subjective Qol for social relations is also significantly correlated with their expectations in terms of Qol improvement (work, money, lodging, affective relations, transport). There is no significant correlation between subjective Qol and expectations in patients treated in part-time services. Our results indicate that part time services treat schizophrenic patients with a lower level of global functioning and a higher level of symptom severity compared with ambulatory patients. These results confirm other studies that show no significant difference between these 2 groups in terms of subjective Qol. The subjective Qol in the field of relations (family and social) in ambulatory patients seems particularly sensitive to illness severity, positive symptoms and global functioning level. This has also been reported by other studies. In patients treated in part-time services, the subjective Qol, particularly for living conditions and security, seems sensitive to anxiety and depression. This has also been shown by other studies. Finally, our results underline the importance of patients' expectations in terms of subjective Qol, particularly in the field of relations (family and social) for ambulatory patients.     

精神分裂症患者认知功能损害与氧化应激关系的初步研究

目的：探讨精神分裂症患者认知功能缺损与氧化应激的关系。方法：对39例精神分裂症患者（患者组），36名健康对照者（对照组）进行神经心理测验和氧化应激指标的检测.结果：（1）在神经心理测验中，患者组与对照组在总测验数、总错误数、持续错误数、语言流畅、领悟、相似和联想学习的差异有非常显著性（P＜0．01），数字广度的差异有显著性（P＜0．05）；（2）患者组后的一氧化氮（NO）浓度与WCST的总错误数呈显著正相关，与相似测验呈显著性负相关，超氧化物歧化酶（SOD）活性与相似性测验、数字广度测验呈显著性负相关（r分别为0．409，－0．404，－0．432，－0．420，P＜0．05）。结论：（1）精神分裂症认知功能缺损的生物学基础可能与氧化应激有关；（2）SOD和NO可能是与认知功能密切相关的氧化应激指标。