Production d’émotions faciales dans la schizophrénie

Converging evidences revealed that facial pattern recognition is severely impaired in schizophrenia. The present article focuses on recognition of their own facial expression by patients with schizophrenia. It seems that schizophrenia is related with a dissociation between facial expression and emotional feeling. Recent experimental data are discussed.     

Reconnaissance de l’émotion faciale et schizophrénie

A broad range of deficits in interpersonal skills characterizes schizophrenia. A natural way to tackle these deficits is to explore the ability of schizophrenic patients to process stimuli that have a well-established psychosocial content: faces, for instance. Schizophrenia deficits in facial recognition and discrimination have been studied extensively and most investigators have pointed out that patients with schizophrenia perform less well than non-patients and psychiatric controls in numerous facial paradigms, including facial identity, emotion and age recognition tests. The extent of the schizophrenic deficit suggests the alteration of a processing mechanism common to all kinds of facial information and the configural information extraction process has then been regarded as a probable candidate. Nevertheless, only a few studies directly tested the hypothesis. In what follows, we draw a general schema of the schizophrenia deficit in facial processing, next we present a series of studies investigating the putative implication of configural information in the abnormal processing of facial emotion in the disease.     

Les spécificités de la schizophrénie à début pendant l'enfance : aspects cliniques et conséquences nosographiques

Should child-onset schizophrenia be considered as included in schizophrenia or should it not? The authors have reviewed available clinical and nosographic data and this has led them to answer positively. They underline the specificities of clinical presentation and of diagnostic criteria in children.     

Remédiation cognitive chez les patients souffrant de schizophrénie

Cognitive remediation aims at correcting some cognitive deficits observed in schizophrenia. These cognitive deficits can be targeted as such (it is the case of attention, memory or executive disorders) or as processes underlying target symptoms. Cognitive remediation supplements the action of drugs (in particular anti-psychotics) and psychotherapy. Its results are significant, in terms of improvement of cognitive functioning, as well as in terms of improvement of positive and negative symptoms and psychosocial functioning.     

Un diagnostic méconnu : la schizophrénie chez l’enfant

Childhood-onset schizophrenia is rare: its prevalence is about 50 times lower than the one observed in adulthood. It is also frequently an unrecognized disorder, notably because its clinical aspect varies with age and intellectual functioning. Differential diagnosis with affective psychoses is also difficult because the high frequency of comorbid disorders. Its consequences on the child social functioning are nevertheless significant: schizophrenia leads to severe behavioral disorders, requiring more often the child hospitalization in a psychiatric department. Outcome studies suggest a continuity in the diagnosis of schizophrenia between childhood and adulthood, and show that its prognosis, although highly varying, is generally somewhat poor. All these data highlight the need for an early diagnosis, in order to start the treatment as precociously as possible.     

Hypothermie aux antipsychotiques : particularités chez le sujet âgé souffrant de schizophrénie

Hypothermia - an adverse drug reaction of antipsychotic drug use potentially severe - seems less well-known than the hyperthermic effects (for example, malignant neuroleptic syndrome) and thus underdiagnosed. Thermoregulation in elderly can be altered. Additionally, some patients suffering from schizophrenia are not able to control their own environment or physical status. Thus, risk factors for hypothermia must be identified and frequent measurements of body temperature must be performed in order to detect developing hypothermia. A case report of hypothermia in a 69 years old patient suffering from schizophrenia is published with this review.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.     

Intérêt d’un nouvel instrument dans l’évaluation cognitive dans la schizophrénie

Background

An increasing interest in the study of cognition in Schizophrenia has developed within the last few years although cognitive problems have been described in this disorder since the beginning of the 20th century. Presently, various data tend to assert that cognitive disorders are the core disturbance in schizophrenia and that their severity is predictive of the course of the disease. Indeed, studies have shown that the disturbances measured in cognitive tests are neither the consequences of positive or negative symptoms, nor related to motivation or global intellectual deficit, nor to anti-psychotic medication. It is also presently known that the severity of cognitive symptoms is a better indicator of social and functional outcome than the severity of the negative or positive symptoms. The patients who have the most severe cognitive deficits during the first episode of the disease are most likely to present a chronic and severe form later on. The aspects of cognition that are specifically impaired in schizophrenia are verbal memory, working memory, motor function, attention, executive functions, and verbal fluency. Cognitive disturbances are thus very important in several fields of research in schizophrenia such as: understanding the psychopathology, epidemiology (indicators of vulnerability), genetics (endophenotypes), neuro-imaging (including functional neuro-imaging), and psychopharmacology (they can be used as a parameter of evaluation in therapeutic trials with new molecules, or cognitive psychotherapy).

Limits of cognition assessments

However, there are some methodological limits to these cognitive evaluations. First, schizophrenia is a heterogeneous disease and there are no specificities of the different subgroups in terms of cognition. Secondly, the time chosen to evaluate the abilities of the patient is also a limiting factor. But most of all, the batteries of tests used in different studies are not standardized.

Brief Assessment of Cognition in Schizophrenia

It is therefore of great interest to create an available and easily used battery of validated tests. This would enable one to measure the different cognitive deficits and to repeat the tests, and assess evolution through longitudinal follow up of the patients. The BACS is a new instrument developed by Keefe et al. in the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre. It evaluates the cognitive dimensions specifically altered in schizophrenia and correlated with the evolution of the disease. This test is simple to use, requiring only paper, pencils and a stopwatch. It can be administered by different carers. The duration of the test session is approximately 35 min. This battery of tests was validated on a sample of 150 patients compared with a sample of 50 controls, matched for age, parent education and ethnic groups. This aim of this study is to create a French adaptation of the BACS (translation and back translation approved by the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre) and then to test its easiness of administration and its sensitivity, performing correlation analysis between the French Version of the BACS (version A) and a standard battery. Its adaptation and validation in French would at first be useful for the French-speaking areas and then would add some new data for the pertinence of using the BACS.

Methods

35 French stabilized schizophrenic patients were recruited from the inpatient and outpatient facilities at the Clermont-de-L’Oise Mental Health Hospital (Picardie area, France) in Dr Boitard‘s Psychiatric Department (FJ 5.) Patients were required to meet DSM-IV criteria for schizophrenia or schizoaffective illness. The patients were tested on two separate days by two independent clinicians with less than two weeks between the two assessments. During the first test session, subjects received the French A version of the BACS and during the second session, they were administered the standard battery of cognitive tests including: the Rey Auditory-Verbal learning test, the Wechsler Adult Intelligence Scale, third edition, subtests (Digit inverse sequencing, Digit Symbol-Coding), the Trail-Making A, Verbal Fluency (Controlled Oral Word Association Test, Category Instances), and the Wisconsin Card Sort Test (128 card version). The factor structure of the French BACS A Version was determined by performing a principal components analysis with oblique rotation. The relationship between the French BACS sub-scores and the standard battery sub-scores was determined by calculating Pearson's correlations among the sub-scores, with a level of significance of α < 0.05.

Results

All the 35 patients completed the standard battery and each subtest of the French BACS A Version without interruption and with good understanding of the instructions. The average duration of the BACS test sessions was 36.51 min (S.D. = 12.14.) compared to the standard battery in which the sessions lasted more than one hour with more difficulty during the Wisconsin tests. The factor analysis conducted on the data collected from patients suggests that there is a single dimension, a factor of general cognitive performance, which accounted for the greatest amount of variance. The BACS thus permits an assessment of overall cognitive function as a global score, more than some individual specific cognitive domains. The sub-scores from the French BACS A Version were strongly correlated with the standard battery corresponding sub-scores. We observed significant correlations for all the subtests evaluating: verbal memory (Pearson = 0.83; p < 0.001; IC [0.69; 0.91]), working memory (Pearson = 0.67; p < 0.001; IC[0.43; 0.80]), verbal fluency (semantic: Pearson = 0.64; p < 0.001; IC[0.40; 0.80]), alphabetical (Pearson = 0.87; p < 0.001;IC[0.77; 0.93]), attention and speed of information processing (Pearson = 0.69; p < 0.001; IC[0.47; 0.83]), executive function (Pearson = 0.64; p < 0.001; IC[0.39; 0.80]). We almost found a significant correlation for motor speed (Pearson = −0. 32; p = 0.06; IC [−0.59; −0.014]).

Conclusion

The French adaptation of the BACS scale is easier to use in schizophrenic patients with French as mother tongue, with a completion rate equal to 1, and also with less than 35 min to complete and check. We obtained significant correlations for all domains except motor speed, which is almost significant. The BACS is as sensitive to cognitive impairment in patients with schizophrenia as a standard battery of tests that required over 2 h to complete. Moreover, these results demonstrate that the BACS, the global score of which may be the most powerful indicator of functional outcome, can also be a good neuropsychological instrument for assessing global cognition in patients with schizophrenia.     

Traitement cognitif du contenu verbal halluciné : tâche de décision lexicale

The psychopathology of auditory verbal hallucinations continues to benefit from a productive experimental and theoretical field of research. The hypothesis of an interior discourse that the hallucinated subject does not recognize as coming from himself, and that of an aberrant activity which disturbs the primary auditory region as an explanation for the development of auditory hallucinations are the two most examined hypotheses at present. In most cases, the verbal content of the auditory hallucinations remains the same from one psychotic episode to another, even if the two episodes are separated by a long period of remission. We advance the hypothesis that the verbal content of auditory hallucinations remains present at an infraclinical level, even during those periods of total remission from hallucinations and that it could be rapidly reactivated during events that are stressful to the subject. We also suggest that the two psychopathological structures proposed above preferentially apply to this specific verbal content. In this study, we have used a lexical decision task to test this hypothesis. The results have shown that even during a period of total remission, the patients recognize more rapidly the words they heard when they were in a hallucinatory state than those which were never included in their hallucinations. This finding demonstrates that there is a possibility that the hallucinatory material may persist at an infraclinical level, even during periods of remission. At the same time, it also raises the possibility of there being a specific lexicon for hallucinatory words.     

Facteurs prédictifs de l’adaptation sociale des patients souffrant de schizophrénie

The past century saw multiple psychopharmacological advances in the treatment of schizophrenia. However, the social adaptation of patients is still quite poor. The authors therefore think it is necessary to develop specific therapies to limit the social handicap due to schizophrenia. In this aim, it is essential to obtain better knowledge of the predictive factors of social adaptation in schizophrenia. Indeed, if some of these factors cannot be changed, some respond to therapies which have been developed recently, such as psychosocial rehabilitation.     

Insight cognitif et schizophrénie

Schizophrenia is usually associated with severe and chronic lack of knowledge of mental illness. This lack of insight is found to be correlated to hypofrontality but not related to the disorder outcome or to the intelligence quotient. The cognitive insight was defined as the difference between self-reflectiveness and self-certainty. This ability is described as decreased in schizophrenia but increased in depression. Thus, schizophrenia with depressive comorbidity is associated with a higher level of insight. The authors discuss how greater awareness of psychotic illness can be lived as traumatic, which appears to be a risk factor for depression and suicide.     

Complications obstétricales dans la schizophrénie : étude comparative en population tunisienne

The neurodevelopmental hypothesis in schizophrenia argues that this disorder may be a result of abnormal brain development due to genetic risk and or to environmental injury such as those due to obstetric complications. Very few studies from emerging countries have been published concerning obstetric complications in schizophrenia. However, meteorological, demographic and health factors in most of these countries are different from those in Western countries, and studies in this field may bring more findings. Our objectives were to compare the frequency of obstetric complications in a group of schizophrenic patients compared to two other groups: a group of first-degree relatives and a healthy control group, and to search for the relationships between these complications and the epidemiological and clinical features of schizophrenic patients. The study is a retrospective case-controlled one: a schizophrenic patient group (N = 55, 43 males and 12 females, median age = 30 years) was compared to a group of non-affected first degree relatives (N = 40, 31 males and 9 females, median age = 29 years) and to healthy controls without familial psychiatric history (N = 38, 25 males and 13 females, median age = 29 years), all matched according to age and sex. Obstetric complications were collected at home from the biological mothers at the time of a visit using the McNeil-Sjostrom questionnaire. Schizophrenic patients were clinically assessed using the Positive and Negative Symptoms (PANSS), the General Assessment of Functioning (GAF) and the Clinical Global Impressions (CGI). Obstetric complications frequency was significantly higher in schizophrenic patients: 67,3 versus 20,0% in their non affected relatives and 28,9% in the healthy controls (P < 0,001). The mean total score of obstetric complications was significantly higher in the schizophrenic group: 1,52 ± 1,47 versus 0,8 ± 1,77 in the non affected relatives and 0,5 ± 0,97 in the healthy controls (P < 0,001). In the schizophrenic patients, obstetric complications were more frequent during delivery period (50,9%) and neonatal period (45,5 %). More particularly in pre-term births (21,8%), low birth weight and fetal distress (18,2%) and premature rupture of the membranes (16,4%). A statistical relationship was established between obstetric complications frequency, autumn-wintry birth season, low school level and negative symptoms in the PANSS. However, no significant correlation was found between obstetric complications frequency, family psychiatric history and age of onset of schizophrenia. Through an investigation involving mental recall, our results proved a higher frequency of obstetric complications in schizophrenic patients. Our results support the role of obstetric complications in the etio-pathology of schizophrenia, in interaction with other environmental or genetic factors. This association favors the neuro-developmental hypothesis in schizophrenia. Further studies assessing influence of weather, specific infectious agents, and demographic factors could also be relevant.     

De l'intérêt clinique du concept d'héboïdophrénie. À propos de deux cas de schizophrénie criminelle

Our clinical experience brings us to believe that not all patients suffering from schizophrenia are dangerous and this in spite of collective representations and dramatic happenings regularly reported by the media.Indeed among the important symptomatic dimensions that are classically bound to this illness, some semiological regroupments seem to predict hetero-aggressive risks more than others. And this perception seems even clearer when the investigation is widened to cover the history of the patient, his/her personality traits, relational modalities and psychic representations. Therefore the concept of heboidophrenia that had become obsolescent in present day nosographies can constitute a clinical model that is still pertinent and propitious for new reflexions. To illustrate our remarks we have decided to present two strikingly similar clinical cases in spite of a great contextual difference. They relate to two patients suffering from schizophrenia who are untypical due to their murderous criminal history. After a comparative discussion our reflexion will widen to whether one can foresee such acts in this type of patient, and to the possibility of medical care…. Under the aegis of the Law.