C. Naveen Kumar

Schizophrenia patients experience substantial social cognition deficits across multiple domains in remission

Knowledge about SC (social cognition) during remission would inform us whether such deficits are trait- or state-markers of the disorder, as well as highlight its relevance for rehabilitation. We aimed to compare SC deficits and their relative independence from NC (neuro-cognition) deficits in remitted schizophrenia patients and matched health controls using comprehensive, culturally sensitive standardized tools. 60 schizophrenia patients meeting modified standardized criteria for remission and 60 age, gender and education matched healthy controls were compared on culturally validated tests of SC-Social Cognition Rating Tool in Indian Setting (SOCRATIS) & Tool for Recognition of Emotions in Neuropsychiatric Disorders (TRENDS) to assess theory of mind, attributional bias, social perception and emotion recognition and NC-(attention/vigilance, speed of processing, visual and verbal learning, working memory and executive functions). Patients had deficits in both SC and NC compared to healthy controls. Deficits in SC were largely independent of NC performance, and SC deficits persisted after adjusting for deficits in NC function. The effect sizes (Cohens d) for SC deficits ranged from 0.37 to 2.23. All patients scored below a defined cut-off in at least one SC domain. SC deficits are likely to be state-independent in schizophrenia, as they are present in remission phase of the illness. This supports their status as a possible composite-endophenotype in schizophrenia.

Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): A new test-battery to assess social cognition

Social cognition is a cognitive domain that is under substantial cultural influence. There are no culturally appropriate standardized tools in India to comprehensively test social cognition. This study describes validation of tools for three social cognition constructs: theory of mind, social perception and attributional bias. Theory of mind tests included adaptations of, (a) two first order tasks [Sally-Anne and Smarties task], (b) two second order tasks [Ice cream van and Missing cookies story], (c) two metaphor-irony tasks and (d) the faux pas recognition test. Internal, Personal, and Situational Attributions Questionnaire (IPSAQ) and Social Cue Recognition Test were adapted to assess attributional bias and social perception, respectively. These tests were first modified to suit the Indian cultural context without changing the constructs to be tested. A panel of experts then rated the tests on likert scales as to (1) whether the modified tasks tested the same construct as in the original and (2) whether they were culturally appropriate. The modified tests were then administered to groups of actively symptomatic and remitted schizophrenia patients as well as healthy comparison subjects. All tests of the Social Cognition Rating Tools in Indian Setting had good content validity and known groups validity. In addition, the social cure recognition test in Indian setting had good internal consistency and concurrent validity.

Cascading and combined effects of cognitive deficits and residual symptoms on functional outcome in schizophrenia - A path-analytical approach.

Understanding the complex relationship among determinants of real-world functioning in schizophrenia patients in remission is important in planning recovery-oriented interventions. We explored two path-analytical models of functioning in schizophrenia. 170 Schizophrenia patients remitted from positive symptoms underwent fairly comprehensive assessments of cognition - neurocognition (NC) and social cognition (SC), residual symptoms - insight, motivation and other negative symptoms, and socio-occupational functioning. We explored (a) a cascading model, where NC predicted functional outcome through its effects on other determinants and (b) a combined model, incorporating additional direct paths from each of the determinants. The combined model, and not the cascading model demonstrated a good fit. Post-hoc trimming of the combined model by elimination of non-significant paths maintained the goodness-of-fit and was retained as the final model. In addition to the direct paths, this final model demonstrated that (a) NC influenced functioning through SC and insight and (b) SC influenced functioning through motivation and negative symptoms. This suggests that NC and SC may influence functional outcome directly, as well as indirectly, via specific impact on insight, and motivation and negative symptoms respectively.

Clinical practice with antidementia and antipsychotic drugs: audit from a geriatric clinic in India.

Background: Dementia is one of the most disabling disorders afflicting the elderly, with a staggering emotional and economic impact. Antidementia agents have been used for delaying cognitive decline. Antipsychotics are commonly prescribed for behavioral symptoms associated with dementia. Objectives: To explore the use of anti-dementing agents and antipsychotics used in patients with a diagnosis of dementia Materials and Methods: A retrospective chart review method; geriatric clinic of tertiary care setting. Results: The study sample included 51 consecutive patients with a diagnosis of dementia. The commonest subtype of dementia that was diagnosed was Alzheimers disease (45%), followed by Frontotemporal dementia (25%).The commonest antidementia drug that was used was donepezil, which alone was prescribed in 27 patients (52%). The commonest antipsychotic used was quetiapine, which was used in 24 patients (47%). Conclusions: The study found donepezil to be the most commonly prescribed antidementia drug and quetiapine to be the most commonly used antipsychotic in a tertiary care geriatric clinic, in a developing country. There is a need to study the cost-effectiveness of antidementia and antipsychotic drugs in patients with dementia, in developing countries.

Enhancing Putative Mirror Neuron Activity with Magnetic Stimulation: A Single-Case Functional Neuroimaging Study

M irror neuron-driven embodied simulation, based on the neural exploitation hypothesis has been proposed as a physiological basis of social cognitive abilities in humans (1). Experimental evidence points to a relationship between social cognition and putative mirror neuron activity in neuropsychiatric disorders like schizophrenia (2) and autism (3). Experiments to explore strategies to modulate mirror neuron activity (MNA) are rare (4). We are unaware of any previous report that applied targeted brain stimulation to improve functional magnetic resonance imaging (fMRI) blood oxygen level-dependent (BOLD) activation during action observation paradigms, an indirect method of measuring MNA. Transcranial magnetic stimulation (TMS) is a safe, noninvasive method of administering targeted brain stimulation (5) to enhance focal brain activity. In this letter, we describe the first report of a single session of high-frequency repetitive TMS (HF-rTMS) delivered at the left inferior frontal gyrus (IFG) enhancing putative MNA as ascertained by functional magnetic resonance imaging (MRI).

Service utilization in a tertiary psychiatric care setting in South India

OBJECTIVE To carry out an audit reviewing the utilization of psychiatric services and types of disorders presenting to a tertiary care psychiatry hospital in a developing Asian country. METHOD Consecutive adult patients who came for detailed consultation in 1 year were included in this study. A senior consultant psychiatrist reconfirmed the diagnosis in each patient who underwent detailed psychiatric evaluation. Psychiatric evaluation consists of clinical history from the patients and the relatives and a mental state examination. Data was obtained from the detailed work up evaluation psychiatry records of these patients. RESULTS Mood disorder was the most common diagnosis followed by substance use disorders and psychotic disorders (ICD 10). There is a substantial delay of more than 2-5 years for seeking treatment in most disorders including schizophrenia. More than 80% of the population directly seeks treatment at this tertiary hospital. Sixty-four percent of the patients came for at least one follow up. CONCLUSION The result suggests the urgent need for strengthening community care in India and similar low and middle-income countries for early and optimal treatment.

Multimodal Sensory Distortions in Postpartum Exacerbation of Schizophrenia.

BACKGROUND Sensory distortions of body image commonly occur during migraine, seizures, nondominant cortical infarcts and hallucinogen abuse. METHODS We report the case of a 30-year-old woman with paranoid schizophrenia presenting with postpartum onset multimodal sensory distortions in the absence of any neurological disorders or substance use. RESULTS Her symptoms involved persistent facial/body metamorphopsia (distorted images) and vocal paracousis (distorted voices), in the absence of visual hallucinations, illusions or agnosia. Neuropsychological assessments revealed deficits on visual processing tasks. Neuroimaging, electroencephalography and ophthalmological evaluation revealed no abnormalities. The multimodal sensory distortions responded to antipsychotic treatment, paralleling improvement in other schizophrenia psychopathology, over a period of one month. CONCLUSIONS Prominent and persistent multimodal sensory distortions like metamorphopsia and paracousis in the presence of psychotic symptoms warrant a detailed neurological and general medical work-up. These symptoms presenting in the absence of neurological or substance use disorders may be a component of schizophrenia.

Standardized Mortality Ratio in Patients with Schizophrenia - Findings from Thirthahalli: A Rural South Indian Community.

Background: Schizophrenia is associated with excess mortality experience than the general population. Though this is one of the important outcome measures, it has not been adequately explored especially in rural community dwelling patients in India. We describe the standardized mortality ratio (SMR) of a cohort of schizophrenia patients of Thirthahalli, one such rural taluk of South India. Materials and Methods: SMRs for the years 2009-2011 were calculated. A number of patients in the cohort were 301, 317, and 325 for those consecutive years, respectively. Observed deaths among the patients were noted for these years separately. Crude death rates (CDRs) of the general population of Shimoga district were obtained from the Statistics Department of the Government of Karnataka. CDR (per 1000) was multiplied by the number of patients in each year to get the expected deaths. Then, observed deaths were divided by the expected deaths to get the SMR. Results: There were totally 12 deaths among the patients in these 3 years. SMRs for the years 2009, 2010, and 2011 were respectively 1.4, 1.8, and 2.2. Six had died out of natural (medical) causes. Four had committed suicide, and one died from an accident. Cause from one death remained unknown. There was no statistically significant difference between the alive and deceased patients in any of the demographic or clinical variables. Conclusions: Mortality among schizophrenia patients in this rural cohort is considerably lower than patients from developed countries. Nevertheless, nearly two-fold excess mortality in schizophrenia calls for attention to their medical and psychosocial needs.

Delusion of polygamy in proxy: An addition in delusional procreation syndrome

The content of a delusion is of special interest to mental health professional and is still expanding. The concept of delusional procreation syndrome (DPS), containing delusions in all possible sequential steps in procreation, has been recently proposed. The authors report the case of a married woman harboring a delusion that her husband has been having 10 wives (ie, married once every year in last 10 years) and, as an extension to that, of having two children from each wife. The authors name this as “delusion of polygamy in proxy,” and describe it as another dimension of DPS.

Diminished modulation of motor cortical reactivity during context-based action observation in schizophrenia

BACKGROUND Deficient mirror neuron system (MNS)-activity is associated with social cognition deficits in schizophrenia. However, it is not known how socio-emotional contexts modulate the MNS-response. In a Transcranial Magnetic Stimulation (TMS)-experiment, we aimed to compare putative MNS-responses to action observation stimuli with and without a context, in patients with schizophrenia and healthy subjects. METHOD TMS-evoked motor cortical reactivity was measured by single and paired [short interval intracortical inhibition (SICI) and facilitation (ICF)] pulse-paradigms in schizophrenia patients (n = 39) and healthy subjects (n = 28) while they observed three experimental-blocks: a static image, a neutral hand action (NA) and a context-based hand action (CA). The degree of cortical reactivity facilitation with the two action observation blocks, relative to the static block provided indirect measures of premotor MNS-activity. A subset of patients (n = 31) also underwent comprehensive social cognition assessments. RESULTS RMANOVA demonstrated significantly higher cortical reactivity during the CA-block in both groups (all TMS-paradigms); albeit significantly less pronounced in patients (SICI and ICF paradigms). MNS-activity during the CA-block was significantly higher compared to that during the NA-block in both groups (all TMS-paradigms), but significantly less pronounced in patients (SICI and single-pulse paradigms). MNS-activity during the CA-block measured by the ICF paradigm was positively correlated with social cognition performance. CONCLUSION Providing a context to the action modulates MNS-activity. This modulation is diminished in schizophrenia patients, suggestive of a diminished sensorimotor associative learning process. This novel, ecologically valid paradigm to tap into the MNS may serve as a neuro-marker of social cognition performance in schizophrenia.