Dong Chung Jung

Changes in heart rate dynamics of patients with schizophrenia treated with risperidone.

Neurocardiac dysregulation has been reported in schizophrenia. Indices of heart rate variability (HRV) are useful in assessing the status of cardiac autonomic regulation. We explored within-subject changes in HRV indices in acutely ill patients with schizophrenia treated with risperidone. Sixteen medication-naïve or medication-free patients with DSM-IV schizophrenia completed electrocardiogram (ECG) assessments at baseline and after six weeks of treatment with risperidone. Indices of HRV were extracted from 5-min resting ECG recordings and compared to those obtained from control subjects matched for age and gender. Psychiatric and drug-induced extrapyramidal symptoms were assessed by the Positive and Negative Syndrome Scale (PANSS) and the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). In comparison with matched controls, patients with acute schizophrenia showed lower values of time-domain measures, lower high-frequency power (HF) and a higher ratio of low to high frequency (LF/HF). In the within-subject analyses, a significant decrease in LF/HF was associated with risperidone treatment. In addition, LF/HF, which initially co-clustered with clinical variables, congregated with other HRV measures after the six-week risperidone treatment. These results indicate that, in the therapeutic process, risperidone treatment may exert a beneficial influence on the sympathovagal imbalance in acute schizophrenia.

The prevalence of metabolic syndrome in Korean patients with schizophrenia receiving a monotherapy with aripiprazole, olanzapine or risperidone

Second-generation antipsychotics (SGAs) increase the risk of metabolic syndrome (MetS). Although ethnicity also contributes to MetS risk, the majority of the studies on the relationship of SGAs to this syndrome come from Western countries, whereas few reports have come from Asian countries, especially regarding patients taking a single SGA. We reviewed the electronic medical records of patients with schizophrenia who received aripiprazole, olanzapine or risperidone monotherapies for at least three months. We evaluated the prevalence of MetS in our sample as well as the indirect standardized prevalence ratio (ISPR) using data from the 4th Korean National Health and Nutrition Examination Survey (KNHNES, 2007). The prevalence of MetS in our sample (n=145) was 31.7%, and the ISPR was 2.09. Male patients had a higher prevalence of MetS than female patients (odds ratio [OR]=4.18, 95% CI=1.93-9.03). The ISPR of male patients was 2.67 and statistically significant, whereas the ISPR of female patients was not significant. In our sample, the frequency of abnormal MetS subcomponents occurred in descending order: increased waist circumference, increased triglyceride levels, decreased HDL-cholesterol levels, elevated blood pressure and elevated fasting blood glucose levels. Patients who received aripiprazole were significantly less likely to have MetS. However, a logistic regression showed that age and sex, but not the type of antipsychotic, its dose or the use of antidepressants, were significantly related to the presence of MetS. There were no statistically significant differences among SGAs in terms of MetS subcomponent abnormalities of after adjusting for age and sex. In conclusion, only male Korean patients with schizophrenia who received a monotherapy of aripiprazole, olanzapine or risperidone for more than three months were more likely to have MetS than the general population.

Automatic detection of seizure termination during electroconvulsive therapy using sample entropy of the electroencephalogram.

Determining the exact duration of seizure activity is an important factor for predicting the efficacy of electroconvulsive therapy (ECT). In most cases, seizure duration is estimated manually by observing the electroencephalogram (EEG) waveform. In this article, we propose a method based on sample entropy (SampEn) that automatically detects the termination time of an ECT-induced seizure. SampEn decreases during seizure activity and has its smallest value at the boundary of seizure termination. SampEn reflects not only different states of regularity and complexity in the EEG but also changes in EEG amplitude before and after seizure activity. Using SampEn, we can more precisely determine seizure termination time and total seizure duration.

Successful Treatment of Refractory Dyskinesia Secondary to Anti-N-Methyl-D-Aspartate Receptor Encephalitis With Electroconvulsive Therapy:

To the Editor: A nti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoantibodymediated neurological disease characterized by psychiatric symptoms, altered consciousness, cognitive dysfunction, autonomic instability, and seizures. It is well known that most patients with anti-NMDA receptor encephalitis respond to immunotherapy. However, a small proportion of patients did not respond to immunotherapy and resulted in severe neurological deficit or death. Furthermore, the treatment for patients with immunotherapy-resistant encephalitis has not been established. To the best of our knowledge, we report the first case of antiNMDA receptor encephalitis with prolonged and refractory dyskinesia, which was not improved by intensive immunotherapy and tumor removal but remarkably responded to electroconvulsive therapy (ECT). A 27-year-old woman, who was previously healthy with no history of psychiatric illnesses, complained of headache and insomnia. For a few days, confusion, visual and auditory hallucination, and disorganized speech developed. Then, she was referred to our institute 10 days after the symptom onset because of the aggravation of psychotic symptoms followed by decreased consciousness. At the time of the emergency room visit, she was observed to be semicomatosewithout focal or lateralized signs in neurologic examination. Laboratory tests showed leukocytosis (white blood cell counts, 16,120/μL)with increased segmented neutrophils (83.5%). Electrolyte panel demonstrated mild hyponatremia (130 mmol/L) with a low serum osmolality (278 mOsm/kg). Other blood test results including liver function tests and serum creatinine level were normal. Cerebrospinal fluid (CSF) study revealed pleocytosis (59/mm) with lymphocytic predominance (89.8%),whereas protein and glucose levels were within reference limits. We tested for an extensive list of infectious pathogens including herpes simplex virus, but results were all negative. Brain magnetic resonance imaging with contrast enhancement was unremarkable. At the day of the admission, we tested neuronal autoantibodies from CSF and blood samples. A computed tomography scan of the abdomen and pelvis demonstrated 2-cm-sized, low-attenuated lesion suggesting ovarian

Longitudinal relationship between Personal and Social Performance (PSP) and anxiety symptoms in schizophrenia

BACKGROUND We aimed to examine the longitudinal relationship between the personal and social functioning and anxiety symptoms in patients with schizophrenia. For this purpose, we confirmed the validity of the anxiety subscale of the Symptom-Checklist-90-Revised (SCL-90-R) and then applied the latent growth modeling method for longitudinal causal relationships. METHODS Five hundred and seventy-eight patients diagnosed with schizophrenia were evaluated and 369 patients were included in the study at baseline. After conducting Rasch model analyses for the validation of the anxiety subscale in the SCL-90-R, we applied latent growth model to determine the causal relationship between the PSP and the anxiety symptoms. RESULTS The validity of the anxiety subscale of the SCL-90-R was confirmed based on the Rasch rating model, where the criteria for Infit, Outfit, item difficulty, and point-measure correlations were satisfied. The results from the latent growth model showed that the intercept and slope (rate of change) of the PSP negatively predicted the slope of anxiety symptoms along the longitudinal trajectory. Together with previous studies examining the predictive role of anxiety symptoms on quality of life, our longitudinal findings lend evidence for bidirectional effects between quality of life and anxiety symptoms. The transactional nature of the relationship between anxiety symptoms and quality of life warrant further investigation using a longitudinal cross-lagged design. CONCLUSION The anxiety subscale of the SCL-90-R may be utilized by clinicians and researcher to make inferences about quality of life in addition to assessing anxiety symptoms in patients with schizophrenia.

Refinement of the SWN-20 based on the Rasch rating model

OBJECTIVES The aim of the present study was to refine the 20-item Subjective Well-Being under Neuroleptic Treatment Scale (SWN-20) using the Rasch rating model to validate measurements of subjective well-being in patients with schizophrenia undergoing antipsychotic treatment. METHODS In total, 854 (403 males, 451 females) inpatients (n=213) and outpatients (n=641) with schizophrenia participated in this study, which was designed as an open-label investigation of paliperidone extended release. The participants completed the Korean version of the SWN-20 themselves. Refinement of the Korean version of the SWN-20 was accomplished using the Rasch rating model. RESULTS Infit and outfit statistics for all 20 items satisfied the criterion for construct validity. Second, all items except items 2 and 20 had suitable point-measure correlations, reflecting content validity. Third, item characteristic curves indicated that roughly 18 items were evenly distributed along the person ability continuum. Finally, option analysis of the category characteristics showed that categories 3 and 4 in the SWN-20 response format were unnecessary. CONCLUSIONS We offer several recommendations for improving the SWN-20: (a) items 2 and 20 should be omitted to ensure construct validity; (b) easier items would be added related to the person ability estimates in the process of validating a short form of the SWN scale based on item response theory; and (c) the number of response categories should be reduced for schizophrenic patients.

The effects of psychopathology on subjective experience of side effects of antipsychotics in patients with schizophrenia

This study was conducted to delineate the relationship between self-reported side effects and psychopathology in schizophrenia patients. Patients with schizophrenia completed the Liverpool University Neuroleptic Side Effects Rating Scale for subjective side effects and were evaluated with the Positive and Negative Syndrome Scale for their psychopathology. Based on a series of multiple linear regression analyses, we derived a model accounting for the relationships among the specific domains of psychopathology and red herring (RH) items of the Liverpool University Neuroleptic Side Effects Rating Scale in predicting subjective side effects. The model with anxiety/depressive symptoms and RH serving as mediators between positive symptoms and side effects was found to show good fit. Positive symptoms caused mostly anxiety symptoms and tendency to report RH items, whereby resulting in over-generalized reporting of subjective side effects. However, a large proportion of variance of side effects was explained by RH, which was only partially explained by positive symptoms alone. Therefore, patients with severe levels of positive and anxiety/depressive symptoms may be prone to nocebo-like effects of antipsychotics. Studies that include acute stage patients presenting severe levels of these symptoms should not rely only on the subjective report of side effects but also apply objective measures.

The prevalence of metabolic syndrome and its association with alanine aminotransferase in clozapine-treated Korean patients with schizophrenia.

Widely ranging prevalence rates for metabolic syndrome (MetS) in patients taking clozapine have been reported on the basis of various criteria, and most studies have been carried out in non-Asian countries. Therefore, we examined the prevalence of MetS in Korean patients using three commonly applied criteria with two waist-circumference cutoff values. The indirectly standardized prevalence ratio (ISPR) was estimated using data from the Fourth Korean National Health and Nutrition Examination Survey (KNHNES, 2007) to compare the prevalence of MetS in patients with that in the general population. In addition, we also examined whether serum alanine aminotransferase (ALT) and aspartate aminotransferase levels serve as biochemical markers for the identification of MetS. We reviewed the electromedical records of patients with schizophrenia who had taken clozapine as the sole antipsychotic for 3 months or more. The prevalence of MetS ranged from 34.5 to 46.9%, and the ISPR ranged from 2.4 to 2.8, given the three definitions of MetS and the two waist-circumference cutoff points for women. The ISPR for MetS among those aged 18–30 years was the highest and decreased with age in both men and women. After adjusting for age, patients with normal serum ALT levels who were in the top third were significantly more likely to have MetS compared with those who were in the bottom third. Logistic regression analysis showed that serum ALT levels and use of antidepressants were significantly related to the presence of MetS. Korean patients with schizophrenia who were receiving clozapine as the sole antipsychotic showed a high prevalence of MetS. Although we found substantial differences in the prevalence according to criteria, the ISPR indicated significantly higher rates of MetS in this group than in the general population. In the general population, younger patients had a much higher risk for MetS than older patients. Elevated levels of serum ALT that were in the normal range were associated with the presence of MetS, which suggests the possibility of using serum ALT level as an early indicator for MetS in patients treated with clozapine.

The longitudinal trends in the relationship between drug-induced extrapyramidal symptoms and personal and social performance in a population of the patients with schizophrenia: A latent growth model

The aim of this study was to explore the longitudinal trends in the relationship between personal and social functioning and drug-induced extrapyramidal symptoms (DIEPS). The baseline sample included 484 patients with schizophrenia. Participants were assessed at baseline, weeks 4 (time 2), 8 (time 3), and 12 (time 4) regarding social functioning, and DIEPS. In latent growth analysis, the path coefficient between the intercept for the DIEPSS and the intercept for the PSP indicated a significant cross-sectional relationship between these two variables. And the path coefficient between the intercept of the DIEPSS and the slope of the PSP was also significant, indicating that patients who initially had more serious side effects tended to exhibit less improvement in their personal and social functioning over time. Similarly, a significant path coefficient between the slopes of the two variables indicated a dynamic and possibly reciprocal association over time. In addition, K-PSP scale showed good construct validity and reliability. Based on the standardized PSP scale, our results demonstrate DIEPSS induced by antipsychotic treatment dynamically affect personal and social functioning over time, a negative association between psychosocial aspects and the DIEPS.