Maryanne O'Donnell

Social cognition, empathy and functional outcome in schizophrenia

Social and occupational functioning difficulties are a characteristic feature of schizophrenia, and a growing body of evidence suggests that deficits in social cognition contribute significantly to these functional impairments. The present study sought to investigate whether the association between social cognition and social functioning in schizophrenia would be mediated by self-reported levels of empathy. Thirty outpatients with a diagnosis of schizophrenia or schizoaffective disorder, and twenty-five healthy controls completed a well-validated facial affect processing task (Ekman 60-faces facial task from the Facial Expressions of Emotion - Stimuli and Tests; FEEST), The Awareness of Social Inference Test (TASIT; to assess emotion perception and complex social cognitive skills such as the detection of sarcasm and deceit, from realistic social exchanges), and measures of self-reported empathy and social functioning. Participants with schizophrenia performed more poorly than controls in identifying emotional states from both FEEST and TASIT stimuli, and were impaired in their ability to comprehend counterfactual information in social exchanges, including sarcasm and lies, on the TASIT. Impairment in the comprehension of sarcasm was associated with higher empathic personal distress, and lower recreational functioning. Impairment in the identification of the emotions of others was found to be associated with lower satisfaction and lower empathic fantasy. However, empathy could not be explored as a mediator of associations between social cognition and functional outcome, due to lack of common associations with functional outcome measures. These findings have implications for the remediation of specific social cognitive deficits with respect to improving functional outcomes in schizophrenia.

Disambiguating ventral striatum fMRI-related BOLD signal during reward prediction in schizophrenia.

Reward detection, surprise detection and prediction-error signaling have all been proposed as roles for the ventral striatum (vStr). Previous neuroimaging studies of striatal function in schizophrenia have found attenuated neural responses to reward-related prediction errors; however, as prediction errors represent a discrepancy in mesolimbic neural activity between expected and actual events, it is critical to examine responses to both expected and unexpected rewards (URs) in conjunction with expected and UR omissions in order to clarify the nature of ventral striatal dysfunction in schizophrenia. In the present study, healthy adults and people with schizophrenia were tested with a reward-related prediction-error task during functional magnetic resonance imaging to determine whether schizophrenia is associated with altered neural responses in the vStr to rewards, surprise prediction errors or all three factors. In healthy adults, we found neural responses in the vStr were correlated more specifically with prediction errors than to surprising events or reward stimuli alone. People with schizophrenia did not display the normal differential activation between expected and URs, which was partially due to exaggerated ventral striatal responses to expected rewards (right vStr) but also included blunted responses to unexpected outcomes (left vStr). This finding shows that neural responses, which typically are elicited by surprise, can also occur to well-predicted events in schizophrenia and identifies aberrant activity in the vStr as a key node of dysfunction in the neural circuitry used to differentiate expected and unexpected feedback in schizophrenia.

Emotion regulation in schizophrenia: Affective, social and clinical correlates of suppression and reappraisal

Individuals can exert considerable control over their experience and expression of emotion by applying different regulatory strategies such as reappraisal and suppression. However, although it has been suggested that blunted affect in schizophrenia, characterized by markedly reduced emotion expressivity alongside apparently normal emotion experience, may reflect overuse of suppression, no study to date has assessed self-reported use of these different emotion regulatory strategies in relation to this disorder. In the present study, 41 individuals with schizophrenia and 38 control participants completed a self-report measure that differentiated between use of suppression and reappraisal. Symptom severity and various aspects of cognitive and psychosocial functioning were also assessed. Relative to controls, individuals with schizophrenia did not differ with regard to their reported use of suppression and reappraisal, and reported use of both strategies was unrelated to clinical ratings of blunted affect. However, whereas (lower) use of reappraisal was associated with greater social function impairment for both groups, only for controls was (greater) use of suppression associated with reduced social functioning. Implications for understanding blunted affect and social dysfunction in schizophrenia are discussed.

A Study of Client-Focused Case Management and Consumer Advocacy: The Community and Consumer Service Project

Objective: The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates. Method: Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services. Results: While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services. Conclusions: Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery.

Replication of a P50 auditory gating deficit in Australian patients with schizophrenia

Schizophrenic patients reportedly have a deficit in the control of sensitivity to auditory stimuli as shown by the P50 auditory evoked potential wave in a conditioning-testing paradigm that measures suppression of response to a repeated stimulus. Although this finding has been replicated by several US laboratories, one European group has not found differences between schizophrenic patients and normal control subjects. In the present study, investigators in the Schizophrenia Research Center at the Prince of Wales Hospital in Sydney, Australia, selected 22 normal control subjects, 11 acutely ill schizophrenic inpatients, and 11 clinically stable schizophrenic outpatients. Both schizophrenic groups were treated with similar doses of classical neuroleptic medications. Evoked potentials were recorded by an investigator from the US laboratory that initially reported the difference; five averages, each the response to 32 stimulus pairs, were recorded from each subject. The normal control subjects demonstrated significantly more suppression of the P50 response to the repeated stimuli than the schizophrenic groups, as previously reported. There were no significant changes in the suppression measure over the five trials. The suppression of the P50 wave by schizophrenic outpatients was somewhat greater than that by schizophrenic inpatients, but both schizophrenic groups had decreased suppression, compared with the normal subjects. The mean P50 suppression for five averages was successfully used in a logistic regression to classify subjects as normal or schizophrenic. This method was more accurate than attempts to classify subjects with only one average. The mean amplitude of the initial conditioning response did not differ between groups. Schizophrenic patients had slightly shorter mean latencies. There was no direct relationship of P50 suppression to measures of clinical psychopathology.

Assessing Outcome in Community Mental Health Patients: A Comparative Analysis of Measures

Background: We undertook a twelve-month intervention study for community mental health patients using a number of measures administered at baseline and at twelve months. Overall improvement in that sample allowed for comparative analyses of the key measures in terms of their ability to measure and to predict outcome. Aims: To assess and compare the usefulness of each of the measures in predicting outcome status. Methods: A patient-rated quality of life (QOL) questionnaire, the DSM-III-R Global Assessment of Functioning (GAF), the Life Skills Profile (LSP) and the Health of the Nation Outcome Scales (HoNOS) were compared and evaluated in a sample of seventy-nine patients. Results: The LSP appeared to measure disability only, while the HoNOS and the GAF assessed composite symptoms and general functioning. The HoNOS was identified as the most distinctive predictor of outcome. Conclusions: The utility of the HoNOS as an overall service measure is supported, while properties and likely utility of other measures in outcome studies are detailed.

Emotional suppression: can it predict cancer outcome in women with suspicious screening mammograms?

BACKGROUND Previous studies have implicated emotional suppression, in particular suppression of anger, in the onset and progression of breast cancer. Many of these studies used non-standardized measures and failed to control for the effects of age and/or possible knowledge of diagnosis. The present study aimed to avoid these methodological errors in investigating the relationship of emotional suppression to a diagnosis of breast cancer in a large mammography screened population. METHOD Data were collected from 1151 women with suspicious mammograms recalled to a breast screening programme. Prior to multidisciplinary assessment women were asked to complete the Courtauld Emotional Control Scale. Imaging assessment outcome data and biopsy results were collected. RESULTS Fifteen per cent of this population subsequently were diagnosed with breast cancer. There were no significant associations between a cancer outcome and emotional suppression before or after the highly significant effect of age was taken into account. CONCLUSIONS These results suggest that suppression of emotion may not be relevant to the development of breast cancer. Its role in the progression of existing disease requires clarification.

Development of a consumer advocacy program

Objective: The aim of the present paper was to describe the development of a consumer advocacy program within the Eastern Suburbs of Sydney (NSW, Australia). Methods: The program was developed within the context of a research project that investigated the effect on outcome of client-focused approaches to community case management for clients with schizophrenia and bipolar disorder. Results: While the development of the advocacy program was limited by the constraints imposed by the research methodology, the study provided the opportunity to delineate the process involved and identify key components that need to be incorporated into future advocacy programs. Conclusions: The main guidelines determined were that consumer participation in service delivery needs to be flexible, consumer driven, have broad-based support, ready access to supervision and debriefing, ongoing training and clear job descriptions. Given adequate support, autonomy and funding, consumer advocates can provide a much needed resource for their fellow consumers.

CURRENT PERSPECTIVES ON IMMUNOLOGY AND PSYCHIATRY

We selectively review recent research findings in the field of psychoimmunology which test the hypotheses that immunological dysfunction may be aetiologically related to mental illnesses such as schizophrenia, and that certain morbid affective states such as depression and other forms of psychosocial distress may be the cause of immunosuppression and through this mechanism affect the outcome of illnesses such as cancer. Our examination of research implicating immunological or infective mechanisms in the aetiology of schizophrenia indicates that most studies have been unable to control for major methodological difficulties but the compatibility of these theories with the dopamine hypothesis suggests that further research attention is warranted. More clearly, there is growing evidence demonstrating a link between depression, other states of psychological distress and immunosuppression, but the clinical significance of these findings remains uncertain. The complex relationship between stress and the outcome of illnesses such as cancer is discussed and the possible implications of these findings for clinical psychiatry are suggested.

Young Rural People at Risk for Schizophrenia: Time for Mental Health Services to Translate Research Evidence into Best Practice of Care

Early intervention into prodromal schizophrenia has shown promise, but controversy continues regarding the ethical acceptability of identifying a group of ‘ultra high risk’ individuals of whom only 30 to 50% will develop a psychotic disorder. With well developed early intervention services this group faces the possibility of being labelled as ‘pre-psychotic’, a condition for which the well known stigma associated with the diagnosis of schizophrenia or bipolar disorder is likely to be associated. In addition, the use of potent antipsychotic and other medications (albeit usually at lower doses than those used for those with manifest psychosis) mandates consideration of the risks associated with their use and neurological and metabolic side effects. The potential for iatrogenic morbidity in the ‘false positive’ group must be weighed against the need of the ‘true positives’ identified through screening and assessment. Current evidence for the concept of ‘at-risk mental state’ was reviewed within a neurodevelopmental framework, including emerging data on the effectiveness of early intervention for the purpose of providing recommendations for community mental health services. The review suggests that different treatment strategies may be appropriate depending on the clinical stage of the condition as long as the benefits of intervention outweigh its risk burden. It further suggests that the severity of psychoses and the evidence of its early onset in utero and its acceleration in adolescence positions ‘ultra high risk’ intervention as a core model for early intervention for young people by teasing apart the symptomatic components of the ‘prepsychotic state’ and ensuring the population is reaching targeted mental health services for screening. The model is not restricted to the delivery of intervention for ‘pre-psychotic’ young people but is applicable for targeted programmes for a number of clinical groups considered at ‘ultra high risk’. However, only further research in naturalistic populations embedded in clinical practice and ideally conducted in partnership of mental health services with academic research institutions will help clarify potential risks of early identification and intervention and assist in updating and making more explicit the clinical guidelines services will use in approaching those in the ‘ultra high risk’ group.