Renata Schoeman

Predictors of long-term outcome in schizophrenia.

Purpose of review Further clarification of factors predicting the outcome in schizophrenia is needed. The present review examines recent research into some of these predictors, focusing on insight, duration of untreated psychosis, cognition and early treatment response. It also addresses the need for standard outcome measures. Recent findings There is good evidence that poor insight predicts poor outcome, although perhaps not simply as a consequence of poor compliance. Further support is provided for a link between duration of untreated psychosis and long-term outcome. The relationship between cognition and outcome is complex, with specific cognitive deficits apparently predicting particular outcome domains. Early treatment response is closely related to long-term outcome. Outcome studies may be flawed by sample selection bias, and a lack of standardized outcome measures. Summary Several predictors are potentially modifiable, indicating that they should be targets for therapeutic intervention. More carefully designed studies are needed. Recently proposed criteria for remission are helpful, and should facilitate cross-sample comparisons.

Deficits in facial affect recognition in unaffected siblings of Xhosa schizophrenia patients: evidence for a neurocognitive endophenotype.

The present study in an African Xhosa sample examined whether familial vulnerability to schizophrenia is associated with deficits in facial affect recognition. Healthy comparison subjects, unaffected siblings of schizophrenia patients, and schizophrenia patients were tested with a task requiring rapid recognition of matched positive (happy), negative (angry), and neutral facial expressions. Siblings and patients demonstrated impaired recognition of negative relative to positive facial expressions whereas comparison subjects recognized negative and positive expressions at an equal level of accuracy. These results suggest that deficits in the processing negative affect from social cues are transmitted in families and may represent a heritable endophenotype of schizophrenia.

Genetics and personality traits in patients with social anxiety disorder: A case-control study in South Africa

BACKGROUND Social anxiety disorder (SAD) is among the most common of all psychiatric disorders with lifetime prevalence estimates ranging from 7% to 13%. Although there is evidence that SAD has a strong familial basis, there are few studies of potential candidate genes. In addition to a genetic association, there is also the possibility that temperamental risk factors for the disorder may be genetically transmitted. Against this background, our aims were threefold: i.) to compare patients and controls with respect to personality traits, ii.) to genotype a subgroup of these participants to investigate the role of genes encoding components of serotonergic (5-HT) and dopaminergic (DA) pathways in patients with SAD and iii.) to compare differences in temperament dimensions between carriers of different (dominant vs. recessive) alleles for selected polymorphisms in SAD patients. METHODS Sixty-three patients (n=63; 35 male, 28 female) with a DSM-IV diagnosis of generalized SAD and SPIN-scores >18, and age-matched control participants (n=150; 31 male, 119 female) were included in the study. The Temperament and Character Inventory (TCI) was used to measure behaviours associated with specific personality dimensions (i.e. temperament/character). DNA was extracted and genotyped to investigate the role of select candidate genes encoding components in serotonergic and dopaminergic pathways in mediating the development of SAD. To achieve this, the frequency of variants in 5-HT and DA genes was compared between a Caucasian subset of SAD patients (n=41) and a convenience sample of Caucasian controls (n=88), using case-control association analyses. We also investigated the frequency of variants in 5-HT and DA-related genes across temperament characteristics in SAD patients, using analyses of variance (ANOVA). RESULTS Patients scored significantly higher on harm avoidance (p<0.001) but lower on novelty seeking (p=0.04) and self-directedness (p=0.004) compared to controls. In the Caucasian subset, there was a difference between patients and controls in distribution of the 5-HT(2A)T102C polymorphism, with significantly more patients harboring T-containing genotypes (T-containing genotypes: [T/T+T/C] vs. [C/C]) (chi2=7.55; p=0.012). Temperament dimensions did not, however, differ significantly between carriers of different (dominant vs. recessive) alleles for the 5-HT(2A)T102C polymorphism in SAD patients. CONCLUSIONS The results suggest a possible role for the 5-HT(2A)T102C polymorphism in the development of SAD. To date genetic findings in SAD have been inconsistent; nevertheless, serotonergic variants, and their associations with temperaments (e.g. reward dependence) deserve further exploration, in the hope that endophenotypes relevant to SAD can ultimately be delineated.

Trauma and posttraumatic stress disorder in South African adolescents: a case-control study of cognitive deficits.

Despite the prominence of neuropsychological deficits in memory, attention and learning in adults exposed to trauma and those who develop posttraumatic stress disorder (PTSD), few studies have explored these cognitive deficits in adolescents. This study aimed to assess the impact of PTSD on various neurocognitive functions in South African adolescents. In a case-control study, 40 traumatized adolescents (20 with PTSD and 20 without) were evaluated for the presence of PTSD and were then referred for neuropsychological evaluation using a standardized neuropsychological test battery. The presence of PTSD itself, rather than trauma exposure, was associated with cognitive deficiencies in attention, visual memory and nonverbal concept formation. This study highlights the impact of PTSD itself—and particularly current symptoms—on the cognitive development of adolescents. As this effect appears to be stronger than the impact of trauma alone, more studies on the long-term consequences of PTSD on youth cognitive development are crucial.

Emotional face processing deficit in schizophrenia: A replication study in a South African Xhosa population

Schizophrenia is associated with a deficit in the recognition of negative emotions from facial expressions. The present study examined the universality of this finding by studying facial expression recognition in African Xhosa population. Forty-four Xhosa patients with schizophrenia and forty healthy controls were tested with a computerized task requiring rapid perceptual discrimination of matched positive (i.e. happy), negative (i.e. angry), and neutral faces. Patients were equally accurate as controls in recognizing happy faces but showed a marked impairment in recognition of angry faces. The impairment was particularly pronounced for high-intensity (open-mouth) angry faces. Patients also exhibited more false happy and angry responses to neutral faces than controls. No correlation between level of education or illness duration and emotion recognition was found but the deficit in the recognition of negative emotions was more pronounced in familial compared to non-familial cases of schizophrenia. These findings suggest that the deficit in the recognition of negative facial expressions may constitute a universal neurocognitive marker of schizophrenia.

Bilingualism and psychosis: a linguistic analysis of a patient with differential symptom severity across languages

Abstract Several lines of evidence suggest important links between language and schizophrenia. Individuals with schizophrenia show numerous abnormalities related to language function, including disorganised speech and verbal memory impairments. Psychotic patients who communicate in two or more languages provide an opportunity to study the relationships between language and psychosis in more detail. This is a case report of a 27-year-old late bilingual male with a first psychotic episode who switched to his second language (English) during the psychotic episode and displayed more psychotic features, including prominent speech and thought disorder, when assessed in his first language (Afrikaans) compared to English. A language history was obtained and a language evaluation conducted, including analysis of a spontaneous language sample for the evaluation of structural and pragmatic aspects. Unexpectedly, the patient displayed more language abnormalities in English than in Afrikaans, suggesting a complex relationship between language and psychosis. One implication of these findings is that clinicians should assess bilingual psychotic patients in both languages in order to elicit the full spectrum of symptoms.

Significance of dietary folate intake, homocysteine levels and MTHFR 677 C>T genotyping in South African patients diagnosed with depression: test development for clinical application

Low folate intake in the presence of the functional MTHFR 677 C > T (rs1801133) polymorphism is an important cause of elevated homocysteine levels previously implicated in major depressive disorder (MDD) and many other chronic diseases. In this study the clinical relevance and inter-relationship of these aspects were evaluated in 86 South African patients diagnosed with MDD and 97 population-matched controls participating in a chronic diseases screening program. A questionnaire-based clinical and nutrition assessment was performed, homocysteine levels determined, and all study participants genotyped for MTHFR 677 C > T (rs1801133) using allele-specific TaqMan technology. The folate score was found to be significantly lower in the patient group compared to controls (p = 0.003) and correlated with increased body mass index (BMI), particularly in females with MDD (p = 0.009). BMI was significantly higher in the MDD patients compared with controls after adjustment for age and sex (p = 0.015), but this association was no longer significant after further adjustment for the level of folate intake in the diet. In MDD patients but not controls, the minor T-allele of MTHFR 677 C > T was associated with increased BMI (p = 0.032), which in turn correlated significantly with increased homocysteine levels. The significant association between BMI and homocysteine levels was observed in both the MDD patient (p = 0.049) and control (p = 0.018) study groups. The significantly higher homocysteine levels observed in MDD patients compared to controls after adjustment for age and sex (p = 0.030), therefore appears to be mediated by the effects of MTHFR 677 C > T and low folate intake on BMI. Detection of the low-penetrance MTHFR 677 C > T mutation reinforces the importance of folate intake above the recommended daily dose to prevent or restore dysfunction of the methylation pathway.

Allocation of attention to the eye and mouth region of faces in schizophrenia patients

Introduction. The present study examined whether reduced attentiveness to facial features and biased weighting of attention to the eye and mouth region might explain deficits in face processing in schizophrenia. Methods. Healthy controls (n=21) and schizophrenia patients (n=28) from an African Xhosa population were asked to detect target stimuli (dots) superimposed on pictures of faces. General attentiveness to facial features was assessed by measuring overall reaction times to targets superimposed on feature areas of faces and attentiveness to the eye versus mouth region by comparing reaction times to targets on the upper and lower parts of faces. Results. Patients exhibited generally slower target detection speed than comparison subjects but the strength of the attentional bias towards the eyes did not differ between groups (i.e., the reaction time gain for targets in the eye region). A regression analysis indicated, however, that generally slower target detection speed and an attentional bias away from the mouth predicted a deficit in the recognition of open-mouth angry facial expressions in schizophrenia patients. Conclusions. The results give partial support for hypothesis that reduced overall attentiveness to faces and a failure to utilise visual information in salient facial features may underlie affect processing deficits in schizophrenia.

Pragmatic assessment of schizophrenic bilinguals' L1 and L2 use 1

Abstract This paper reports on a study investigating the pragmatic skills and deficits of schizophrenic bilinguals in their spontaneous first language (L1) and second language (L2) speech. Smit (2009) (see also Smit et al., this volume) argues that the locus of deficits in schizophrenic speech is semantics and suggests that a next step would be to investigate the pragmatic skills of schizophrenic bilinguals, given the close relationship between semantics and pragmatics. The study reported here followed up on Smits suggestion and employed Prutting and Kirchners (1987) Pragmatic Protocol to pragmatically assess the spontaneous L1 Afrikaans and L2 English use of four schizophrenic bilinguals who exhibited differential symptomatology, that is presented with different symptoms, as well as a difference in the severity thereof, when assessed in their L1 than when assessed in their L2. On the basis of the results of the assessment we conclude that such pragmatic assessment (i) provides insight into the nature of schizophrenic speech but (ii) does not provide insight into the phenomenon of differential symptomatology.

A grammatical analysis of the spontaneous L2 English use of schizophrenic bilinguals compared to typical bilinguals 1

Abstract The study reported in this paper aimed to investigate whether the grammatical errors made by schizophrenic bilinguals in their spontaneous second language (L2) use are typical L2 learner errors, as reported previously. Southwood et al. (2009) report on a case study of a schizophrenic patient who expressed a preference for his L2 when he started presenting with psychotic symptoms. Southwood et al. (2009) note that the majority of the grammatical errors made by this patient in his spontaneous L2 use are typical of L2 learner language use. To determine whether the grammatical errors made by schizophrenics are similar to or different from those made by typical L2 English speakers, we employed Morice and Ingrams (1982) assessment tool for the grammatical analysis of the spontaneous L2 speech of four schizophrenics and four (non-psychotic) controls who were matched to the schizophrenics in terms of age, gender and first language (L1) and L2 dialects. Following a comparison of the types and frequency of the two groups’ phonological, morphological, semantic and syntactic errors, it was found that the two groups differed significantly only in terms of their semantic errors. It is, therefore, concluded that semantics is the locus of language-related problems in schizophrenia.