Bimonthly, Established in 1959
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In this issue

Original research article

Prefrontal Cortex GABA in Schizophrenia and Abnormal Glutamate Concentration: An in Vivo 1H-MRS Study

Tianyi CHEN, Yingchan WANG, Jianye ZHANG, Zuowei WANG, Jiale XU, Yao LI, Zhilei YANG, Dengtang LIU

Background: The etiology and pathomechanism of schizophrenia are unknown. The traditional dopamine (DA) hypothesis is unable to fully explain its pathology and therapeutics. The glutamate (Glu) and γ-aminobutyric acid (GABA) hypotheses suggest Glu or GABA concentrations are abnormal in the brains of patients with schizophrenia. Magnetic resonance spectroscopy (MRS) show glutamate level increases in the ventromedial prefrontal cortex (vmPFC) including the anterior cingulated cortex (ACC) in those with schizophrenia.
Aims: To investigate the function of the glutamate system (glutamate and γ-aminobutyric acid) in the etiology and pathomechanism of schizophrenia.
Methods: 24 drug naïve patients with schizophrenia and 24 healthy volunteers were matched by gender, age, and educational level. The Siemens 3T MRI system was used to collect the magnetic resonance spectroscopy (MRS) data of the subjects. The regions of interest included the left dorsolateral prefrontal cortex (lDLPFC), ventromedial prefrontal cortex (vmPFC), and anterior cingulate cortex (ACC). LCModel software was used to analyze the concentrations of γ-aminobutyric acid (GABA), glutamate (Glu), glutamine (Gln), N-acetylaspartate(NAA), and N-acetylaspartylglutamate (NAAG) in the region of interest. Meanwhile, the Positive and Negative
Syndrome Scale (PANSS) and the Clinical Global Impression Scale (CGI) were used to assess the mental symptoms and severity of the disease.
Results: The median GABA concentrations in the anterior cingulate cortex of the schizophrenia group and the healthy control group were 1.90 (Q1=1.55, Q3=2.09) and 2.16 (Q1=1.87, Q3=2.59) respectively; the mean (sd) Glu concentrations were 6.07 (2.48) and 6.54 (1.99); the median Gln concentrations were 0.36 (Q1=0.00, Q3=0.74) and 0.29 (Q1=0.00, Q3=0.59); the between-group difference of the GABA concentrations was statistically significant (Z=-2.95, p=0.003); the between-group difference of the GABA/(NAA+NAAG) was
statistically significant (Z=-2.72, p=0.012); the between-group difference of Glu and Gln was not statistically significant. The age of the schizophrenia group was negatively correlated with the GABA concentration in the anterior cingulate (R=-0.494, p=0.014), and negatively correlated with GABA/ (NAA+NAAG) (R=-0.473, p=0.020). Yet there was no such correlation in the control group. After calibration, no significant correlation was found between the clinical symptoms and the concentrations of the metabolites.
Conclusions: The concentration of glutamate in the vemtromedial prefrontal cortex of patients with schizophrenia was abnormal, whereas the concentration of GABA in the anterior cingulate cortex decreased, supporting the hypothesis of abnormal glutamate -GABA in the brains of those individuals with schizophrenia. In patients with schizophrenia, the GABA in the anterior cingulate cortex had an accelerated decline with age. The clinical symptoms may be correlated to the metabolite concentration of the anterior
cingulate cortex.
Key words: schizophrenia; magnetic resonance spectroscopy; γ-aminobutyric acid; glutamate


A cross-sectional study on the characteristics of tardive dyskinesia in patients with chronic schizophrenia

Yanan HUANG, Lizhen PAN, Fei TENG, Geying WANG, Chenhu LI, Lingjing JIN

Background: Tardive dyskinesia (TD) is an abnormal involuntary movement disorder caused by patients’ longterm use of antipsychotic medication. It diminishes the social functioning of patients with mental disorders, thereby affecting their compliance with antipsychotic medication. The cause and nosogenesis of TD remains unclear; furthermore, because the presentation differs greatly among individuals it often goes undiagnosed or can be easily misdiagnosed. The present study aims to evaluate the abnormal movement patterns in patients with TD, and analyze the differences among different TD patterns, in order to seek effective methods of preventing, diagnosing and treating TD.
Aims: To describe the movement patterns of patients with chronic schizophrenia with TD, and analyze their clinical characteristics and risk factors.
Methods: A cross-sectional study was carried out on a psychiatric unit of the Xuhui Mental Health Center with inpatients who had chronic schizophrenia as participants. Abnormal Involuntary Movement Scale (AIMS) was employed to screen for patients with schizophrenia who also had TD. These patients’ movement disorders were evaluated, and they were divided into groups based on their movement patterns. Positive and Negative Syndrome Scale (PANSS) was used to assess the psychotic symptoms of patients, collect clinical information, compare the differences between the two groups and analyze the clinical characteristics and
risk factors of TD.
Results: (1) A total of 448 patients met the inclusion criteria for chronic schizophrenia with 46 in the TD group and 402 in the control group. After the TD group and the control group was compared, significant differences were seen between the two groups in gender, age, total duration of illness, age of onset, dosage of antipsychotic medication (daily chlorpromazine equivalent), factor scores of negative symptoms on PANSS and PANSS total scores. (2) It was possible that age, factor scores of negative symptoms in PANSS,
the amount of antipsychotic medication used (daily chlorpromazine equivalent) and gender are correlated with the occurrence of TD. (3) There were significant differences among the number of TD patients with movement disorders in facial and oral areas (67.4%), limbs (58.7%) and torso (37%). The AIMS scores corresponding with movement disorders in different parts of the body were also significantly different. (4) Comparing TD patients with single affected area and those with multiple affected areas, we found that they had significant differences in gender, age of onset, AIMS total scores, severity scores of abnormal movements and loss of range due to abnormal movements.
Conclusion: (1) Compared to the control group, the TD group had more men, was older, had a longer duration of illness, later age of onset, generally took a higher dosage of antipsychotic medication and presented with more severe negative symptoms. It is possible that age, factor scores of negative symptoms on PANSS, dosage of antipsychotic medication (daily chlorpromazine equivalent) and gender are correlated with the occurrence of TD. (2) The occurrence of movement disorders in facial and oral areas for patients
with chronic schizophrenia with TD was the most frequent, and the symptoms were the most severe. (3) Compared to TD patients with a single affected area, TD patients with multiple affected areas may have an earlier age of onset, more severe movement disorders, and more setbacks in their movement and functioning.
Key words: tardive dyskinesia; schizophrenia, clinical characteristics


Pleasure Experience and Emotion Expression in Patients with Schizophrenia

Min-yi CHU, Xu LI, Qin-yu LV, Zheng-hui YI, Eric F. C. CHEUNG, Raymond C. K. CHAN

Background: Impairments in emotional experience and expression have been observed in patients withschizophrenia. However, most previous studies have been limited to either emotional experience (especially anhedonia) or expression. Few studies have examined both the experience and expression of emotion in schizophrenia patients at the same time.
Aims: The present study aimed to examine pleasure experience and emotion expression in patients with schizophrenia. In particular, we specifically examined the relationship between emotion impairments (both pleasure experience and expression) and negative symptoms.
Methods: One hundred and fifty patients completed the Temporal Experience of Pleasure Scale and Emotional Expressivity Scale.
Results: Schizophrenia patients exhibited deficits in experiencing pleasure, but showed intact reported emotion expression. Patients with prominent negative symptoms showed reduced anticipatory pleasure, especially in abstract anticipatory pleasure.
Conclusion:The present findings suggest that patients with schizophrenia have deficits in pleasure experience, while their abilities to express emotion appear intact. Such deficits are more severe in patients with prominent negative symptoms.
Key words: Emotional experience; Emotional expression; Schizophrenia


Psychiatry and Cinema: What Can We Learn from the Magical Screen?

Soumitra DAS, Nimisha DOVAL, Shabna MOHAMMED, Neha DUA, Seshadri Sekhar CHATTERJEE

Summary: Cinema, a vehicle of social transformation sheds light on different aspects of mental illness. Due to its dramatic and stigmatising depictions, it often spreads a negative aspect of psychiatric disorders and the patients who are suffering from them. Though it brings out a few positive and inspiring stories, they are sparse in comparison to its negative views. Here, we are going to describe the dual impact of cinema on psychiatry.
Key words: cinema, mental illness, psychiatric disorder


Commentary on “Psychiatry and Cinema: What can We Learn from the Magical Screen?”

Qiuqing ANG

Case report

Multidimensional Approaches for A Case of Severe Adult Obsessive – Compulsive Disorder

Zhongyong SHI, Xinchun MEI, Yingbo ZHU, Yu SHUAI, Yupeng CHEN, Yujie WU, Yuan SHEN

Summary: Obsessive-compulsive disorder (OCD) is a chronic, distressing and substantially impairing neuropsychiatric disorder, characterized by obsessions or compulsions. The current case describes a 44-year old adult female diagnosed with OCD. The patient had an incomplete response to several SSRIs alone during her past treatment, and led a poor-quality life for at least three years. Current multidimensional approaches, including combined cognitive behavioral therapy (CBT) and the Selective Serotonin Reuptake
Inhibitor (SSRI, Sertraline) with a small dose of antipsychotics (Aripiprazole) for augmentation, as well as familial support and resources from the internet were provided for the patient for six months. Standardized assessments with Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) every two months indicated significant reductions in obsessive and compulsive symptoms, with significant improvements in her social functioning and quality of life. A case such as this one provides preliminary support to multidimensional approaches for
OCD treatment in order to achieve an optimal response, though further rigorous clinical trials are needed to provide more evidence.
Key words: Obsessive-compulsive disorder, Psychotherapy, Psychopharmacology

Biostatistics in psychiatry

Sample Size Calculations for Comparing Groups with Binary Outcomes

Xunan ZHANG, Jiangnan LYU, Justin TU, Jinyuan LIU, Xiang LU

Summary: Sample size is a critical parameter for clinical studies. However, to many biomedical and psychosocial investigators, power and sample size analysis seems like a magic trick of statisticians. In this paper, we continue to discuss power and sample size calculations by focusing on binary outcomes. We again emphasize the importance of close interactions between investigators and biostatisticians in setting up hypotheses and carrying out power analyses.
Key words: sample size, binary outcomes