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Aggressive behavior among treatment-resistant schizophrenic patients is a major clinical challenge whose prevalence is underestimated.In our 420-bed psychiatric hospital, some 15% of patients exhibit active psychosis and high rates of verbal/physical aggression necessitating physical restraints. In addition to their condition, these individuals endanger staff and other patients, consume extensive resources, and induce a sense of clinical helplessness.Physicians managing such complex patients face dilemmas regarding choice of treatment, criteria for treatment decisions, treatment goals, and outcome assessments. We address some of these by following the progress of a persistently psychotic severely aggressive treatment-resistant inpatient treated with repeated electroconvulsive therapy (ECT). The motivation for this report was our desire to examine whether there was objective evidence to support our clinically based treatment decisions.To this end, we compiled a retrospective chronological life chart recording ECT administrations and aggression using case note information. Physical restraint was chosen as the outcome measure, as it was accurately documented. Because it was used only after all other means failed, a recorded incident represents an extreme peak of ongoing aggressive behavior.

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BACKGROUND: It has been proposed that social and cognitive deficits in schizophrenia may result from impaired error monitoring. OBJECTIVE: We tested the hypothesis that among schizophrenia patients, impaired error monitoring contributes to poor face recognition, an important social skill. METHODS: 79 schizophrenia patients and 57 healthy individuals were administered a computerized face recognition test which allowed collection of accuracy and latency performance parameters. Error monitoring was assessed by analyzing reaction times for correct (RTC) and incorrect (RTI) responses. Tests of working memory (WM) and processing speed were also administered. RESULTS: RTI was longer than RTC in patients and controls and did not differ between the groups. RTC was significantly longer in patients than controls. Error monitoring effort, calculated by dividing the difference between RTI and RTC by the sum of RTC and RTI, was significantly smaller in patients than controls. A regression model with face recognition performance as dependent variable showed independent contributions of error monitoring effort, spatial working memory and group (patient/healthy) to test performance and explained 26.1% of the variance. CONCLUSION: Error monitoring function influences face recognition accuracy and is impaired in schizophrenia. Impairments in error monitoring, and spatial WM contribute to face recognition deficits in schizophrenia.

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Lack of insight of patients with schizophrenia into various aspects of their illness and treatment is an important clinical issue. Poor insight has been reported to be associated with neurocognitive deficits, particularly in the frontal and parietal functions. The aim of this study was to examine relationships between insight and cognitive and emotional function in patients with schizophrenia. Thirty-five male forensic patients suffering from chronic schizophrenia participated. The Scale for the Assessment of Unawareness of Mental Disorder was used to assess insight. Neuropsychological function was assessed with a comprehensive battery of tests. Clinical state was also assessed. Of 35 patients, 18 (51%) believed that they had a mental disorder. A similar proportion reported awareness of a need for medication and correctly attributed symptoms to illness. Measures of insight showed significant associations with visual object learning, verbal working memory, and identification of facial emotions but not with measures of frontal lobe function. Poorer insight was associated with a higher occurrence of violent events. Our findings support an association between poor insight and cognitive impairment in patients with chronic schizophrenia but suggest that the relationship may not specifically involve frontal lobe dysfunction.

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The present study aimed to test the hypothesis that dopamine agonists may enhance cognitive function. The effect of amantadine on neuropsychological function in medicated schizophrenia patients was investigated. The study comprised an add-on, double-blind, placebo-controlled, cross-over 6-week trial. Participants comprised 29 inpatients at Sha'ar Menashe Mental Health Center who were diagnosed with chronic schizophrenia or schizoaffective disorder. Amantadine 200 mg/day or identical placebo was added to ongoing antipsychotic treatment for 3 weeks. Study medications were then switched for an additional 3 weeks. Assessments were performed at baseline, and weeks 3 and 6, including cognitive and visuomotor assessments. Clinical ratings included positive, negative and depressive symptoms and extrapyramidal side-effects. Blood prolactin levels were assayed. A mixed model was used to examine differences in the data at the three assessment points. Amantadine was associated with improved visuomotor coordination compared to placebo. No significant changes in cognitive functions were noted. Clinical symptoms, extrapyramidal side-effects and blood prolactin levels were not altered. Amantadine improved visuomotor coordination independently of extrapyramidal side-effects but not cognitive function. Because prolactin concentrations were unchanged, the mechanism is more likely to involve glutaminergic NMDA than dopaminergic mechanisms. Further studies of amantadine with different doses and treatment duration, as well as more glutamate selective agents such as memantine, are indicated.

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There is evidence that neurosteroids such as DHEA and its sulfated form DHEAS can modulate cognitive function. We hypothesize that DHEA/S concentrations may be linked to cognitive impairment in schizophrenia. The aim of this pilot study was to test this hypothesis by examining the relationship between blood levels of DHEAS and cognitive function. The performance of 26 stable medicated chronic schizophrenia patients in a range of neuropsychological domains including verbal memory (Wechsler Memory Scale), executive function (AIM), memory of faces (PFMT), memory for objects (VOLT) and identification of facial emotional expressions (PEAT) was assessed. Single morning blood samples were assayed for levels of DHEAS and cortisol. Significant associations were found between DHEAS levels and DHEAS/Cortisol ratio and verbal memory, executive function and memory for faces. The relationship was independent of the age related reduction in DHEAS levels. These preliminary results suggest that DHEAS may be associated with cognitive impairment in schizophrenia.

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BACKGROUND: Impaired processing of emotions may relate to violent behavior in schizophrenia patients. We compared emotional function in schizophrenia patients with and without a history of severe violent behavior. METHOD: Tests of identification and differentiation of facial emotions were performed to compare 35 patients with chronic schizophrenia or schizoaffective disorder (DSM-IV criteria) and a history of severe violent behavior with 35 non-violent schizophrenia patients and 46 healthy controls. Tests of executive function, attention, visual orientation, working memory, memory for faces and objects, and motor function were also administered. RESULTS: Violent and nonviolent schizophrenia patients showed impaired emotional and cognitive function compared with controls. Violent patients showed a significantly better ability to identify facial emotional expressions but a poorer ability to discriminate between intensity of emotions than nonviolent schizophrenia patients. There was no difference in cognitive performance between the 2 patient groups. CONCLUSION: Violent schizophrenia patients may have a better ability to identify facial emotional cues than nonviolent schizophrenia patients but may be less able to assess the intensity of these cues. This trait may contribute to conflict generation and failure to recognize resolution signals, leading to conflict escalation and violence in violence-prone schizophrenia patients.

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A lack of insight into illness and negative attitudes towards medication are common among individuals with schizophrenia and impact clinical outcomes. This study aimed to examine the relationships between attitudes towards medication and cognitive function in schizophrenia patients. Thirty-five male forensic inpatients who were suffering from chronic schizophrenia participated in the study. A drug attitude inventory was used to evaluate the attitudes of the patients towards medication. Neuropsychological function was assessed with a comprehensive battery of tests. Patients with positive attitudes towards medication performed significantly better than those with negative attitudes on tests of verbal working memory (digit span forwards and backwards), inhibition and set shifting (Penn Inhibition test), delayed object memory and overall mental status (Mini Mental State Examination). There were no differences in age, education, hospitalizations or clinical symptoms between the groups. Our findings support an association between negative attitudes towards medication and poor cognitive performance, particularly of working memory.

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Impaired emotional communication may be an important contributing factor to poor social function in schizophrenia. This pilot study examined the effect of emotion training exercises on the perception of facial emotional expression. Twenty male chronic schizophrenia patients underwent three training sessions using a computerized Emotion Training program, developed for teaching autistic children, which was adapted to the clinical setting. Patients were assessed before and after training with validated tests of identification of facial emotions (PEAT, ER40), differentiation of facial emotions (EmDiff) and working memory. In comparison to baseline, patients performed significantly better on the PEAT and ER40 tests after training. No change was observed in EmDiff or in cognitive test performance. Brief Emotion Training can improve recognition of facial emotional expressions in chronic schizophrenia patients. This may be due to increased patient awareness of emotional aspects of stimuli and/or improvement in specific emotional perceptual skills. Further studies of Emotion Training as a potential treatment modality are warranted.

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