In This Issue
Processing of Emotion in Schizophrenia
Emotion-related hypoactivation in the brains of patients with schizophrenia is more nuanced than previously indicated. Patients studied by Ursu et al. (p. Original article: 276) had normal responses to facial expressions across the frontal cortex, basal ganglia, and amygdala. But when they were asked to recall the information after a delay (figure), they had decreased activation of the dorsolateral prefrontal cortex relative to comparison subjects. Patients accurately detected emotion expressions in others, but their memory of the emotion became disrupted, often because of the introduction of negative feelings even when their initial perception was positive. Gold's editorial (p. Original article: 237) suggests the need for compensatory cognitive strategies directed to this deficiency in emotional memory. Pinkham et al. (CME, p. Original article: 293) also found that persons with schizophrenia are able to discern emotions, even when a person is not looking directly at them, but they are generally hyporesponsive, particularly to anger and threat. They point out that diminished response to threat, typical of paranoid patients, suggests that they have difficulty in discriminating what is truly threatening.
Are schizophrenia patients' emotions misrepresented by reporting? (Ursu et al., p. 276)
Skodol et al. (CME, p. Original article: 257) identify borderline personality disorder as a chief cause of persistent depression. Over 15% of adults with depression in a national survey had persistent illness over the next 3 years. Borderline personality disorder was estimated to account for over half of these cases of persistent depression. Other comorbid disorders associated with persistent depression were schizoid and schizotypal personality disorders, any anxiety disorder (the strongest axis I disorder predictor), and dysthymic disorder. Substance abuse was not a significant predictor. A complementary study by Morey et al. in May 2010 (p. 528) found that borderline personality disorder diagnosed when patients are depressed persists whether or not the depression remits, which indicates that the personality disorder diagnosis is an enduring trait and not simply another manifestation of depression.
Patients with schizophrenia whose psychosis began in the previous 2 years were treated with risperidone for 18 months and were classified by biweekly pills counts as adherent, mildly nonadherent (50%–75% of pills for at least 2 consecutive weeks), moderately nonadherent (<50% for 2–4 consecutive weeks), or severely nonadherent (<50% for 4 or more consecutive weeks). Even periods of mild nonadherence led to a markedly elevated risk of the return of overt psychotic symptoms. Subotnik et al. (p. Original article: 286) found that every nonadherent patient had relapsed by the end of 1 year, whereas only 40% of adherent patients relapsed by the end of 18 months. Robinson points out in an editorial (p. Original article: 240) that early-onset schizophrenia should be treated as an illness requiring intensive intervention, including consideration of depot medication.
Genetics Guides Alcoholism Treatment
Treatment of alcoholism with ondansetron in patients who have particular variants of two DNA sequences (“polymorphisms”) in the serotonin transporter gene was more effective than in patients with other genotypes. Ondansetron, a 5-HT3 receptor antagonist, was effective only in patients with the LL promoter variant in the study by Johnson et al. (p. Original article: 265). Perlis in an editorial (p. Original article: 234) points out that this study is the first major clinical trial to assign patients to treatments based on genotype and thus is an important first step in genomic medicine for a psychiatric illness, a strategy that has been very effective for cancer chemotherapy.
