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Association between Cognitive Functions, Association between Cognitive Functions, Cortisol Release and Symptoms Severity in Cortisol Release and Symptoms Severity in
Patients with SchizophreniaPatients with Schizophrenia
Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA memberHanI Hamed and Heba Fathy*, Khadiga Mohamed Ali **
*Assistant Professor of Psychiatry, Cairo University**Professor of Clinical and Chemical Pathology, Benisuef University,
• Schizophrenia is severe mental disorder with
life time prevalence 1-2%.
• Schizophrenia is ranked within the top five causes
of disability and it is considered to be one of the
leading unsolved disorders affecting humans.
Digestive disorder (6%) Musculoskeletal
disorders (4%)
Endocrine (4%)
Neuropsychiatricdisorders (28%)
Cancer (11%)
Cardiovascular disease (22%)
Sense organ impairment (10%)
Other non-communicable diseases (7%)
Respiratory disease (8%)
Schizophrenia
Bipolar disorder
Dementia
Substance-use andalcohol-use disorders
Other mental disorders
Epilepsy
Other neurological disorders
Other neuropsychiatric disorders
MDD
2%
10%
2%
2%
4%
3%
1%
2%
3%
Prince et al. Lancet 2007;370(9590):859–877
Contribution (%) by different non-communicable diseases to disability-adjusted life-years (DALYs) worldwide in 2005
Psychiatric disorders – underestimated and disabling conditions
• Researchers have found higher levels of this 'stress
hormone' in people with schizophrenia.
• The system that is responsible for controlling the
production of cortisol is called the HPA –
hypothalamic-pituitary-adrenal – axis.
• Researchers think higher than normal cortisol levels
might mean the HPA axis isn't working properly.
INTRODUCTION
• The studies indicate a relation between
hypothalamopituitary adrenal axis (HPA) activity and
symptomatology in schizophrenia.
• Cortical secretion was primarily associated with more
severe positive symptoms .
INTRODUCTION
• It has suggested that the relation between
cortisol level and symptoms severity is due to the
augmenting effects of cortisol on dopamine
activity .
• To assess the cortisol level, the cognitive
deficits in schizophrenia.
• To assess the correlation between cognitive
functions, severity of positive & negative
symptoms and cortisol level in patients with
schizophrenia.
• Thirty patients having the diagnosis of
Schizophrenia diagnosed according to DSM-IV
criteria recruited from the Psychiatric outpatient
clinic and inpatient from Kasr El Aini University
hospitals.
• Thirty control subjects (healthy volunteers among
medical and paramedical personnel staff of Kasr
Al-Aini University hospitals.
• All the scales show absence of psychopathology
in the control group.
• They were matched in age and sex.
• The interviews were done over 5 months from July 2012 to November 2012. The interview ranged from one and a half to two hours.
• Semi-structured interview derived from the psychiatric sheet of Kasr Al Aini was done for 60 patients. Then, the diagnosis was confirmed by SCID-I.
• A written informed consent was taken from participants after discussing with them the aim of the study.
• I- Psychiatric examination:
• To assess personal data, positive family history, past
history of neurological or psychiatric condition,
scholastic achievement, duration of illness, ECT,
hospitalization
1. Structured Clinical Interview for DSM IV Axis I
Disorders (SCID I) :It is a diagnostic tool used to
determine the presence of DSM-IV Axis I disorders
(schizophrenia ).
• It is a rating scale scored by the researcher according to
his clinical judgment. PANSS is used to estimate the
severity of psychotic symptoms in patients. The scale has
three parts including:
• positive symptoms scale (P 1-7) which assess delusions,
conceptual disorganization, hallucinations, hyperactivity,
grandiosity, suspiciousness/persecution and hostility.
• Negative symptoms scale (N 1-7) which assess blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation and stereotyped thinking
• General psychopathology scale (G 1-16) which assess Somatic concern, anxiety, guilt feelings, tension, mannerisms and posturing, depression, motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, poor impulse control, preoccupation and active social avoidance.
• Figural memory, Visual paired association, Delayed
visual reproduction, and Visual memory span. They are
clinical instruments for appraising major dimensions of
memory functions. In this work, we selected the subtests
which assess the visual memory.
• In this study researchers choose two of the verbal
subtests (Digit span for auditory verbal short-term
(working) memory and Similarities for verbal concept-
formation) and two of the performance subtests (Digit
symbol to assess problem solving abilities, as an indicative
of executive function ,coordination and attention and Block
design to assess visuo-constructive abilities and excutive
planning)
• Salivary samples for cortisol levels assessment were collected and preserved at -20o C in the clinical laboratories of chemical pathology Department.
• Free cortisol levels were assessed by using enzyme-linked immunosorbent assay DRG® Salivary Cortisol ELISA
Results
• In viewing the demographic data of the sample,
there were no statistically significant differences
between the patient groups as regards the
sociodemographic data including age, sex.
• This indicated that the samples were matched
and fit for the study and comparison.
• While regarding educational level, occupation and
marital status, the differences were statistically
significant
Levels of education of patients.
-
Comparison of occupation between both groups.
Comparison of marital status in both groups.
• 2-psychometric tools
• -Wechsler Memory Revised Subtests in both groups:
Wechsler memory Case control P
Mean SD. Mean SD.
Figural memory 6.47 1.776 8.73 1.081 0.003
Visual memory span (forward) 7.77 1.995 9.90 1.807 <0.001
Visual memory span (backward) 5.73 2.303 11.43 1.654 <0.001
Visual paired association 6.83 2.842 13.73 2.815 <0.001
Visual reproduction 20.53 8.274 35.13 3.441 <0.001
• It was reported that Cognitive impairment, particularly in memory and executive function, is a core feature of psychosis.
Tyson P, Laws K and Roberts K, (2005) Tyson P, Laws K and Roberts K, (2005)
Wechsler Case Control P
Mean SD. Mean SD.
Similarities 9.37 4.173 18.67 3.144 <0.001
Digit span 10.30 2.336 14.40 1.773 <0.001
Block.design 14.63 7.271 26.17 6.276 <0.001
Digit symbols 20.78 14.792 44.43 8.675 <0.001
2-Wechsler Adult Intelligence subtests in both groups:
• Dickinson et al., (2007) who found that digit symbol coding task is reliable and easy to administer an information processing inefficiency that is a central feature of the cognitive deficit in schizophrenia.
• There is generalized cognitive decline in patient with schizophrenia and they often have pervasive cognitive deficits ,the cognitive symptoms are a main reason for disability and dysfunction.
Cortisol
level
Case control P
Mean SD. Mean SD.
Cortisol A 29.660 8.2012 5.547 1.8589 <0.001
Cortisol B 17.547 4.8583 2.680 1.0199 <0.001
3-Salivary cortisol level in both groups:
• Moreover, psychosis is characterized by a more prominent history of stress exposure, and by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.
Tyson P, Laws K and Roberts K, (2005) Tyson P, Laws K and Roberts K, (2005)
Wechseler memory Positive Negative Total
Figural memory P R P R P R
0.561 -0.110 0.015 -0.441 0.060 -0.347
Visual memory span forward P R P R P R
0.320 -0.188 0.204 -0.238 0.271 -0.208
Visual memory span backward P R P R P R
0.041 -0.376 0.040 -0.377 0.026 -0.407
Visual paired assossiation P R P R P R
0.073 -0.332 0.002 -0.552 0.008 -0.476
Visual reproduction P R P R P R
0.282 -0.203 0.193 -0.244 0.230 -0.226
Correlation between Positive and Negative Syndrome Scale and Wechseler Memory Revised Scale.
Correlation between Positive and Negative Syndrome
• Krishnadas et al., (2007) found that the forward and backward digit span tasks tap different cognitive abilities that are differentially affected with the diathesis for schizophrenia.
Wechseler intelligence positive negative total
Similarities P R P R P R
0.007 -0.480 0.082 -0.323 0.008 -0.473
Digit span P R P R P R
0.184 -0.249 0.029 -0.398 0.044 -0.370
Block design P R P R P R
0.269 -0.208 0.012 -0.451 0.013 -0.488
digit symbols P R P R P R
0.079 -0.326 0.006 -0.491 0.005 -0.497
Correlation between Wechsler Adult Intelligence Subtests and Positive and Negative Syndrome Scale.
• Reichenberg et al. (2010) reported that patients with schizophrenia had an impaired block design subtest and lower linear slope values than healthy comparison subjects.
• The sample size is small (30 patients), so the results
couldn’t be generalized.
• The inclusion of Kasr Al Ainy patients, who have poor
educational level and low socioeconomic standard,
may limit the results only to those patients.
• The schizophrenic patients have impairment in
cognitive performance.
• The level of cortisol is elevated in patient with
schizophrenia than normal people.
• There is negative correlation between the cognitive
performance and the severity of symptoms
• There is no correlation between cortisol level
and symptoms expression.
• There is no correlation between cortisol level
and cognitive performance
• Further researches are needed to confirm relation between cortisol, psychosis and cognitive performance.
• Cortisol level can be considered a measure of severity and improvement of psychosis.
• More studies using modern technology e.g. MRI and SPECT.