Neuroimaging in Schizophrenia - What Does It Tell the Clinician

Neuroimaging in schizophrenia

195Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

Advances in Psychiatric Treatment (2005), vol. 11, 195202

This article continues the series introduced by Robin McCreadieseditorial Schizophrenia revisited (McCreadie, 2004). Previouscontributors to the series are Leask (2004), Rowlands (2004),Connolly & Kelly (2005), Gopal & Variend (2005), Kerwin &Bolonna (2005) and (Singh & Fisher, 2005).

Neuroimaging promises much. The immediacy andvisual impact of a scan are appealing to patients,carers and doctors alike. It reduces the divideseparating psychiatry from the rest of medicine, andappeals to medical practitioners who are trained tomake diagnoses on the basis not just of history butalso of objective investigations. This is especiallytrue of magnetic resonance imaging (MRI), whichhas relatively few side-effects, good soft-tissueresolution and the ability to highlight real-timefunctional changes (when used in the form offunctional MRI (fMRI)). However, to the practisingclinician the promise remains just that. Neuro-imaging is still perceived to lack everyday utility forpsychiatry. Where is the diagnostic scan forschizophrenia? Can a scan help to predict who islikely to benefit most from the latest expensiveantipsychotic, or reassure us that an older drug isjust as good? Can neuroimaging even help us withthe increasing number of patients who request a scanjust to check everything is OK, when we think that,even if the scan is, the patient may not be?

Exclusion of organic causes

This is a common reason for requesting a scan insuspected schizophrenia and it is gaining accep-tance as scanning (especially MRI) becomes morewidely available and affordable. Between 5 and 10%of patients with psychosis (depending on the study)will have an organic disorder that underlies theirsymptoms, rather than a functional psychosissuch as schizophrenia or bipolar disorder (Falkai,1996). Other disorders that can be associated withpsychotic symptoms include epilepsy, brain injury,slow-growing tumours, demyelinating diseases andencephalitis. The treatment for these conditions (e.g.anticonvulsants or tumour resection) may be funda-mentally different from that for the major psychoses.Although some organic disorders are associatedwith neurological signs that can be detected onclinical examination, 50100% of patients withschizophrenia also have neurological soft signs(Dazzan et al, 2004), and referral to a neurologistusually results in a request that the patient has anMRI scan. Thus, it is increasingly considered goodclinical practice to scan all patients presenting withpsychosis for the first time (American PsychiatricAssociation, 2004) and this is now recommendedin contemporary textbooks of clinical psychiatry(Weinberger & Hirsch, 2003).

James Woolley is a clinical research fellow at the Institute of Psychiatry and an honorary specialist registrar at the MaudsleyHospital, London (Section of Neuroimaging, PO67, Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK. Tel: 020 78480369; fax: 020 7848 0956; [email protected]). His research interests include neuroimaging in obsessivecompulsivedisorder and early psychosis, and clinical interventions to reduce the impact of pre-psychotic symptoms. Philip McGuire isProfessor of Psychiatry and Cognitive Neuroscience and Head of the Section of Neuroimaging at the Institute of Psychiatry,London. His research is focused on neurocognitive processes that are putatively defective in psychosis. He is also ClinicalDirector of Outreach and Support in South London (OASIS) and of the Voices Clinic, Maudsley Hospital, and an honoraryconsultant to the Lambeth Early Onset (LEO) service.

Neuroimaging in schizophrenia:what does it tell the clinician?James Woolley & Philip McGuire

Abstract Neuroimaging has been used in clinical practice for over 30 years, but it is still perceived as rarelyoffering the psychiatrist much help in direct patient management. As newer imaging modalities areintroduced (from computed tomography and positron and single photon emission tomography tomagnetic and functional magnetic resonance imaging), the promise of imminent clinical utility isreawakened, only to fade as the innovation is shown to be another, albeit useful, research tool. Theaim of this article is to update readers on some recent advances that are starting to align the researchand clinical functions of neuroimaging. As imaging becomes more accessible and affordable there isreal promise that both clinicians and patients will begin to benefit more directly.

196 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

Woolley & McGuire

Radiological anomalies andabnormalities in schizophrenia

Some radiological abnormalities reflect the presenceof conditions that could account for psychosis,whereas others are more common in psychosis butare not themselves responsible for the disorder. Alarge cavum septum pellucidum, for example, ismore common in patients with schizophrenia thanin controls, but it is not a causal factor in the disorder(Kasai et al, 2004). Estimates of the incidence of suchnon-causal anomalies range between 30 and 40%(compared with 512% in the general population),and it has been suggested that they are evidence ofthe aberrant neurodevelopmental processes thoughtto contribute to schizophrenia. Lubman et al (2002)found that 30% of patients with schizophrenia werereported by a neuroradiologist to have abnormalscans. Most required no further action, but 4 of 242individuals benefited directly from neuroimaging,being referred for alternative treatment. Standardclinical radiology can also identify some of the majorneuroanatomical changes associated with schizo-phrenia, such as ventriculomegaly (Fig. 1) andcortical atrophy. There is a good correspondencebetween the detection of these major features inresearch analyses and in clinical radiology (Lawrie

et al, 1997), especially when standardised reportingmethods are used (Smith et al, 1997).

Costbenefit analyses

There is little published information on the costbenefit utility of neuroimaging in psychiatry. Thecost of scanning is often perceived as expensive(typically 300400 per patient), but this should be

Fig. 1 Ventriculomegaly in discordant monozygotic twins seen on T2-weighted MRI scans. Healthy twin (left)compared with twin with schizophrenia (right). With permission of Dr M. Picchioni.

Box 1 Pathologies for which CT and MRI areuseful screening tools

Computed tomography Stroke (haemorrhagic or old ischaemic) Tumours (large ones) Bleeding (intra- or extracranial) Volume loss Hydrocephalus Trauma

Magnetic resonance imaging Epilepsy Multiple sclerosis Certain tumours (e.g. pituitary adenomas) Vasculitis



weighed against the cost of keeping patients inhospital while they are being assessed using clinicalmeasures (of the order of 200 a day) and the costsof delaying appropriate treatment or providing in-appropriate treatment. As with any investigation itis helpful to consider what is being looked for, howlikely it is to be present, the costs involved and actiondepending on the result. The choice between themost commonly available types of scan computedtomography (CT) and MRI may depend on thenature of suspected pathology (Box 1). Computedtomography is cheap(er), quick and tolerable andcan be used as a screening tool for psychiatricpresentations. In patients with schizophrenia it isoften considered in specific circumstances such as:

the first presentation of psychosis (especiallyin unusual circumstances);

rapid or unusual development of psycho-pathology;

dementia; presence of focal neurological signs and

symptoms.

However, the cost saving per scan for CT comparedwith MRI must be balanced against the risk ofexposure to ionising radiation and of false-negativereports.

Magnetic resonance imaging is more expensivebut provides much better image resolution and,because it does not involve X-rays, there are no risksor contraindications associated with exposure toradiation. In schizophrenia, MRI is indicated in thesame circumstances as CT. However, it is better thanCT at detecting some pathologies (Box 1).

What else would help clinicians?

Although there has been extensive research usingstructural and functional imaging in psychiatricdisorders, there has been relatively little use ofneuroimaging for purely clinical purposes inpsychiatry (in contrast to its widespread use in therest of medicine). Diagnosis and assessment ofprognosis and effectiveness of treatments continueto be largely dependent on clinical history andcurrent psychopathology. At present, neuroimagingdoes not to play a significant role in these areas, butthere are signs that it might.

Since the landmark demonstration, using CTscanning, of enlarged ventricles in schizophrenia(Johnstone et al, 1976), a host of neuroimagingstudies have identified areas of reduced grey matterin the disorder, including the hippocampus, para-hippocampal gyrus, cingulate gyrus, insula,thalamus and the prefrontal and temporal cortex(Saykin et al, 1991). These structural studies have

been complemented by functional imaging researchwhich has indicated that schizophrenia is particu-larly associated with altered function in theprefrontal, cingulate and temporal cortex (McGuire& Matsumoto, 2004) and that symptoms such asauditory hallucinations and thought disorder aremediated by these brain regions.

Predicting course

There is evidence that the severity of volumetricabnormalities at first presentation and theirsubsequent rate of progression are associated witha relatively poor prognosis in schizophrenia. In first-episode patients, smaller cerebellum (Wassink et al,1999), smaller Sylvian fissure and larger thirdventricle (van Os et al, 1995), larger lateral ventricles(DeLisi et al, 1991) and ventriculomegaly andcortical atrophy (Zipursky et al, 1998a) have beenfound to be predictors of various measures of clinicaland social outcome (Ho et al, 2003). More recentstudies indicate that, although imaging findings atthe time of the first episode may have somepredictive value, the change within an individualsbrain over time may be a better predictor of clinicaloutcome. Cahn and colleagues found that MRIabnormalities at baseline had little relation tosubsequent course. However, the extent of greymatter loss, as revealed by comparison of follow-upand baseline scans, significantly correlated withclinical outcome (Cahn et al, 2002, 2004).

Predicting response to treatment

Neuroimaging may prove to be helpful in predictingwhich patients with schizophrenia are most likelyto respond to treatment, especially in the firstepisode. Practical applications have been suggestedfor over a decade, with neuroimaging as part of abattery of tests (including baseline symptom severity,early reduction in symptom severity, initial sub-jective response to antipsychotic treatment, brainatrophy on neuroimaging and early changes inplasma homovanillic acid levels) at least partiallypredicting treatment outcome (Stern et al, 1993). Earlystudies suggested the predictive value of widelydistributed brain changes such as average corticalsulcal width on CT scans (Schrder et al, 1993) orrelatively increased grey matter volume on MRI(Zipursky et al, 1998b).

More recently, attempts have been made to makepredictions in relation to more specific regions, butthe results have been inconsistent. Clinical improve-ment with clozapine has been found in the presenceof structural brain abnormalities such as wideSylvian fissures, features previously associated with


Woolley & McGuire

non-responsiveness to conventional antipsychotics(Lauriello et al, 1998). Similarly, Konicki et al (2001)found that patients with the greatest degree of func-tional improvement at follow-up had significantlyless prefrontal sulcal widening on baseline MRI thanthose whose symptoms remained unchanged. Inaddition, there was no relationship betweenclozapine response and general sulcal widening.

Functional imaging studies, especially those usingpositron emission tomography (PET) to examinereceptor occupancy, have been more directly useful,but it is difficult to apply their results to individualpatients. They have illustrated the relationshipbetween dopamine D2 receptor occupancy, clinicalresponse and side-effects, for example in first-episodeschizophrenia (Kapur et al, 2000). Being able topredict that the likelihood of clinical response,hyperprolactinaemia and extrapyramidal side-effects increases significantly as D2 occupancyexceeds specific thresholds facilitates the selectionof the appropriate antipsychotic dose. D2 occupancycan also help explain many of the observed clinicaldifferences between typical and atypical anti-psychotics. PET could be used to establish theminimum dose that provides optimal D2 receptoroccupancy (instead of titrating the dose accordingto clinical response and side-effects). However, thisis impracticable because of the general unavailabilityof PET and single photon emission tomography(SPET), the cost (thousands of pounds per scan forPET) and the fact that many patients are too ill toscan. Consequently, this approach is mainly used inresearch, for example in evaluating the optimal doseof a new antipsychotic.

Neuroanatomy may predict response to electro-convulsive therapy (ECT), with a greater third-ventricle-to-brain ratio correlating with a largernumber of treatments required to achieve benefit(Dequardo et al, 1997).

Dose and drug selection

Neuroimaging, and in particular functionaltechniques such as PET and SPET which measureneuroreceptor occupancy in vivo (Fig. 2), hasbolstered the scientific rationale for moving awayfrom high-dose antipsychotic treatment. Thesemethods have confirmed findings previouslysuspected from clinical experience and suggestedby animal models. Scherer et al (1994) showed thatD2 receptor occupancy differs between patientswith and without extrapyramidal side-effects.Dopamine PET studies have shown that a receptoroccupancy of 65% or higher is needed to achievean antipsychotic effect, but exceeding 72%causes hyperprolactinaemia and over 78% leads

to extrapyramidal side-effects (Tauscher & Kapur,2001). This translates into the clinically usefulconcept of response to low-dose antipsychotictreatment, and has allowed approximate dose

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Fig. 2 (a) PET image showing dopamine receptorbinding in the basal ganglia; (b) measurements ofD2 receptor occupancy made using PET illustratehow occupancy increases with increasing anti-psychotic dose. With permission of ProfessorP. Grasby. Part (a) appears in colour in the onlineversion of this article (accessible via http://apt.rcpsych.org).



equivalence between alternative antipsychotics tobe calculated (e.g. 5 mg haloperidol per day =risperidone 2 mg = olanzapine 7.5 mg; Kapur et al,1999). Gold et al (1991) demonstrated that neuro-imaging can help to predict other side-effects suchas tardive dyskinesia. Patients with tardivedyskinesia had significantly smaller ventricle-to-brain ratios than controls.

Recent studies expand on this and help theclinician in the selection of drugs as well as of dose.Increasingly, different side-effect profiles areemerging between the various atypical anti-psychotics, and again PET and SPET can illustratethe differing receptor-affinity profiles, allowing theclinician to predict the likelihood of specific side-effects and tailor drug selection accordingly.

Relapse prediction

Neuroimaging, in combination with other factors,may highlight the likelihood of relapse. For example,from a host of potential relapse predictors followingfirst-episode schizophrenia or schizoaffectivedisorder, one of the few positive indicators washippocampal volume (Robinson et al, 1999).

Identifying risk factors

Within groups of patients in their first psychoticepisode, significant deficits have been found incortical grey matter, temporal lobe grey matter andwhole brain volume as well as significant enlarge-ment of the lateral and third ventricles. As theseoccur in both treatment-nave and minimally treatedindividuals (Fannon et al, 2000), it is likely that atleast some abnormalities were present before theonset of frank psychosis. Furthermore, unaffectedrelatives of individuals with schizophrenia showmany of the volumetric abnormalities seen in peoplewith the disorder, although generally to a lesserdegree (Lawrie et al, 1999). The same applies toindividuals with prodromal signs who are at highrisk of developing psychosis. Within this at-riskgroup, the severity of the abnormalities may begreater in those who develop psychosis than in thosewho do not (Pantelis et al, 2003). In addition, thedevelopment of psychosis in vulnerable individualsappears to be associated with progressive changesin baseline MRI abnormalities (Pantelis et al, 2003;Job et al, 2004). These observations raise thepossibility that neuroimaging may provide a meansof identifying the subgroup within a population athigh risk who are especially likely to developpsychosis. This would be of great clinical utility.Consequently, any clinical intervention intended toreduce the risk of transition has to be applied to the

entire group, raising ethical concerns aboutunnecessary treatment (McGuire, 2002).

Since disturbances of regional brain function maybe evident before macroscopic loss of grey matter,functional imaging may be a more sensitive meansof detecting such differences than structuralimaging. However, to date there have been fewstudies of this type and various neuroimagingtechniques (e.g. fMRI, PET, psychopharmacologicalchallenge such as tryptophan depletion) are beingadapted to explore this.

Future directions

As already mentioned, there are practical problemsin using generalised findings from research tointerpret results for individual patients. A key issuefor many research studies in schizophrenia is thatneuroimaging differences are usually quantitativerather than qualitative and are evident at the grouprather than the individual level. A major objective offuture work will be to develop a way of using datafrom a single patient to inform clinical assessmentand management. In a move in this direction,Kawasaki et al (2002) has used standard clinicalMRI scans and a multivariate analysis technique toexamine which patterns of grey matter changesdifferentiate best between groups of individualswith schizophrenia and with schizotypal disorder.They were able to separate the scans of individualpatients from those of controls, and the scans ofpatients with schizophrenia from those withschizotypal disorder, with a sensitivity of 7688%.

Neuromorphometry, involving the manualselection of a particular region of interest andmeasurement of the overall size or volume of thatstructure, is the basis of much research. Newerapproaches also examine shape, which can changewithout major alterations in size or volume.Csernansky et al (1998) showed that, althoughoverall and regional brain volume is smaller inpeople with schizophrenia than in controls, thereare many confounding variables such as indivi-duals height and gender. However, they found thatmeasuring the shape of the hippocampus provideda more robust means of differentiating patientsfrom controls (successful in about 70% of cases).Combining shape measures from more than oneregion (e.g. the hippocampus and pulvinar, a partof the thalamus) appears to increase the sensitivityof this approach (Csernansky et al, 2004).

Broadening the phenotype beyond strict DSMor ICD schizophrenia may help to reveal moreprimary mechanisms, allowing more probabilisticpredictions for individual clinical patients. Thestudy of intermediate phenotypes (identified


Woolley & McGuire

symptomatically or genetically) is shedding lighton the role of global and regionally specificdysfunction (Callicott, 2003), so the future holdspromise that a risk profile for individual patientsmay be defined as advances tie fMRI abnor-malities to gene function. Already, relationshipsbetween gene function and neuroimaging resultshave been seen in small samples of individualswith intermediate phenotypes whose behaviouror neuropsychological profile does not necessarilydiffer from those of healthy controls, emphasisingthe potential power of such an approach at last tobegin giving us useful information about geneticvariation in individuals (Hariri & Weinberger,2003).

Attempts are also being made to exploit thepotential statistical power of combining largenumbers of scan datasets derived from bothresearch and clinical practice (Governing Councilof the Organisation for Human Brain Mapping,2001). By comparing the results of such analyseswith data from individual patient scans, some ofthe more subtle abnormalities seen in researchfindings might be more robustly applicable toindividual clinical cases.

The wider context

Despite the best efforts of voluntary sector andprofessional groups, individuals with schizo-phrenia are still subject to discrimination, stereo-typing and stigma. Patients and their families oftenhesitate in or avoid seeking help. Neuroimaging canhelp to counter this by making otherwise invisibleand intangible internal processes easier to see andconceptualise externally. This can help to reducethe sense of personal blame and guilt, allowingpatients to ask for and receive help and treatmentwithout shame. As Insel comments,

We already have some pretty effective treatmentsThe frustrating thing is that even though we knowhow to treat many of these disorders, there are stillmany, many people who are not getting treat-ment. Theres a gap between what we know how todo and what actually happens in the real world. ...Part of [making sure that these treatments aredelivered] a very important part involvesreducing the stigma of mental disease (NeuroscienceQuarterly, 2003).

Although clearly not a justification in itself, wehave found that neuroimaging can help reduce thisgap for patients, and it is hard to exaggerate theimpact that a brain scan image has in an increasinglymedicalised society driven by visual media.

Reintegrating psychiatric practice into main-stream medicine is appealing to many, and in its

broad application neuroimaging may help thisprocess. However, there is often the temptation tothink that neuroimaging is only of use if oneconcentrates exclusively on biological theories ofpsychopathology. We suggest it has a role in broadermodels too, for example in stress-vulnerabilityconcepts of psychosis, where it can inform on eventsin the earliest stages (Pantelis et al, 2003), or inilluminating the nature of subtle neurodevelop-mental abnormalities acting as predisposing factorsfor subsequent illness (Dazzan et al, 2004). It isencouraging to see neuroimaging taking this broadapproach, and the manner in which it can beadapted to complement other approaches (e.g. usinggenetics and neuropsychology) means that it islikely to teach us more about schizophrenia andbecome even more clinically relevant.

In summary, it seems that the most promisingareas in which research imaging will translate intoclinically useful scanning are likely to be: baselineMRI at first episode, in order to exclude otherdisorders and to predict outcome; serial scanningduring the first few years of psychosis, to categoriserate of progression and thus predict outcome; andscanning at-risk individuals to facilitate estimationof the risk of transition to full-blown psychosis andso decide whom to treat.

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MCQs1 Johnstone et al first used neuroimaging to demon-

strate ventriculomegaly in schizophrenia in:a the 1950sb the 1960sc the 1970sd the 1980se the 1990s.


Woolley & McGuire

MCQ answers

1 2 3 4 5a F a F a F a F a Fb F b T b F b T b Fc T c F c T c F c Td F d F d T d F d Fe F e F e F e F e F

2 The percentage of patients with psychosis who havean abnormality that accounts for their symptomsdetected in a routine radiological MRI scan is:

a zerob up to 10%c up to 30%d up to 50%e more than 50%.

3 Recent neuroimaging research suggests that:a there are no MRI abnormalities prior to the first

episode of schizophreniab there are no MRI abnormalities in the unaffected

relatives of patients with schizophreniac some of the MRI abnormalities in patients with

schizophrenia may progress over timed prior to the first episode of schizophrenia some of

the MRI abnormalities may progress over timee all of the MRI abnormalities in patients with

schizophrenia progress over time.

4 The percentage of patients with psychosis who haveabnormalities of any kind on an MRI scan detectablein a routine radiological assessment is:

a up to 12%b up to 30%b up to 40%d up to 50%e more than 50%.

5 The lowest level of striatal D2 receptor occupancyrequired for a therapeutic response to mostantipsychotic drugs is:

a 45%b 55%c 65%d 75%e 85%.

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Clinical Evidence Mental Health (third edition)Royal College of Psychiatrists/BMJ Publishing Group

This book contains the mental health section extracted from Clinical Evidence, Issue 11 (BMJ PublishingGroup), the international source of the best available evidence for effective healthcare. The book presentsclear, concise summaries of the current state of the evidence on the prevention and treatment of mentalhealth disorders derived, where possible, from randomised controlled trials and systematic reviews.This third edition covers 15 different mental health disorders, 27 questions, and over 200 interventions. Based on the latest Clinical Evidence search and appraisal results. Includes evidence on the short- and long-term treatment of mental health disorders

and their complications. Assesses drug treatments, non-drug treatments and psychological therapies. Uses explicit methodology for selecting which evidence to summarise. Categorises interventions according to whether they have been found to be

effective or not. Presents key messages and structured summaries of filtered evidence. Presents the balance between benefits and harms of intervention.August 2004, Paperback, 210pp, ISBN 1 904671 16 0, Price 14.00

Neuroimaging in Schizophrenia - What Does It Tell the Clinician

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Transcript of Neuroimaging in Schizophrenia - What Does It Tell the Clinician