Neural correlates of planning performance in patients with schizophrenia — Relationship with apathy
Introduction
Patients with schizophrenia frequently experience markedly reduced levels of interest and a lack of initiative in daily activities, which is a hallmark of apathy. Apathy is a core feature of negative symptoms in schizophrenia (Foussias and Remington, 2010). Research has shown that 30% of the patients with a first episode psychosis show enduring levels of apathy (Faerden et al., 2010). Understanding apathy in schizophrenia has important implications, as it has been argued to be the critical component, especially with regard to poor (social) functioning, unemployment, severity of illness and poor functional outcome (Bottlender et al., 2010, Faerden et al., 2010, Foussias and Remington, 2010, Kiang et al., 2003).
Apathy can be described as a quantitative reduction of voluntary, goal-directed behaviors. Levy and Dubois (2006) state that apathy may arise from “planning and working memory impairments, through difficulties in sequencing ideas, maintaining mental representation of goals and sub-goals and manipulating them, may abort the elaboration of goal-directed behaviors, thereby quantitatively (and qualitatively) reducing goal-directed behaviors”. In this view apathy may be rooted, in part, in planning deficits. Planning has been defined as “the goal-directed, trial-and-error exploration of a tree of alternative moves” (Dehaene and Changeux, 1997). Indeed, a direct relation between apathy and executive function or goal-directed behavior has also been observed (Faerden et al., 2010, Foussias and Remington, 2010, Roth et al., 2004), but the neural correlates of this association, to the best of our knowledge, have not been investigated as yet.
Goal-directed behavior and executive functioning are both regulated by a fronto-striatal-parietal brain circuit (Fuster, 2009, Goldberg, 2009) and a similar brain circuit has been implicated in apathy (Levy and Dubois, 2006). Impaired function of a fronto-striatal-parietal network may thus be related to apathy as a consequence of problems in goal-directed behavior (Konstantakopoulos et al., 2011, Roth et al., 2004). Schizophrenia patients with deficit syndrome, showing high levels of negative symptoms, including apathy, have shown abnormal regional cerebral blood flow (Lahti et al., 2001) and white matter deficits (Rowland et al., 2009) in fronto-parietal regions. Moreover, higher levels of apathy in schizophrenia have been related to decreased gray matter volumes in these areas and to neuropsychological deficits (Roth et al., 2004). In the current paper we address the question whether hampered activation of this fronto-striatal-parietal network during planning may be associated with apathy in schizophrenia.
The Tower of London task (ToL) is a suitable task to investigate higher order planning processes in fronto-striatal-parietal brain circuits as it requires subjects to perform a set of subsequent mental operations that involve planning (Shallice, 1982) and thus resembles the definitions of planning and apathy as defined above (Baker et al., 1996, Beauchamp et al., 2003, Unterrainer and Owen, 2006, Wagner et al., 2006). An early PET study using the ToL has shown decreased medial prefrontal activation in schizophrenia, related to the severity of negative symptoms (Andreasen et al., 1992). A more recent fMRI study reported some evidence for prefrontal dysfunction in schizophrenia, but these results were not unequivocal (Rasser et al., 2005).
The ToL has also been used to study frontal lobe lesions, which are characterized by apathy and impaired organizational abilities (Owen et al., 1996). Patients with frontal lobe damage show impaired performance on the ToL task (Dehaene and Changeux, 1997) similar to schizophrenia patients (Morris et al., 1995, Pantelis et al., 1997). Moreover, patients with depression (Elliott et al., 1997) and Parkinson's disease (Dagher et al., 2001, Owen et al., 1996) – both involving apathy and anhedonia – also showed frontal, parietal and striatal dysfunction during the ToL task. Taken together, these findings suggest that apathy in schizophrenia may be related to planning impairments associated with dysfunction of frontal, parietal and striatal connections.
We hypothesized that schizophrenia patients with high levels of apathy would show impaired function of fronto-striatal-parietal brain areas involved in planning. We included a task with different levels of difficulty (1–5 move problems) (Dagher et al., 1999, Schall et al., 2003) to account for differences in task performance between study participants. Furthermore, a healthy control group was included for reference.
Section snippets
Subjects
Baseline fMRI data of two trials were combined, i.e. before any intervention took place. The first trial that investigated the effects of treatment with aripiprazole compared to risperidone on negative symptoms (EUDRA-CT: 2007-002748-79). The second fMRI study was part of a double-blind multicenter randomized controlled trial investigating the effect of rTMS on negative symptoms (Dutch Trial Registry: NTR1261). The procedures for the baseline measurements used in the current study were
Demographics
Data of 47 patients and 20 control subjects were available. Demographic characteristics are shown in Table 1. The subject groups, patients versus controls, did not differ significantly in age, gender, handedness, or educational level. 76% of the patients had a diagnosis of schizophrenia; the other patients were diagnosed with other diagnoses in the psychotic spectrum. For the patients with a diagnosis of psychotic disorder, a diagnosis of schizophrenia could not be confirmed due to their short
Discussion
In this study we investigated whether apathy is related to reduced fronto-parietal activation in schizophrenia patients, using the Tower of London task. Both contrasts of planning with either the baseline or the counting balls condition showed reduced planning-related brain activation with higher levels of apathy. The planning > baseline association was also significant after correction for education.
Thus, we observed abnormal parietal and thalamic activation in relation to apathy, but no
Role of funding source
The study was funded in part by an ERC grant (StG2012-312787) and in part by a European Science Foundation EURYI grant (NWO no. 044035001), both awarded to AA.
Contributors
Edith Liemburg and André Aleman designed the study and wrote the protocol. Matthias van Osch developed the imaging protocol. Edith Liemburg and Remco Renken undertook statistical analysis. Edith Liemburg wrote the first draft of the manuscript. Leonie Bais, Henderikus Knegtering and Jozarni Dlabac-De Lange helped in writing the manuscript. All authors contributed to and have approved the final manuscript.
Conflicts of interest statement
Henderikus Knegtering, MD, PhD is on the speakers' list of and/or has received unconditional grants from Janssen, Eli Lilly, Bristol Meyers Squibb, Astra Zeneca Eli Lilly. All other authors declare that there are no conflicts of interest.
Acknowledgments
We thank all participants for participation in our study and all mental health care organizations for their cooperation. We thank Dr. Ann Faerden (Oslo University Hospital) for providing us with the PANSS-AES correlations from her dataset.
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