SPECT neuroimaging in schizophrenia with religious delusions
Introduction
The clinically heterogeneous nature of disorders such as schizophrenia limits the value of studies that group patients under this global label. One method of addressing such heterogeneity is to adopt a syndromal approach. However, while most syndromal structures, such as those of Liddle, 1987a, Liddle, 1987b, are essentially based on clinical rating-scale analyses, an alternative syndromal model that was originally founded on physiological measures, and that has subsequently been shown to have considerable etiological validity, is that of Gruzelier (Gruzelier and Manchanda, 1982, Gruzelier, 1996a, Gruzelier, 1999). The delineation by Gruzelier of a three-syndrome structure in schizophrenia, that is, the active, withdrawn and unreality syndromes (Gruzelier, 1991, Gruzelier, 1994), was derived from studies of patterns of cerebral hemispheric imbalance using both electrophysiological and neuropsychological measures (Gruzelier, 1996b). Gruzelier's delineation of his ‘active syndrome’ consists of raised activity levels, accelerated cognition, positive thought disorder, positive labile affect and affective delusions, and is associated with a greater left than right functional asymmetry. In contrast, the opposite pattern of functional hemispheric imbalance (greater right than left hemispheric activation) is associated with the ‘withdrawn syndrome’, comprising the essential negative features of schizophrenia, including poverty of speech, blunted affect, social withdrawal and motor retardation. Gruzelier's third syndrome, the ‘unreality syndrome’, involving Schneiderian delusions and hallucinations, is not consistently associated with lateral imbalance, and can coexist with either the active or withdrawn syndromes.
Functional neuroimaging techniques, such as single-photon emission computerised tomography (SPECT) and positron emission tomography (PET), have considerable potential for furthering our understanding of the disturbances in brain activity that underlie schizophrenia syndromes. A particular advantage of the use of the radiotracer [99mTc]-d,l-hexamethylpropylene amine oxime (99mTc-HMPAO) with SPECT stems from the fact that this radiopharmaceutical displays regional cerebral blood-flow (rCBF)-dependent uptake, with little redistribution over time (Puri and Lewis, 1992). The lipophilic 99mTc complex has been demonstrated, in vitro, to convert slowly to a secondary complex, and this may underlie the relative lack of cerebral redistribution (Neirinckx et al., 1987); after crossing the blood–brain barrier on first pass, 99mTc-HMPAO enters brain cells, where the pH change renders the molecules lipophobic. Following the formation of the cerebral lipophilic 99mTc complex, a relatively high proportion of the radioactivity left in the blood is trapped in erythrocytes, possibly by a similar mechanism to that causing cerebral retention. However, as the total volume of blood in the adult human brain is of the order of 0.031 l, the contribution of photons from the blood to the total photon count from the brain is very small, being less than 2% at 1 h postinjection. Therefore, following injection of the radiotracer, the SPECT scan can be delayed for, say, up to 1 h; when scanned, the rCBF found will represent the blood flow pattern immediately following the injection.
By studying the differences in rCBF found by carrying out SPECT neuroimaging during the manifestation of a particular symptom of schizophrenia, and then repeating the examination in the same patient(s) when well, it is possible to localise those cerebral regions associated with that symptom. For example, using this methodology McGuire et al. (1993) found that auditory hallucinations in schizophrenia are associated with an increased blood flow in Broca's area.
Here, the case is described of a patient with the active syndrome of schizophrenia who underwent SPECT neuroimaging on two occasions: first, while suffering from florid religious delusions, and again during remission.
Section snippets
Subject
The patient was a 37-year-old right-handed man with a history of schizophrenia and no family psychiatric history, who was admitted to a psychiatric hospital with a relapse of his illness. At the time of admission he indicated that the Bible was speaking to him literally. His speech was spontaneous and exhibited thought disorder. For example, he related that
HeThe Queen's making a speech…I teach myself physics and chemistry…about interstellar space…I read about…my milk teeth…projected my skull.
Results
The SPECT images were analysed in detail on a workstation with relevant internal referencing and matched scaling between the serial scans. A representative image of the uptake of the 99mTc-HMPAO radiotracer by the brain during the first scan, when the patient was suffering from religious delusions, is shown in Fig. 1, while Fig. 2 shows a representative image of the radiotracer uptake during the second scan, 6 months later.
Compared with the second scan carried out when the patient was in
Discussion
To the best of our knowledge, this is the first functional neuroimaging study of a case of specifically religious delusions. Gruzelier's active syndrome is associated with a greater left than right functional asymmetry (Gruzelier, 1999), which is consistent with our finding of increased left temporal rCBF during the manifestation of religious delusions. Again, Gur, 1978, Gur, 1979 found evidence of left hemisphere overactivation in schizophrenia and neuropsychological test performance,
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