Official Title: “Oxytocin Treatment of Social Deficits and Paranoia in Schizophrenia”
Purpose: Test whether intranasal administration of the neuropeptide, oxytocin, improves social cognition, social functioning and decreases paranoia and other psychotic symptoms in schizophrenia.
Participants: 80 adults with schizophrenia for at least one year and with a high rating for paranoia.
Procedures (methods): Oxytocin or placebo will be administered twice daily in an intranasal spray (6 insufflations/dose or 24 IU) for 6 weeks. Before, during and at the end of the trial, each subject will undergo psychiatric symptom ratings and tests of mental abilities used in social functioning and social competence and subjects and an informant will complete ratings of social functioning.
- Study Type: Interventional
- Study Design: Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Outcomes Assessor), Primary Purpose: Treatment
- Study Primary Completion Date: November 2012
Detailed Clinical Trial Description
Inclusion criteria: meeting DSM-IV criteria for paranoid or undifferentiated schizophrenia for at least 1 year; scoring > 4 on the suspiciousness/persecution (hereafter referred to as paranoia) subscale of the Positive and Negative Symptoms Scale (PANSS) or 3 on the paranoia subscale and > 3 on the hostility, active social avoidance, passive/apathetic social withdrawal or uncooperativeness subscale and > 60 on the full PANSS: stability of symptom severity and on the same medication(s) and dose(s) for at least 1 month; low to moderate depressive symptoms.
Exclusion criteria: low literacy as indicated by an inability to read and understand the consent form; dependence on substances other than tobacco or caffeine; positive urine drug screen for illegal substances or drugs that have not been prescribed; debilitating medical conditions (including AIDS; HIV infection alone will not be grounds for exclusion); major surgery or trauma in the past year will be grounds for exclusion although subjects determined to be recovered and stable may be included at the discretion of the PI; pregnancy, breast-feeding; having given birth in the past 6 months or breast-feeding in the past 3 months. Individuals judged unable to learn self-administration of intranasal treatments and/or not sufficiently reliable to do so will be excluded. Abnormalities found during medical evaluation will be grounds for exclusion (see details below) although subjects with laboratory measures somewhat out of the normal range may be included at the discretion of Drs. Pedersen, Gilmore, Rau and/or Salimi.
Study Design: We will use a randomized, double-blind, placebo-controlled design. 80 subjects will complete the protocol; 40 subjects will be treated with oxytocin and 40 with normal saline placebo. Prior to the treatment trial, baseline measures of social cognition, social competence, paranoia, other psychotic and psychiatric symptoms will be obtained. Social cognition and psychiatric symptoms will be measured on days 7, 14, 28 and 42 of the 6 week treatment trial. Social competence measures will be obtained on day 14 and 42 of the treatment trial.
Procedures: Subjects will be recruited from the UNC Department of Psychiatry Schizophrenia Treatment and Evaluation Program outpatient clinics, the UNC Hospitals Psychotic Disorders inpatient unit, the inpatient units of Central Regional Hospital (at Dorothea Dix Hospital in Raleigh or Butner, NC) and from the community. After giving informed consent, they will be evaluated using the Positive and Negative Symptoms Scale (PANSS). If their total PANSS score is > or equal to 60, their PANSS sub-score for suspiciousness/persecution (paranoia) is > or equal to 4 (maximum sub-score is 7), their medical history will be reviewed including medications and dosages over the past month. If they do not have exclusionary medical or medication history, their psychiatric history will be reviewed. If necessary to confirm their diagnosis, they will undergo the Structured Clinical Interview for DSM-IV (SCID) patient version. If they have met criteria for schizophrenia, paranoid or undifferentiated type, for at least one year, they will undergo a physical exam and blood will be drawn and urine collected for laboratory measures including CBC, electrolytes, BUN, creatinine, liver function tests, glucose, TSH, urinanalysis, urine drug screen and pregnancy test. This initial evaluation may require up to 3-4 hours. Prospective subjects will be encouraged to rest for 20-30 minutes between the initial interviews (PANSS, SCID) and the history, physical exam and blood/urine collections. Psychiatric, medical and medication history will be confirmed by reviewing medical records and contacting clinicians in charge of the prospective subject's psychiatric care. The initial evaluation will be conducted in the CTRC outpatient clinic or at the UNC Psychiatry Clinical Research Unit (CRU) at Central Regional Hospital (Raleigh or Butner).
SCID, PANSS, other psychological results and medical labs and history will be reviewed during conferences with Dr. Pedersen accompanied by Drs. Gilmore, Salimi and/or Rau. Drs. Pedersen and Gilmore are Board-certified Psychiatrists and Full Professors in the UNC Department of Psychiatry. Drs. Salimi and Rau are Board-certified Assistant Professors in the UNC Department of Psychiatry and co-Directors of the Department of Psychiatry CRU at Central Regional Hospital (currently at Dorothea Dix Hospital but soon to be moved to Butner, NC). Consensus decisions will be made during these conferences about whether subjects meet the diagnostic and other criteria for inclusion in the study.
If prospective subjects meet inclusion but not exclusion criteria, they will be eligible to continue in the study. In the week prior to initiating the daily treatment trial, baseline measurements of social cognition, social competence, social functioning, paranoia, other psychotic and psychiatric symptoms will be obtained (see descriptions below). This will require approximately 3 hours. Social cognition and competence testing will be conducted by Psychology graduate or advanced undergraduate students or postdoctoral fellow who have been trained and are supervised by Dr. Penn, Professor of Clinical Psychology and an expert in social cognition measurement and a prominent investigator of social cognition deficits in psychotic disorders and autism. Psychiatric ratings will be made by one of the Co-PIs, Psychology graduate students, an experienced research RN or a Psychology or Psychiatry postdoctoral fellow. Research staff conducting social cognition testing and psychiatric ratings will be blind to treatment group. Baseline measurements will be conducted in the CTRC outpatient clinic or at the UNC Psychiatry Clinical Research Unit (CRU) at Central Regional Hospital (Raleigh or Butner).
During the treatment trial, twice daily test treatments will be self-administered by subjects in the morning shortly after breakfast and late in the afternoon/early evening prior to dinner. Each treatment will consist of 6 insufflations (3/nostril alternating between nostrils) of Syntocinon Spray (Novartis), which contains approximately 24 international units (IU) of oxytocin, or placebo. There will be a 30-60 second pause between each insufflation. The placebo solution will be a solution that has all ingredients in Syntocinon Spray except for oxytocin in 2 oz vials containing 30 ml of solution designed to deliver 0.1 ml metered volume per insufflation prepared by Triangle Compounding Pharmacy. Treatment assignments will be random within each gender. Vials containing oxytocin and placebo spray will be relabeled by the Dorothea Dix Hospital Pharmacy or UNC Investigational Drug Service so that subjects and raters are blind to treatment.
Social cognition and competence testing will begin 50 min after the morning treatment on days 14, 28 and 42 of the treatment trial and will be followed by ratings of psychotic, mood and anxiety symptoms (requiring 1-3 hr depending on how much social cognition testing is done). The FEIT, Reading the Mind in the Eyes test (Eyes Test) and Trustworthiness Tasks (see below) as well as psychiatric ratings will be conducted at all time points and the Brüne, AIHQ, and social competence tasks (see below) will be conducted on treatment days 14 and 42. On these treatment days, subjects will take 20-30 min breaks after the FEIT, Eyes Test, Trustworthiness and Brüne tasks and after the ensuing AIHQ and social competence tasks which will be followed by psychiatric ratings. At the end of the treatment protocol (treatment day 42), subjects and research staff who have conducted social cognition testing or made psychiatric ratings will be asked to guess which treatment the subjects received.
Subjects may take part in this study as outpatients or inpatients or may start as inpatients and complete the protocol in the outpatient setting. Subjects will be trained by research nurses during their first dosing with test substance in intranasal self-administration shortly after baseline measurements are completed. During preliminary studies at the Dorothea Dix CRU, all 10 subjects that were enrolled quickly and easily mastered this procedure. After learning intranasal self-administration, subjects who wish to participate in the study as outpatients will be given written instructions about the timing of each day's test treatments and other procedures to follow at home. They will then be given one 2 ounce vial containing 30 ml of test substance and other supplies to last until their first outpatient clinic testing appointment and instructed when to begin the twice daily intranasal treatments. Subjects who wish to be studied in the hospital who are not already inpatients on the CRU will be admitted shortly after completing baseline measurements. Outpatient subjects will visit an outpatient study site (CTRC or CRU) on the mornings of treatment days 14, 28 and 42 (where they will be provided with a snack or breakfast and lunch depending on the length of the visit). They will self administer test substance at the site so staff can confirm they are using proper technique. In addition to social cognition/competence testing and psychiatric ratings, blood samples as well as vital signs will be obtained during these visits. At 40 min after the last intranasal insufflation, blood (15 ml) will be drawn to measure plasma oxytocin concentrations and other lab values (Na, K, glucose [treatment days 14, 28 and 42], CBC, BUN, creatinine, GGT [treatment days 14, 42]). An ECG will also be obtained on the morning of treatment days 14 and 42 approximately 3-4 hr after intranasal treatment (when social cognition/competence testing and psychiatric ratings are completed). Urine will also be collected from female subjects on the day of baseline measurements and on treatment days 28 and 42 for pregnancy testing. These same procedures will conducted on the morning of treatment days 14, 28, 42 in subjects studied as inpatients.
After procedures at the study site on the morning of treatment days 14 and 28, outpatient subjects will be given a new vial containing 30 ml test substance so they can self administer doses twice daily until their next visit to the study site. Subjects will be instructed to store vials at room temperature and to clean the tip of the spray nozzle with an alcohol wipe after each dose is administered. Vials will be weighted before dispensing and upon return to the clinic 2 wks later to determine how much solution was actually ejected from the vial.
Measurements: A battery of well-validated instruments to quantify psychiatric symptoms, social cognition and social competence will be used in this study. The domains to be measured and the instruments that will be used are summarized below. Psychiatric symptoms will be rated by research staff among which good inter-rater reliability will be established.
Psychiatric Measures Psychotic symptoms: The Positive and Negative Symptoms Scale (PANSS, White et al., 1997) is a 30-item scale on which an interviewer rates the subject for severity of positive and negative psychotic symptoms and mood and behavioral symptoms after asking a standard series of questions. Items are rated on a scale of 1 (absent) to 7 (severe), and yield five scaled scores: positive symptoms (this includes several subscales including paranoia), negative symptoms, dysphoric mood, activation, and autistic preoccupation.
Depressive symptoms: The Montgomery-Åsberg Depression Rating Scale (Montgomery & Åsberg 1979) is administered by an interviewer who rates the severity of the subject's depressive symptoms between 0 and 6 in 10 symptom domains.
Anxiety (general and social) and other psychiatric symptoms: The Brief Symptom Inventory (BSI, Derogatis 1993) consists of 53 questions covering nine symptom dimensions: Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism (each rated on a 0-4 scale). Only the subset of questions used to measure anxiety will be used (items 1, 12, 19, 38, 45, 49). Subjects will rate themselves on these questions which should require no more than 2-3 min. The Liebowitz Social Anxiety Scale (Liebowitz 1987) is a self-rating instrument that lists 24 social situations on which the subject rates (0-3) how much fear/anxiety he/she would experience and how much he/she would avoid each situation (0-3). The instrument requires approximately 5 min to complete.
Paranoia: The Paranoia Scale (Fenigstein & Vanable, 1992) is a questionnaire filled out by the subject on which he/she rates on a 1-5 scale whether each of 20 statements applies to him/her.
Social Cognition Measures Emotion recognition: The Face Emotion Identification Task (Kerr & Neale 1993) is comprised of 19 images of faces expressing one of six basic emotions (happy, sad, angry, afraid, surprised, and ashamed) that are presented sequentially on a computer screen. The participant's task is to identify the emotion that is being expressed by each face. The scoring sheet accompanies this application although the facial expression pictures are not.
The Reading the Mind in the Eyes Test- Revised Version: The Eyes Test (Baron-Cohen et al 2001) consists of 36 photographs and participants are asked to guess the mental state (i.e. what the person is thinking or feeling) from among 4 choice words. Participants are given a practice item to ensure that they understand the task. Each eye region is presented on a note card or is displayed on a computer screen with the four choice mental states shown in the four corners of the card or computer screen (one target word and three foil words). There is no time constraint in choosing the mental state. A glossary of the mental states is made available, if the participants are unsure of the meaning of a word. Performance is measured by the number of faces correctly discriminated.
Trustworthiness task: This task (Adolphs et al., 1998) is comprised of 42 faces of unfamiliar people. Participants will be shown each picture individually (on a computer monitor) and will be asked to rate how much they would trust that person (with their money or their life) on a 7-point scale, ranging from -3 (very untrustworthy) to +3 (very trustworthy).
Theory of mind: In the Theory of Mind Picture Stories Task (Brüne, 2003), the subject is shown a series of 6 sets of 4 cartoon pictures that illustrate interactions between two or more individuals. The subject is asked to rearrange the pictures, initially presented in an illogical sequence, in an order that conveys a logical story. The period of time the subject takes to complete the task and the accuracy of the sequencing is recorded. Then, after the subject or (if the subject fails to do so) the examiner correctly organizes the pictures, the subject is asked questions about characters in the cartoons own beliefs and beliefs of other characters in the cartoons. The subject's interpretations of the characters' beliefs are scored as correct or incorrect.
Attributional style: The Ambiguous Intentions Hostility Questionnaire (AIHQ, Combs et al 2007) is comprised of 15 short vignettes that reflect negative events that vary in intentionality (i.e., obvious, accidental, and ambiguous intentions). Participants are asked to read each vignette, to imagine the scenario happening to her/him (e.g., "You walk past a bunch of teenagers at a mall and you hear them start to laugh"), and to write down the reason why the other person (or persons) acted that way toward her/him. Two independent raters subsequently code this written response for the purpose of computing a "hostility bias". The participant then rates, on Likert scales, whether the other person (or persons) performed the action on purpose (anchored by , definitely no, and , definitely yes), how angry it would make her/him feel (anchored by , not at all angry, and , very angry), and how much they would blame the other person (or persons) (anchored by , not at all, and , very much). Finally, the participant is asked to write down how she/he would respond to the situation, which is later coded by two independent raters to compute an "aggression index.".
Neurocognition Measures: The Brief Assessment of Cognition in Schizophrenia (BACS) will be administered to assess non-social cognition.
Social Skill Measures Social competence: This task is comprised of two brief, 3-min role plays (which are videotaped). The first role-play is an unstructured conversation whereby the research confederate tells the participant that she/he is a new patient admitted to an inpatient ward and they should get to know one another. We have used similar role plays like this one in the past (Pinkham & Penn, 2006). In the second role play, we instruct the participant that their task is to comfort another patient who is in distress (because they aren't being discharged from the hospital that day).
Social Functioning: The Specific Levels of Functioning (SLOF) questionnaire will be filled out by the subject and a reliable informant who has known the subject well for over a year at baseline and at the end of the treatment trial.
Interventions Used in this Clinical Trial
- Drug: intranasal oxytocin spray
- 6 insufflations (24 IU of oxytocin total) given twice daily for 6 weeks
- Other: formulated solution containing all ingredients as Syntocinon Spray except for oxytocin
- Treatment consists of 6 insufflations (0.1 metered dose/insufflation) twice daily for 6 weeks of a formulated solution that contains all ingredients in Syntocinon Spray except for oxytocin.
Arms, Groups and Cohorts in this Clinical Trial
- Experimental: oxytocin
- Twice daily oxytocin treatments will be self-administered by subjects.
- Placebo Comparator: control spray
- Self administration twice daily of intranasal spray that does not contain oxytocin.
Outcome Measures for this Clinical Trial
- PANSS total and subscores
- Time Frame: 6 week trial
Safety Issue?: No
- Time Frame: 6 week trial
- Social cognition, skill task performance and ratings of social functioning
- Time Frame: 6 week trial
Safety Issue?: No
- Time Frame: 6 week trial
Criteria for Participation in this Clinical Trial
- Meeting DSM-IV criteria for paranoid or undifferentiated schizophrenia for at least 1 year.
- Scoring > or equal to 4 on the suspiciousness/persecution (paranoia) subscale of the Positive and Negative Symptoms Scale (PANSS), a full PANSS score > or equal to 60: stability of symptom severity and on the same medication(s) and dose(s) for at least 1 month; low to moderate depressive symptoms.
- Low literacy as indicated by an inability to read and understand the consent form.
- Dependence on substances other than tobacco or caffeine.
- Positive urine drug screen for illegal substances or drugs that have not been prescribed.
- Debilitating medical conditions (including AIDS; HIV infection alone will not be grounds for exclusion).
- Major surgery or trauma in the past year will be grounds for exclusion although subjects determined to be recovered and stable may be included at the discretion of the PI.
- Pregnancy, breast-feeding.
- Having given birth in the past 6 months or breast-feeding in the past 3 months.
- Individuals judged unable to learn self-administration of intranasal treatments and/or not sufficiently reliable to do so will be excluded.
- Abnormalities found during medical evaluation will be grounds for exclusion although subjects with laboratory measures barely outside the normal range may be included at the discretion of the Principal Investigator.
Gender Eligibility for this Clinical Trial: Both
Minimum Age for this Clinical Trial: 18 Years
Maximum Age for this Clinical Trial: 55 Years
Are Healthy Volunteers Accepted for this Clinical Trial: No
Clinical Trial Investigator Information
- Lead Sponsor
- University of North Carolina, Chapel Hill
- Provider of Information About this Clinical Study
- Cort Andrew Pedersen, The University of North Carolina, Chapel Hill, Department of Psychiatry
- Overall Official(s)
- Cort A Pedersen, M.D., Principal Investigator, University of North Carolina, Chapel Hill