NeuroMark-SZ: A Holistic Resting-State-fMRI-Based Model for Divergent Functional Circuitry in Schizophrenia

Schizophrenia is a severe neuropsychiatric disorder. Efforts to describe the underlying biology and establish diagnostic markers through non-invasive neuroimaging methods are ongoing, resulting in a range of theoretical brain-based frameworks. Prominent frameworks for aberrant schizophrenia-associated functional connectivity in resting-state functional magnetic resonance imaging (rsfMRI) include the dysconnectivity hypothesis, theory of cognitive dysmetria, and triple network theory. Although informative, prior work can be improved by increasing sample size, avoiding confirmation bias, and accounting for individual variability and the effects of medication and chronicity. With these recommendations in mind, we employed a data-driven, whole-brain approach using a large multi-site rsfMRI dataset (N = 2,656; schizophrenia = 1,248). We used reference-guided independent component analysis (ICA) to generate subject-specific whole-brain functional network connectivity (FNC) and extract imaging markers of similarity to schizophrenia patterns. We modeled the relationship between medication dosage, age of onset, chronicity, symptom severity, and cognitive performance and FNC. Our analysis identified a reliable schizophrenia-FNC signature characterized by aberrantly stronger negative cerebellothalamic and positive thalamocortical connectivity, implicating sensory, motor, and associative cortical circuits. While medication and chronicity were significantly associated with these signatures, the core cerebellothalamic disruptions remained a robust marker of schizophrenia. This work represents the largest schizophrenia-focused rsfMRI study to date, refines existing theoretical frameworks with a more nuanced map of how clinical variables interact with brain connectivity, and provides a high-fidelity template of schizophrenia-related connectivity. We have released this template as an open-source resource to facilitate reproducibility and accelerate the development of reliable rsfMRI-based schizophrenia biomarkers.