A comprehensive review and model of putative prodromal features of bipolar affective disorder

BACKGROUND

Identifying prodromal features that predate the onset of bipolar disorder (BD) may enable the prevention of BD and aid early intervention. This review addresses two key questions: Is there a bipolar prodrome? And, if there is, what are its characteristic features?

METHOD

A comprehensive search of databases (PubMed, Medline, EMBASE and PsycINFO) supplemented by hand searches was used to identify studies of symptoms preceding the onset of BD.

RESULTS

Fifty-nine studies were identified, of which 14 met inclusion criteria. Symptoms can predate the onset of BD by months to years and can be categorized as attenuated forms of BD symptoms, general symptoms common to a range of mental disorders, and personality traits, particularly cyclothymia. Two studies provided sufficient data to enable sensitivity and specificity to be calculated. Specificity of several of the features was high (>90%) but sensitivity was generally low (all <60%). We propose a model based on the findings in the studies reviewed to illustrate the potential trajectory to BD and the points at which it may be possible to intervene.

CONCLUSIONS

Clinical features preceding the onset of BD can be identified. However, conclusions about whether there is a distinct prodrome to BD are restricted by the limitations of current evidence. The high specificity of some features suggests they may be useful in clinical practice. Large-scale longitudinal studies are needed to validate these features and characterize their specificity and sensitivity in independent samples.

Strategies for effective recruitment of individuals at risk for developing psychosis

AIM

Early identification of individuals in the prodrome and first episode of psychosis can lead to pre-emptive intervention and perhaps prevention of the significant functional decline that often accompanies a first psychotic episode. The development of an extensive community outreach and education campaign is essential for programmes that aim to identify and treat individuals in the early stages of psychotic illness.

METHODS

Over the last decade, the Cognitive Assessment and Risk Evaluation (CARE) programme at the University of California San Diego has implemented a recruitment strategy to increase public awareness about early psychosis and establish community collaboration in San Diego county. Educational materials were distributed to community partners, local media and via the Internet. The number and pattern of referrals were then analysed to inform ongoing recruitment efforts.

RESULTS

Overall, 799 referrals were telephone screened. Of the 313 who completed diagnostic interviews, 223 were enrolled including 122 in an 'At Risk' state and 101 in an early psychotic episode. The majority who met inclusion criteria were referred by outpatient mental health practitioners (46.6%), whereas 16.1% came from inpatient facilities and 16.1% were from Internet sites. Other important referral sources were the public schools, community colleges and the National Alliance on Mental Illness.

CONCLUSIONS

The successful recruitment efforts of the CARE programme reflect not only the extensive educational outreach but also the emphasis on enhancing professional relationships with community partners. The Internet became an important source of information and referrals and will likely be an essential component of any public education campaign.

Startle reactivity and prepulse inhibition in prodromal and early psychosis: effects of age, antipsychotics, tobacco and cannabis in a vulnerable population

The use of biomarkers in the study of the prodrome and first episode of psychosis provides a means of not only identifying individuals at greatest risk for psychosis but also understanding neurodevelopmental abnormalities early in the course of illness. Prepulse inhibition (PPI), a marker that is deficient in schizophrenia and after developmental manipulations in animal models, was assessed in 75 early psychosis (EP), 89 at risk (AR) for psychosis and 85 comparison subjects (CS) at baseline and 6 months. Consistent with findings in chronic schizophrenia, PPI was stable with repeated assessment and EP subjects had reduced PPI but this was most evident in tobacco smokers. A significant positive PPI and age association in AR and EP samples, but not CS, demonstrated potential neurodevelopmental differences in early psychosis. Unexpected findings included the fact that medication naive EP subjects, as well as AR subjects who later developed psychosis, had greater PPI, introducing the possibility of early compensatory changes that diverge from findings in chronic patients. In addition, subjects with a history of cannabis use had greater startle reactivity while EP and AR subjects who used cannabis and were also taking an antipsychotic had greater PPI, again highlighting the potentially important cannabis/psychosis association.

Prodromal symptoms in adolescents with 22q11.2 deletion syndrome and schizotypal personality disorder

Adolescents with 22q11.2 Deletion Syndrome (22q11.2DS) and Schizotypal Personality Disorder (SPD) are at increased risk for the development of psychosis based, respectively, on genetic or behavioral factors. Thus both groups would be expected to manifest heightened rates of the prodromal signs that typically precede psychosis. Although there are now standardized procedures for assessing prodromal symptoms, there has been little research on the manifestation of these symptoms in 22q11.2DS patients, and no studies of differences in prodromal symptom patterns between genetically and behaviorally defined at-risk groups. In this study, demographically matched groups of 23 SPD, 23 22q11.2DS, and 23 control participants were administered the Structured Interview for Prodromal Syndromes (SIPS). Both risk groups showed elevated positive, negative, disorganized, and general prodromal symptoms, as well as elevations on 10 of the same individual symptom items, relative to the control group. Approximately 60% of individuals in the 22q11.2DS group and 70% of individuals in the SPD group met symptom criteria for a prodromal psychosis syndrome. The 22q11.2DS group scored significantly higher than the SPD group on the "decreased ideational richness" item and showed a trend toward greater motor abnormalities. The results suggest that these two high-risk groups are similar in prodromal symptom presentation, possibly as a result of overlapping causal mechanisms, and that standardized measures of prodromal syndromes like the SIPS can be used to identify 22q11.2DS patients at greatest risk for conversion to psychosis.

Pre-illness cannabis use and the early course of nonaffective psychotic disorders: associations with premorbid functioning, the prodrome, and mode of onset of psychosis

INTRODUCTION

Limited research indicates that pre-illness cannabis use may result in an earlier age at onset of psychosis, though little is known about the influence of prior cannabis use on the premorbid and prodromal phases. This study examined the effects of prior or concurrent cannabis (as well as nicotine and alcohol) use on: (1) early adolescent (12-15 years) premorbid functioning, (2) late adolescent (16-18 years) premorbid functioning, (3) two features of the prodrome, and (4) mode of onset of psychosis.

METHODS

Participants included 109 well-characterized first-episode patients hospitalized in public-sector settings. Assessments included ages at initiation of first, weekly, and daily use of substances, the Premorbid Adjustment Scale, the Symptom Onset in Schizophrenia inventory, and a consensus-based best estimate of mode of onset.

RESULTS

Participants having used cannabis at ≤15 years had better early adolescence social functioning than those who had not used cannabis (p=0.02). Conversely, those who had used cannabis at ≤18 years had poorer late adolescence academic functioning (p<0.001). Participants having used cannabis before onset of psychotic symptoms did not differ from those who had not in terms of having had an identifiable prodrome or the number of prodromal symptoms experienced. Whereas 42% of those having used cannabis daily had an acute mode of onset of psychosis, only 20% of those without prior daily cannabis use had an acute onset (p=0.04).

CONCLUSIONS

Findings suggest that cannabis use is associated with premorbid social and academic functioning and mode of onset. Further research is warranted to elucidate the complex associations between cannabis use and diverse early-course features.

Self-reported coping strategies in families of patients in early stages of psychotic disorder: an exploratory study

AIM

Coping by families of patients with schizophrenia include 'approach' strategies considered to be adaptive (e.g. reinterpretation) and potentially maladaptive 'avoidant' strategies (denial/disengagement, use of alcohol and drugs). Little is known about coping strategies used by families of individuals with incipient or emergent psychosis.

METHODS

Self-reported coping styles were assessed in family members of 11 ultra high risk and 12 recent-onset psychosis patients, using a modified version of Carver's Coping Orientations to Problems Experienced questionnaire.

RESULTS

Families reported moderate use of 'approach' coping (e.g. planning, seeking social support, positive reinterpretation, acceptance and turning to religion) and rare use of 'avoidant' coping strategies (denial/disengagement and use of alcohol and drugs).

CONCLUSIONS

The greater endorsement of 'approach' coping by these families is consistent with findings for families of first episode psychosis patients, and it is in contrast to more prevalent 'avoidant' coping by families of patients with more chronic psychotic illness. Early intervention could plausibly help families maintain the use of potentially more adaptive 'approach' coping strategies over time.

Neuropsychological profiles in individuals at clinical high risk for psychosis: relationship to psychosis and intelligence

BACKGROUND

Characterizing neuropsychological (NP) functioning of individuals at clinical high risk (CHR) for psychosis may be useful for prediction of psychosis and understanding functional outcome. The degree to which NP impairments are associated with general cognitive ability and/or later emergence of full psychosis in CHR samples requires study with well-matched controls.

METHODS

We assessed NP functioning across eight cognitive domains in a sample of 73 CHR youth, 13 of whom developed psychotic-level symptoms after baseline assessment, and 34 healthy comparison (HC) subjects. Groups were matched on age, sex, ethnicity, handedness, subject and parent grade attainment, and median family income, and were comparable on WRAT-3 Reading, an estimate of premorbid IQ. Profile analysis was used to examine group differences and the role of IQ in profile shape.

RESULTS

The CHR sample demonstrated a significant difference in overall magnitude of NP impairment but only a small and nearly significant difference in profile shape, primarily due to a large impairment in olfactory identification. Individuals who subsequently developed psychotic-level symptoms demonstrated large impairments in verbal IQ, verbal memory and olfactory identification comparable in magnitude to first episode samples.

CONCLUSIONS

CHR status may be associated with moderate generalized cognitive impairments marked by some degree of selective impairment in olfaction and verbal memory. Impairments were greatest in those who later developed psychotic symptoms. Future study of olfaction in CHR samples may enhance early detection and specification of neurodevelopmental mechanisms of risk.

Comparing clinical and neurocognitive features of the schizophrenia prodrome to the bipolar prodrome

BACKGROUND

There is an increased interest in early intervention strategies for severe mental disorders with hopes of mitigating the emergence and impact of the illness. Individuals at clinical high-risk (CHR) for schizophrenia have been primarily identified by the presence of attenuated positive symptoms. Although bipolar disorder and schizophrenia may have overlapping etiologies, few studies have investigated the potential prodrome in bipolar disorder. We sought to determine if there is a prodrome to bipolar disorder and if clinical or neurocognitive measures could distinguish between the bipolar and schizophrenia prodromes.

METHODS

We examined subjects who were initially identified as CHR for schizophrenia during the prodromal phase of the illness and followed them prospectively. Unexpectedly, eight subjects developed bipolar disorder. Baseline data from subjects who eventually developed bipolar disorder (pre-BP; N=8), schizophrenia or a psychotic disorder (pre-SZ; N=24) and a non-converter comparison group (NCC; N=115) were compared.

RESULTS

The pre-BP and pre-SZ groups did not differ on attenuated positive symptom severity, global measures of functioning or on the global neurocognitive score. Compared to NCC individuals, both pre-BP and pre-SZ patients reported more severe attenuated positive symptoms and were more likely to be on antipsychotic medication at baseline. The pre-SZ group had a significantly lower current IQ and was significantly more impaired than the NCC group on the overall neurocognitive score.

CONCLUSIONS

This study provides preliminary support for a bipolar prodrome, which may be indistinguishable from the schizophrenia prodrome based on clinical and neurocognitive measures currently used in high-risk schizophrenia programs.

Treatment history in the psychosis prodrome: characteristics of the North American Prodrome Longitudinal Study Cohort

AIM

Early identification and better characterization of the prodromal phase of psychotic illness can lead to targeted treatment and, perhaps, prevention of many of the devastating effects of a first psychotic episode. The primary aim of this manuscript is to describe the treatment histories of a large cohort of individuals who entered into one of seven prodromal research programs in a North American Prodrome Longitudinal Study consortium.

METHODS

Treatment histories from 372 clinical high-risk subjects are described along with demographic, symptom, diagnostic and functional variables that may have contributed to treatment decisions for this group of individuals.

RESULTS

Of all subjects included, 82.1% had received psychosocial and/or pharmacologic treatment prior to entry. Psychosocial interventions were more common in the attenuated psychotic syndrome prodromal sample, especially those with more negative, disorganized or general symptoms and more impaired functioning. Psychotropic medication had been administered to individuals with a history of Axis I disorders.

CONCLUSIONS

Given the many potential clinical presentations, treatments and ethical issues connected with the psychosis-risk syndrome, it is not surprising that clinicians administered a broad range of interventions to study participants prior to their entry into the various research programs. Those individuals with milder and non-specific symptoms were more likely to have received psychosocial treatments, whereas those with more severe symptoms received pharmacologic intervention. Clinical treatment research is needed that addresses the complexities of these psychosis-risk states and helps to specify appropriate treatment at different stages of the psychosis prodrome.

"Excessive thinking" as explanatory model for schizophrenia: impacts on stigma and "moral" status in Mainland China

Although psychiatric stigma in China is particularly pervasive and damaging, rates of high expressed emotion ("EE" or family members' emotional attitudes that predict relapse) are generally lower than rates found in Western countries. In light of this seemingly incongruous juxtaposition and because Chinese comprise approximately one-fifth of the world's mentally ill, we examine how one of the most widely held causal beliefs of schizophrenia--excessive thinking (xiang tai duo)--may powerfully shape how those exhibiting psychotic symptoms pass from "normal" status to stigmatized "other." Using a framework by which stigma threatens an actor's capacity to participate in core everyday engagements, we examine how expressions of excessive thinking intersect with psychotic symptoms and how this idiom reduces stigma by preserving essential moral standing. Four focus groups with family members (n = 34 total) of schizophrenia outpatients, who had participated in psychoeducation, were conducted in Beijing. Open coding was conducted by 2 bilingual coders achieving high interrater agreement. Common expressions of excessive thinking--taking things too hard that is perceived as a causal factor and unwarranted suspicion that is used to benignly interpret paranoid symptoms encapsulated disruptive behaviors that closely overlapped with psychotic symptoms. Because excessive thinking is understood to occur universally, this idiom encourages socially accommodating behavior that signifies acceptance of these individuals as full-status community members. In contrast, due to beliefs implying moral contamination, those labeled mentally ill are threatened with both subtle and outright social exclusion. We discuss implications of this idiom for EE and the detection of schizophrenia "prodrome" in China.

The psychosis risk syndrome and its proposed inclusion in the DSM-V: a risk-benefit analysis

The inclusion of a psychosis risk syndrome has been proposed for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. The appropriateness of inclusion of this new risk syndrome in the DSM depends on a careful analysis of both anticipated benefits and risks. Purported benefits include early recognition and case identification, and the hypothetical benefit of preventive intervention of psychotic disorders, for which there is as yet no clear evidence base. However, there is a potential for high rates of false positives particularly at the community level given the difficulty in discriminating mild symptoms from normal variants and low base rates of the syndrome in the general population. High false-positive rates in and of themselves are not necessarily problematic if the risk-benefit ratio is significantly favorable, as with screening for cardiovascular risk factors. For the psychosis risk syndrome, by contrast, there are substantial risks, for both stigma and discrimination, and for unnecessary exposure to antipsychotic medications, which make the high false-positive rate associated with the psychosis risk designation particularly problematic. More research is needed to improve the positive predictive value of the psychosis risk syndrome so that it can be considered for inclusion in future editions of the DSM.

Markers of basal ganglia dysfunction and conversion to psychosis: neurocognitive deficits and dyskinesias in the prodromal period

BACKGROUND

Movement abnormalities and cognitive deficits may represent external markers of an underlying neural process linked with the early etiology of psychosis. As basal ganglia function plays a governing role in both movement and cognitive processes, an understanding of the relationship between these phenomena stands to inform etiologic conceptualizations of vulnerability and psychotic disorders.

METHODS

In this investigation, trained raters coded movement abnormalities in videotapes from structured interviews of adolescents and young adults with a prodromal risk syndrome (n = 90). The participants were administered a neuropsychological battery including measures of verbal comprehension, perceptual organization, immediate/delayed auditory memory, and an estimate of full-scale intelligence quotient. Diagnostic status was followed for a 2-year period utilizing structured clinical interviews, during which time 24 high-risk participants (26.66%) converted to an Axis I psychotic disorder.

RESULTS

Elevated dyskinetic movements in the upper-body region were correlated with deficits in domains of verbal comprehension, perceptual organization, and both immediate and delayed auditory memory. Further, discriminant function analyses indicated that baseline movement abnormalities and neurocognitive deficits significantly classified those high-risk participants who would eventually convert to a psychotic disorder (72.3%).

CONCLUSIONS

Results support a common cortico-striato-pallido-thalamic circuit irregularity, underlying both movement abnormalities and cognitive deficits in individuals at high risk for psychosis. Models incorporating external markers of progressive basal ganglia dysfunction may enhance detection and preventive intervention for those high-risk individuals most in need of treatment.

Potential stigma associated with inclusion of the psychosis risk syndrome in the DSM-V: an empirical question

While the "clinical high-risk state" for psychosis has demonstrated good reliability and fair predictive validity for psychotic disorders, over 50% of identified subjects do not progress to psychosis. Despite the benefits that early detection and treatment might offer, debate concerning the official inclusion of a "psychosis risk syndrome" in the upcoming DSM-V frequently involves concerns about the impact of stigma on patients, families and institutions. We add to this debate by providing an analysis of the theoretical and empirical stigma literature to evaluate the potential effects of stigma associated with the psychosis risk syndrome. Theorists' conceptualizations of how stigma exerts its negative effects emphasize internalization of pejorative societal stereotypes ('self-stigma'), negative emotional reactions, harmful behavioral coping strategies, and structural discrimination as key mechanisms. Studies assessing the comparative effects of symptomatic behavior when compared with a psychiatric diagnosis label in predicting rejecting social attitudes indicate that treating symptomatic behaviors is likely to diminish overall stigma. However, any publically held 'preexisting conceptions' about what a psychosis risk syndrome means are still likely to exert negative effects. Additionally, particular features of this syndrome--that it occurs during adolescence when identity formation may be in flux--may also shape manifestations of stigma. Utilizing other well-established 'at-risk' conditions (e.g., genetic susceptibility) to model potential discrimination for this syndrome, we suggest that future discrimination is likely to occur in insurance and family domains. We conclude by proposing stigma measurement strategies, including recommending that field trials prior to DSM-V adopt systematic measures to assess any stigma that this psychosis risk syndrome might confer via future community use.

Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis

The current study examined the relationship between the family environment and symptoms and functioning over time in a group of adolescents and young adults at clinical high risk for psychosis (N=63). The current study compared the ability of interview-based versus self-report ratings of the family environment to predict the severity of prodromal symptoms and functioning over time. The family environmental factors were measured by interviewer ratings of the Camberwell Family Interview (CFI), self-report questionnaires surveying the patient's perceptions of criticism and warmth, and parent reported perceptions of their own level of criticism and warmth. Patients living in a critical family environment, as measured by the CFI at baseline, exhibited significantly worse positive symptoms at a 6-month follow-up, relative to patients living in a low-key family environment. In terms of protective effects, warmth and an optimal level of family involvement interacted such that the two jointly predicted improved functioning at the 6-month follow-up. Overall, both interview-based and self-report ratings of the family environment were predictive of symptoms and functioning at follow-up; however patient's self-report ratings of criticism had stronger predictive power. These results suggest that the family environment should be a specific target of treatment for individuals at risk for psychosis.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.

Sex differences in Wisconsin Schizotypy Scales--a meta-analysis

Previous single studies have found inconsistent results on sex differences in positive schizotypy, women scoring mainly higher than men, whereas in negative schizotypy studies have often found that men score higher than women. However, information on the overall effect is unknown. In this study, meta-analytic methods were used to estimate sex differences in Wisconsin Schizotypy Scales developed to measure schizotypal traits and psychosis proneness. We also studied the effect of the sample characteristics on possible differences. Studies on healthy populations were extensively collected; the required minimum sample size was 50. According to the results, men scored higher on the scales of negative schizotypy, ie, in the Physical Anhedonia Scale (n = 23 studies, effect size, Cohen d = 0.59, z test P < .001) and Social Anhedonia Scale (n = 14, d = 0.44, P < .001). Differences were virtually nonexistent in the measurements of the positive schizotypy, ie, the Magical Ideation Scale (n = 29, d = -0.01, P = .74) and Perceptual Aberration Scale (n = 22, d = -0.08, P = .05). The sex difference was larger in studies with nonstudent and older samples on the Perceptual Aberration Scale (d = -0.19 vs d = -0.03, P < .05). This study was the first one to pool studies on sex differences in these scales. The gender differences in social anhedonia both in nonclinical samples and in schizophrenia may relate to a broader aspect of social and interpersonal deficits. The results should be taken into account in studies using these instruments.

The relation of antipsychotic and antidepressant medication with baseline symptoms and symptom progression: a naturalistic study of the North American Prodrome Longitudinal Sample

A substantial number of patients who meet criteria for a prodromal syndrome for first psychosis are treated with antipsychotic and/or antidepressant medications. There is suggestive evidence that both classes of medication may reduce prodromal symptoms. This longitudinal study examined the relation of antipsychotic and antidepressant medication with prodromal symptom severity at baseline and 6-month follow-up. Participants met Structured Interview for Prodromal Syndromes (SIPS) criteria for the prodrome, and were evaluated at eight centers as part of the North American Prodrome Longitudinal Study (NAPLS). Symptom ratings (positive, negative, disorganized and general) and data on antipsychotics, SSRIs, and other antidepressant medications were obtained at baseline and 6-month follow-up. Analyses revealed that all symptom dimensions declined in severity over time, but there were differences in the magnitude of the decline as a function of antipsychotic medication. Those never on antipsychotics showed less reduction in positive and disorganized symptoms over time. SSRIs and other antidepressants were not linked with declines in symptom severity. Consistent with findings from small-sample, clinical trials, the present results suggest that atypical antipsychotics may be effective in reducing the severity of attenuated positive symptoms associated with the prodrome to psychotic disorders. Limitations of the present study are noted, including the fact that it is not a randomized trial, and data on duration and dosage of medication and 2-year follow-up were not available for most participants. The results are discussed in light of the relative risks and benefits of preventive interventions, both medication and cognitive therapies, and the importance of future clinical trials.

Association of pre-onset cannabis, alcohol, and tobacco use with age at onset of prodrome and age at onset of psychosis in first-episode patients

OBJECTIVE

Several reports suggest that cannabis use is associated with an earlier age at onset of psychosis, although not all studies have operationalized cannabis use as occurring prior to onset of symptoms. This study addressed whether pre-onset cannabis use, alcohol use, and tobacco use are associated with an earlier age at onset of prodromal and psychotic symptoms. Effects of the progression of frequency of use were examined through time-dependent covariates in survival analyses.

METHOD

First-episode patients (N=109) hospitalized in three public-sector inpatient psychiatric units underwent in-depth cross-sectional retrospective assessments. Prior substance use and ages at onset of prodromal and psychotic symptoms were determined by standardized methods, and analyses were conducted using Cox regression modeling.

RESULTS

Whereas classifying participants according to maximum frequency of use prior to onset (none, ever, weekly, or daily) revealed no significant effects of cannabis or tobacco use on risk of onset, analysis of change in frequency of use prior to onset indicated that progression to daily cannabis and tobacco use was associated with an increased risk of onset of psychotic symptoms. Similar or even stronger effects were observed when onset of illness or prodromal symptoms was the outcome. A gender-by-daily-cannabis-use interaction was observed; progression to daily use resulted in a much larger increased relative risk of onset of psychosis in females than in males.

CONCLUSIONS

Pre-onset cannabis use may hasten the onset of psychotic as well as prodromal symptoms. Age at onset is a key prognostic factor in schizophrenia, and discovering modifiable predictors of age at onset is crucial.

White matter integrity and prediction of social and role functioning in subjects at ultra-high risk for psychosis

BACKGROUND

White matter microstructural disruptions have been observed in patients with schizophrenia. However, whether changes exist prior to disease onset or in high-risk individuals is unclear. Here, we investigated white matter integrity, as assessed by diffusion tensor imaging (DTI), in individuals at ultra-high risk for psychosis (UHR) relative to healthy control subjects (HC) and the relationship between baseline DTI measures and functional outcome over time.

METHODS

Thirty-six UHR participants and 25 HCs completed baseline DTI scans. Subjects also completed clinical follow-up assessments approximately 6 months (26 subjects) and 15 months (13 subjects) later. We used a rigorous registration approach (Tract-Based Spatial Statistics [TBSS]) to examine fractional anisotropy (FA) in six major white matter tracts.

RESULTS

Relative to the HC group, UHR subjects showed lower baseline FA in the superior longitudinal fasciculus, the major frontoparietal white matter connection. Cross-sectional analyses demonstrated that UHR youth failed to show the same age-associated increases in FA in the medial temporal lobe (MTL) and inferior longitudinal fasciculus as HCs. Finally, lower baseline FA in the MTL and inferior longitudinal fasciculus predicted deterioration in social and role functioning in UHR participants at 15-month follow-up.

CONCLUSIONS

This is the first investigation of white matter microstructural alterations in a clinical high-risk sample. Our findings indicate that white matter development may be altered in youth at risk for psychosis, possibly due to disrupted developmental mechanisms, and further, that white matter integrity may be predictive of functional outcome.

Who is at risk for a psychotic disorder?

Accurate assessment of the individual risk for psychotic disorders has great value. We need to determine the reliability and rate of conversion to a psychotic disorder in clinical samples before we can recommend a risk syndrome diagnosis for general practice. The assessment of risk carries its own risks, including stigmatization and inappropriate treatment, potentially leading to adverse outcomes.

Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study

Treatment and prevention studies over the past decade have enrolled patients believed to be at risk for future psychosis. These patients were considered at risk for psychosis by virtue of meeting research criteria derived from retrospective accounts of the psychosis prodrome. This study evaluated the diagnostic validity of the prospective "prodromal risk syndrome" construct. Patients assessed by the Structured Interview for Prodromal Syndromes as meeting criteria of prodromal syndromes (n = 377) from the North American Prodrome Longitudinal Study were compared with normal comparison (NC, n = 196), help-seeking comparison (HSC, n = 198), familial high-risk (FHR, n = 40), and schizotypal personality disorder (SPD, n = 49) groups. Comparisons were made on variables from cross-sectional demographic, symptom, functional, comorbid diagnostic, and family history domains of assessment as well as on follow-up outcome. Prodromal risk syndrome patients as a group were robustly distinguished from NC subjects across all domains and distinguished from HSC subjects and from FHR subjects on most measures in many of these domains. Adolescent and young adult SPD patients, while distinct from prodromal patients on definitional grounds, were similar to prodromals on multiple measures, consistent with SPD in young patients possibly being an independent risk syndrome for psychosis. The strong evidence of diagnostic validity for the prodromal risk syndrome for first psychosis raises the question of its evaluation for inclusion in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).

When does cognitive decline occur in the period prior to the first episode of schizophrenia?

Cognitive impairment is common in people with schizophrenia. These impairments are detectable prior to any signs of illness in people who are destined to develop the disease and they are as severe at the time of the first psychotic episode as they are after many years of illness. It was formerly believed that the major decline from the minor impairments seen in childhood to those seen at the time of the first episode occurred during the prodrome. Recent data suggests that there is little cognitive decline during the prodrome and that at the detection of the prodrome, decline has already occurred. Thus, the period of cognitive decline must be very early in the prodrome to psychosis.

Olfactory identification in young relatives at risk for schizophrenia

OBJECTIVE

Olfactory identification deficits (OIDs) are seen in schizophrenia, but it is unclear whether they are state- or trait-related.

METHODS

We examined the prevalence of OIDs, as assessed by the University of Pennsylvania Smell Identification Test (UPSIT), and their correlations with prodromal symptoms in young relatives at risk for schizophrenia or schizoaffective disorder (HR-S).

RESULTS

UPSIT scores were lower in HR- S than in healthy controls, but were non-significant after covarying the effects of age, gender and IQ. OID deficits in HR-S were correlated, after covarying out the effects of age and IQ, with prodromal disorganisation.

CONCLUSION

The potential value of OID deficits as markers of psychopathological vulnerability in young relatives at risk for schizophrenia deserves further investigation.

Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis

AIM

Stigma is pervasive among families of individuals with psychotic disorders and includes both general and 'associative' stigma - that is, the process by which a person is stigmatized by virtue of association with another stigmatized individual. These forms of stigma may present a barrier to help seeking. However, little is known about stigma in the early stages of evolving psychotic disorder.

METHODS

Family members of 11 individuals at clinical high risk and of nine patients with recent-onset psychosis were evaluated for generalized and associative stigma using the Opinions about Mental Illness (modified) and the Family Experiences Interview Schedule.

RESULTS

In this small study, the level of stigma was low, as families endorsed many supportive statements, for example, patients should be encouraged to vote, patients want to work, mental illness should be protected legally as a disability and parity should exist in insurance coverage. Families also endorsed that both talking and a belief in God and prayer can help someone get better. Only ethnic minority families of individuals with recent-onset psychosis endorsed a sense of shame and need to conceal the patient's illness.

CONCLUSIONS

This preliminary study suggests that family stigma is low in the early stages of psychotic disorder, a finding that requires further investigation in a larger and more representative sample. This may be an opportune time to engage young people and families, so as to reduce duration of untreated illness. Ethnic differences in stigma, if replicated, highlight the need for cultural sensitivity in engaging individuals and their families in treatment.

Obsessive compulsive symptoms in the psychosis prodrome: correlates of clinical and functional outcome

OBJECTIVES

Obsessive-Compulsive Disorder (OCD) is a common co-morbid condition in schizophrenia, associated with poor prognosis. However, the prevalence of obsessive compulsive symptomatology (OCS) and its relationship to outcome has not been evaluated in adolescents at ultra high-risk for psychosis (UHR).

METHODS

Sixty-four UHR and 26 non-prodromal comparison (NPC) youth were ascertained using the Structured Interview for Prodromal Syndromes (SIPS). Participants completed diagnostic interviews and the Padua Inventory (Sanavio, E., 1988. Obsessions and compulsions: the Padua Inventory. Behav. Res. Ther. 26, 169-177.), a self-report measure of OCS.

RESULTS

UHR youth reported significantly higher rates of OCS on the Padua Inventory compared to NPC youth. Clinical diagnosis of OCD (20% of sample) was associated with lower risk of conversion to psychosis over the follow-up period, but was unrelated to clinical severity or psychosocial functioning. However, dimensional ratings of OCS were significantly associated with positive symptom severity, self-reported depression, and a trend toward increased suicidal ideation within the UHR sample.

CONCLUSIONS

OCS rates in UHR youth are well above estimated prevalence rates in normal populations, and commensurate with rates of comorbidity observed in schizophrenia. Although clinical diagnosis of OCD was not associated with later conversion to psychosis, OCS severity in UHR youth was associated with more acute symptomatic presentation, including more severe depression and suicidality.