Intensive Auditory Cognitive Training Improves Verbal Memory in Adolescents and Young Adults at Clinical High Risk for Psychosis

OBJECTIVE

Individuals at clinical high risk (CHR) for psychosis demonstrate cognitive impairments that predict later psychotic transition and real-world functioning. Cognitive training has shown benefits in schizophrenia, but has not yet been adequately tested in the CHR population.

METHODS

In this double-blind randomized controlled trial, CHR individuals (N = 83) were given laptop computers and trained at home on 40 hours of auditory processing-based exercises designed to target verbal learning and memory operations, or on computer games (CG). Participants were assessed with neurocognitive tests based on the Measurement and Treatment Research to Improve Cognition in Schizophrenia initiative (MATRICS) battery and rated on symptoms and functioning. Groups were compared before and after training using a mixed-effects model with restricted maximum likelihood estimation, given the high study attrition rate (42%).

RESULTS

Participants in the targeted cognitive training group showed a significant improvement in Verbal Memory compared to CG participants (effect size = 0.61). Positive and Total symptoms improved in both groups over time.

CONCLUSIONS

CHR individuals showed patterns of training-induced cognitive improvement in verbal memory consistent with prior observations in schizophrenia. This is a particularly vulnerable domain in individuals at-risk for psychosis that predicts later functioning and psychotic transition. Ongoing follow-up of this cohort will assess the durability of training effects in CHR individuals, as well as the potential impact on symptoms and functioning over time. Clinical Trials Number: NCT00655239. URL: https://clinicaltrials.gov/ct2/show/NCT00655239?term=vinogradov&rank=5.

Resilience in individuals at clinical high risk for psychosis

AIMS

It has been suggested that resilience may be a protective factor with respect to mental illness. This may be an important factor for those who are vulnerable to psychiatric illness. Thus, the aims of this paper were to compare levels of resilience between individuals at clinical high risk (CHR) for psychosis and healthy controls, and to examine associations between resilience and clinical measures, functioning and trauma of CHR participants.

METHODS

Eighty participants, 40 CHR and 40 University of Calgary undergraduate students, completed two resilience questionnaires: the Connor-Davidson Resilience Scale and the Child and Youth Resilience Measure.

RESULTS

A t-test revealed a significant difference between the groups on levels of resilience (t = 4.34, P < 0.01), demonstrating that CHR participants have lower levels of resilience than healthy controls. In terms of the associations between resilience and measures of mental health of CHR participants, it was found that higher levels of resilience were related to lower negative symptoms, depression and anxiety. Furthermore, resilient CHR participants showed higher levels of role functioning and generally reported higher positive schemas of self and others, as well as lower stress to reported life events. No associations were found between resilience and attenuated psychotic symptoms, social functioning, IQ and trauma.

CONCLUSIONS

The results of the current study suggest that resilience may be beneficial to other mental issues present in CHR individuals but this may not be the case for attenuated psychotic symptoms.

Distress in relation to attenuated psychotic symptoms in the ultra-high-risk population is not associated with increased risk of psychotic disorder

AIM

The 'ultra-high-risk' criteria identify a clinical population at substantially increased risk for progressing to schizophrenia and other psychotic disorders. Although a number of clinical variables predictive of transition to psychotic disorder have been identified within this population, the predictive value of the level of distress associated with attenuated psychotic symptoms has not yet been examined. This was the aim of the present study.

METHOD

The level of distress (0-100) associated with attenuated psychotic symptoms was recorded for 70 ultra-high-risk (UHR) patients using the Comprehensive Assessment of At-Risk Mental State (CAARMS). Transition to psychosis was assessed over a 16-month follow-up period.

RESULTS

Of the 70 UHR patients, 15 transitioned to psychosis (21.4%). Of the four CAARMS subscales measuring attenuated positive symptoms, Perceptual Abnormalities was rated as the most distressing. There were no differences in CAARMS scales rated as the most distressing between those who transitioned to psychosis and those who did not. There was also no association between higher levels of distress associated with attenuated psychotic symptoms and transition to psychosis.

CONCLUSION

Although the findings require replication, they indicate that the degree of distress associated with attenuated psychotic symptoms should not be used as a criterion for enriching UHR samples for risk of frank psychotic disorder.

Stress Sensitivity, Aberrant Salience, and Threat Anticipation in Early Psychosis: An Experience Sampling Study

While contemporary models of psychosis have proposed a number of putative psychological mechanisms, how these impact on individuals to increase intensity of psychotic experiences in real life, outside the research laboratory, remains unclear. We aimed to investigate whether elevated stress sensitivity, experiences of aberrant novelty and salience, and enhanced anticipation of threat contribute to the development of psychotic experiences in daily life. We used the experience sampling method (ESM) to assess stress, negative affect, aberrant salience, threat anticipation, and psychotic experiences in 51 individuals with first-episode psychosis (FEP), 46 individuals with an at-risk mental state (ARMS) for psychosis, and 53 controls with no personal or family history of psychosis. Linear mixed models were used to account for the multilevel structure of ESM data. In all 3 groups, elevated stress sensitivity, aberrant salience, and enhanced threat anticipation were associated with an increased intensity of psychotic experiences. However, elevated sensitivity to minor stressful events (χ(2)= 6.3,P= 0.044), activities (χ(2)= 6.7,P= 0.036), and areas (χ(2)= 9.4,P= 0.009) and enhanced threat anticipation (χ(2)= 9.3,P= 0.009) were associated with more intense psychotic experiences in FEP individuals than controls. Sensitivity to outsider status (χ(2)= 5.7,P= 0.058) and aberrantly salient experiences (χ(2)= 12.3,P= 0.002) were more strongly associated with psychotic experiences in ARMS individuals than controls. Our findings suggest that stress sensitivity, aberrant salience, and threat anticipation are important psychological processes in the development of psychotic experiences in daily life in the early stages of the disorder.

Comparison of measures of functioning for use with treatment-seeking adolescents experiencing attenuated symptoms of psychosis

AIM

A growing body of research documents a relation between psychosis risk and functional impairment. Although a general picture of psychosis risk and impaired functioning is emerging, less is known about how different functional measures relate to specific psychosis-risk symptoms.

METHODS

The current study examines the relative contribution of psychosis-risk symptoms across multiple measures of functioning in a sample of treatment-seeking adolescents and young adults.

RESULTS

Results indicate that different domains of psychosis-risk symptoms (negative and positive psychotic symptoms, related affective symptoms) contribute differentially to measures of different types of functioning.

CONCLUSION

Study of the relation between psychosis-risk symptoms and different measures of functional impairment can potentially contribute towards a more efficient use of measures of functioning and help inform individualized treatment considerations.

INCREASED INTERNET USE AND POORER ABILITY TO MANAGE EMOTIONS IN YOUTH AT HIGH-RISK FOR PSYCHOSIS

The relationship between Internet use and social behavior remains unknown. However, research indicates that Internet use (IU) may have some causal role in certain types of psychopathology and overall functioning. In contrast, other work suggests that IU may be protective and buffer against social isolation. Poorer emotional processing (EP) is characteristic of schizophrenia, and these deficits are present prior to illness onset (the ultra high-risk period (UHR)). UHR adolescents/young adults also fall within an age demographic characterized by extensive IU, which suggests that evaluating a link between IU and social behavior in this population may be especially informative. The present study examined the relationship between IU and emotional processing in 98 adolescents/young adults (52 UHR youth and 46 controls). UHR youth exhibited greater problematic IU (β = − 6.49, F(1,95) = 8.79, p = 0.002) and social withdrawal/problems resulting from this use (β = − 3.23, F(1,95) = 11.43, p < 0.001), as well deficits in emotional processing in comparison to healthy peers (β = 4.59, F(1,94) = 5.52, p = 0.011). Furthermore, the social problems resulting from IU were significantly related to the ability to process emotional information in the UHR group (β = − 0.51, t(1,48) = − 2.10, p = 0.021). UHR youth showed evidence of problematic IU relative to controls, and the social problems resulting from IU related to poorer EP. Findings replicate extant research involving other psychosis risk populations, while adding information regarding how social processes may relate to IU.

Childhood maltreatment and transition to psychotic disorder independently predict long-term functioning in young people at ultra-high risk for psychosis

BACKGROUND

Individuals identified as at ultra-high risk (UHR) for psychosis are at risk of poor functional outcome regardless of development of psychotic disorder. Studies examining longitudinal predictors of poor functioning have tended to be small and report only medium-term follow-up data. We sought to examine clinical predictors of functional outcome in a long-term longitudinal study.

METHOD

Participants were 268 (152 females, 116 males) individuals identified as UHR 2-14 years previously. A range of clinical and sociodemographic variables were assessed at baseline. Functioning at follow-up was assessed using the Social and Occupational Functioning Assessment Scale (SOFAS).

RESULTS

Baseline negative symptoms, impaired emotional functioning, disorders of thought content, low functioning, past substance use disorder and history of childhood maltreatment predicted poor functioning at follow-up in univariate analyses. Only childhood maltreatment remained significant in the multivariate analysis (p < 0.001). Transition to psychosis was also significantly associated with poor functioning at long-term follow-up [mean SOFAS score 59.12 (s.d. = 18.54) in the transitioned group compared to 70.89 (s.d. = 14.00) in the non-transitioned group, p < 0.001]. Childhood maltreatment was a significant predictor of poor functioning in both the transitioned and non-transitioned groups.

CONCLUSIONS

Childhood maltreatment and transition to psychotic disorder independently predicted poor long-term functioning. This suggests that it is important to assess history of childhood maltreatment in clinical management of UHR individuals. The finding that transition to psychosis predicts poor long-term functioning strengthens the evidence that the UHR criteria detect a subgroup at risk for schizophrenia.

Perceptions of family criticism and warmth and their link to symptom expression in racially/ethnically diverse adolescents and young adults at clinical high risk for psychosis

AIM

Little is known about the role of expressed emotion (EE) in early symptom expression in individuals at clinical high risk (CHR) for psychosis. In patients with established schizophrenia, the effects of EE on clinical outcomes have purportedly varied across racial/ethnic groups, but this has not yet been investigated among CHR patients. Furthermore, studies have traditionally focused upon caregiver levels of EE via interview-based ratings, whereas the literature on patient perceptions of caregiver EE on psychosis symptoms is relatively limited.

METHODS

Linear regression models were conducted to examine the impact of criticism and perceived warmth in the family environment, from the CHR patient's perspective, on positive and negative symptom expression in non-Latino white (NLW; n = 38) and Latino (n = 11) adolescents and young adults at CHR for developing psychosis.

RESULTS

Analyses examining the sample as a whole demonstrated that perceived levels of maternal criticism were negatively associated with negative CHR symptomatology. Additional analyses indicated that race/ethnicity moderated the relationship between criticism/warmth and clinical symptomatology. We found evidence of a contrasting role of patient perceived criticism and warmth depending upon the patient's race/ethnicity.

CONCLUSION

Family processes shown to impact the course of schizophrenia among NLWs may function differently among Latino than NLW patients. These findings have important implications for the development of culturally appropriate interventions and may aid efforts to improve the effectiveness of mental health services for diverse adolescents and young adults at CHR for psychosis. Given the small sample size of this study, analyses should be replicated in a larger study before more definitive conclusions can be made.

Reinforcement Learning Performance and Risk for Psychosis in Youth

Early identification efforts for psychosis have thus far yielded many more individuals "at risk" than actually develop psychotic illness. Here, we test whether measures of reinforcement learning (RL), known to be impaired in chronic schizophrenia, are related to the severity of clinical risk symptoms. Because of the reliance of RL on dopamine-rich frontostriatal systems and evidence of dopamine system dysfunction in the psychosis prodrome, RL measures are of specific interest in this clinical population. The current study examines relationships between psychosis risk symptoms and RL task performance in a sample of adolescents and young adults (n = 70) receiving mental health services. We observed significant correlations between multiple measures of RL performance and measures of both positive and negative symptoms. These results suggest that RL measures may provide a psychosis risk signal in treatment-seeking youth. Further research is necessary to understand the potential predictive role of RL measures for conversion to psychosis.

Negative symptoms and impaired social functioning predict later psychosis in Latino youth at clinical high risk in the North American prodromal longitudinal studies consortium

AIM

Examining ethnically related variables in evaluating those at risk for psychosis is critical. This study investigated sociodemographic and clinical characteristics of Latino versus non-Latino clinical high-risk (CHR) subjects and healthy control (HC) subjects in the first North American Prodrome Longitudinal Study.

METHODS

Fifty-six Latino CHR subjects were compared to 25 Latino HC and 423 non-Latino CHR subjects across clinical and demographic variables. Thirty-nine of the 56 CHR subjects completed at least one subsequent clinical evaluation over the 2.5-year period with 39% developing a psychotic illness. Characteristics of Latino CHR subjects who later converted to psychosis ('converters') were compared to those who did not ('non-converters').

RESULTS

Latino CHR subjects were younger than non-Latino CHR subjects and had less education than Latino HC subjects and non-Latino CHR counterparts. Latino CHR converters had higher scores than Latino non-converters on the Structured Interview for Prodromal Syndromes total negative symptoms that were accounted for by decreased expression of emotion and personal hygiene/social attentiveness subsections. Latino CHR converters scored lower on the global functioning:social scale, indicating worse social functioning than Latino non-converters.

CONCLUSION

Based on this sample, Latino CHR subjects may seek treatment earlier and have less education than non-Latino CHR subjects. Deficits in social functioning and impaired personal hygiene/social attentiveness among Latino CHR subjects predicted later psychosis and may represent important areas for future study. Larger sample sizes are needed to more thoroughly investigate the observed ethnic differences and risk factors for psychosis in Latino youth.

Neurophysiological differences between patients clinically at high risk for schizophrenia and neurotypical controls--first steps in development of a biomarker

BACKGROUND

Schizophrenia is a severe, disabling and prevalent mental disorder without cure and with a variable, incomplete pharmacotherapeutic response. Prior to onset in adolescence or young adulthood a prodromal period of abnormal symptoms lasting weeks to years has been identified and operationalized as clinically high risk (CHR) for schizophrenia. However, only a minority of subjects prospectively identified with CHR convert to schizophrenia, thereby limiting enthusiasm for early intervention(s). This study utilized objective resting electroencephalogram (EEG) quantification to determine whether CHR constitutes a cohesive entity and an evoked potential to assess CHR cortical auditory processing.

METHODS

This study constitutes an EEG-based quantitative neurophysiological comparison between two unmedicated subject groups: 35 neurotypical controls (CON) and 22 CHR patients. After artifact management, principal component analysis (PCA) identified EEG spectral and spectral coherence factors described by associated loading patterns. Discriminant function analysis (DFA) determined factors' discrimination success between subjects in the CON and CHR groups. Loading patterns on DFA-selected factors described CHR-specific spectral and coherence differences when compared to controls. The frequency modulated auditory evoked response (FMAER) explored functional CON-CHR differences within the superior temporal gyri.

RESULTS

Variable reduction by PCA identified 40 coherence-based factors explaining 77.8% of the total variance and 40 spectral factors explaining 95.9% of the variance. DFA demonstrated significant CON-CHR group difference (P <0.00001) and successful jackknifed subject classification (CON, 85.7%; CHR, 86.4% correct). The population distribution plotted along the canonical discriminant variable was clearly bimodal. Coherence factors delineated loading patterns of altered connectivity primarily involving the bilateral posterior temporal electrodes. However, FMAER analysis showed no CON-CHR group differences.

CONCLUSIONS

CHR subjects form a cohesive group, significantly separable from CON subjects by EEG-derived indices. Symptoms of CHR may relate to altered connectivity with the posterior temporal regions but not to primary auditory processing abnormalities within these regions.

Visual context processing dysfunctions in youth at high risk for psychosis: Resistance to the Ebbinghaus illusion and its symptom and social and role functioning correlates

Impaired visual context processing is closely linked with expression of symptoms in people with psychosis. However, to date, there have been no investigations of this phenomenon in the critical ultra high-risk (UHR) period immediately preceding the onset of psychosis. In total, 73 participants (33 UHR, 40 control) were evaluated with clinical and global functioning interviews and with a computerized task that required comparing the size of 2 target circles. Targets could appear by themselves (no-context condition), or within a context that made size judgment easier (helpful condition) or more difficult (misleading condition). Susceptibility to illusion was measured as the accuracy differences between the no-context and the helpful (i.e., helpful-index) and the misleading (i.e., misleading-index) conditions. Both groups exhibited approximately the same percentage of accurate responses to the no-context condition. However, the UHR subjects exhibited significantly less susceptibility to the illusion, performing superior to controls on the misleading index. The UHR group also showed less susceptibility on the helpful index, but this was not significant. Lower susceptibility on the misleading index was associated with increased negative symptoms and role functioning at a trend level. Lower susceptibility on the helpful index was significantly associated with increased negative symptoms and both poor role and social functioning. These results indicate that visual context processing is impaired during the UHR period, and is related to core illness features, suggesting that this task may be a useful biomarker in studies of UHR participants.

Symptoms at Onset in First Episode Schizophrenia: Caregivers Perspectives

BACKGROUND

Early recognition of symptoms is important in the management of psychosis. Caregivers understanding and attribution of symptoms plays a major role in treatment selection.

AIM

The aim was to identify the various symptoms cluster recognized by caregivers at illness onset in first episode schizophrenia.

SUBJECTS AND METHODS

In a cross-sectional study 40 key caregivers of patients with first episode of Schizophrenia (International Classification of Diseases-10) attending the outpatient services of Schizophrenia Research Foundation were recruited. Caregivers were assessed using a questionnaire adapted from the Psychiatric and Personal History Schedule.

STATISTICAL ANALYSIS

Principal component (PCP) analysis.

RESULTS

Caregivers were predominantly women. Parents (58%), siblings (18%), spouse (12%), and children (12%) formed the sample. The caregiver easily recognized depressive symptoms. An analysis was done to analyze symptom data rated on the caregiver questionnaire indicated a four-factor solution. PCP analysis produced a clear depressive, anxious, irritable, and vegetative factor (Eigenvalue >0.05). Caregivers (40%) attributed present lifestyle as causality. The first contact of help in almost half of the sample (45%) was to a psychiatric facility.

CONCLUSION

Caregiver's perception about mental illness and ability to identify the four factors has important treatment implications. Studying patterns of help seeking may be a useful strategy in early intervention programs.

Screening tools for clinical high risk for psychosis

AIM

The purpose of this article was to review existing screening instruments that could be used to identify individuals who may be at increased risk for psychosis and to determine the suitability of these instruments.

METHODS

Medline (Ovid) and PubMed were searched for peer-reviewed articles published in English, which reported performance evaluation of screening instruments for symptoms of high risk for psychosis. The articles' titles, abstracts and, when necessary, full texts were read to filter them against the selection criteria. Citations within relevant articles were hand searched for other potentially eligible studies.

RESULTS

This selection strategy resulted in identifying 56 articles (including three articles available only in an abstract format) that reported performance evaluation of 17 screening instruments.

CONCLUSIONS

The sensitivity of these scales ranged from 67% to 100% and the specificity ranged from 39% to 100%. The positive predictive value was less precise with scores ranging from 24% to 100%, and the negative predictive value ranging from 58% to 100%. There were several scales that might be useful for screening for individuals who are at increased risk for developing psychosis; however, the majority of measures are underexplored with poor validation.

Emotion recognition deficits as predictors of transition in individuals at clinical high risk for schizophrenia: a neurodevelopmental perspective

BACKGROUND

Schizophrenia is characterized by profound and disabling deficits in the ability to recognize emotion in facial expression and tone of voice. Although these deficits are well documented in established schizophrenia using recently validated tasks, their predictive utility in at-risk populations has not been formally evaluated.

METHOD

The Penn Emotion Recognition and Discrimination tasks, and recently developed measures of auditory emotion recognition, were administered to 49 clinical high-risk subjects prospectively followed for 2 years for schizophrenia outcome, and 31 healthy controls, and a developmental cohort of 43 individuals aged 7-26 years. Deficit in emotion recognition in at-risk subjects was compared with deficit in established schizophrenia, and with normal neurocognitive growth curves from childhood to early adulthood.

RESULTS

Deficits in emotion recognition significantly distinguished at-risk patients who transitioned to schizophrenia. By contrast, more general neurocognitive measures, such as attention vigilance or processing speed, were non-predictive. The best classification model for schizophrenia onset included both face emotion processing and negative symptoms, with accuracy of 96%, and area under the receiver-operating characteristic curve of 0.99. In a parallel developmental study, emotion recognition abilities were found to reach maturity prior to traditional age of risk for schizophrenia, suggesting they may serve as objective markers of early developmental insult.

CONCLUSIONS

Profound deficits in emotion recognition exist in at-risk patients prior to schizophrenia onset. They may serve as an index of early developmental insult, and represent an effective target for early identification and remediation. Future studies investigating emotion recognition deficits at both mechanistic and predictive levels are strongly encouraged.

Ethical, Legal, and Clinical Considerations when Disclosing a High-Risk Syndrome for Psychosis

There are complex considerations when planning to disclose an attenuated psychosis syndrome (APS) diagnosis. In this review, we evaluate ethical, legal, and clinical perspectives as well as caveats related to full, non- and partial disclosure strategies, discuss societal implications, and provide clinical suggestions. Each of the disclosure strategies is associated with benefits as well as costs/considerations. Full disclosure promotes autonomy, allows for the clearest psychoeducation about additional risk factors, helps to clarify and/or correct previous diagnoses/treatments, facilitates early intervention and bolsters communication between providers but there are important considerations involving heritability, comorbidity, culture, and stigma. Non-disclosure advances nonmaleficence by limiting stigma and stress (which may inadvertently exacerbate the condition), and confusion (related to the rapidly evolving diagnosis) in a sensitive developmental period but is complicated by varying patient preferences and the possibility that, as new treatments without adverse effects become available, the risk with false positives no longer justifies the accompanying loss of autonomy. Partial disclosure balances ethical considerations by focusing on symptoms instead of labels, but evidence that laypersons may interpret this information as a pseudo-diagnosis and that symptoms alone also contribute to stigma limits the efficacy of this approach. In addition, there are notable societal considerations relating to disclosure involving conservatorship, the reach of insurance companies, and discrimination. We advocate a hybrid approach to disclosure and recommend future research aimed at understanding the effects of stigma on clinical course and a renewed focus on those help-seeking cases that do not transition but remain clinically relevant.

Exercise practices in individuals at clinical high risk of developing psychosis

AIM

Recent research suggests aerobic exercise has a positive impact on symptoms and cognition in psychosis. Because individuals with psychosis are at risk of weight gain and the resultant metabolic side-effects, developing effective exercise programmes is of interest. Furthermore, this may be a useful intervention for those who are at risk of developing psychosis, that is, those at clinical high risk (CHR). The aim of this initial exploratory project was to examine the role of exercise in participants at CHR for psychosis.

METHODS

A comprehensive questionnaire was developed to assess current physical activity involvement; exercise levels in terms of frequency, intensity and duration; and perceived fitness levels. Reported barriers to exercise and reasons for exercising were also considered. Eighty participants, 40 CHR and 40 healthy controls, were assessed with this questionnaire.

RESULTS

Overall, both groups were involved in a wide range of physical activity. Healthy controls reported higher levels of participation in indoor/outdoor activities and strength and/or flexibility training. They also exercised more frequently, more intensely and reported higher perceived fitness levels than CHR participants. Levels of exercise were unrelated to clinical symptoms and functioning in CHR participants. CHR youth reported more barriers to exercise and less positive reasons for exercising that were related to self-perception.

CONCLUSION

The results suggest that exercise should be investigated further in the CHR population as it may have treatment implications.

Substance use in individuals at clinical high risk of psychosis

BACKGROUND

A series of research reports has indicated that the use of substances such as cannabis, alcohol and tobacco are higher in youth at clinical high risk (CHR) of developing psychosis than in controls. Little is known about the longitudinal trajectory of substance use, and findings on the relationship between substance use and later transition to psychosis in CHR individuals are mixed.

METHOD

At baseline and 6- and 12-month follow-ups, 735 CHR and 278 control participants completed the Alcohol and Drug Use Scale and a cannabis use questionnaire. The longitudinal trajectory of substance use was evaluated with linear mixed models.

RESULTS

CHR participants endorsed significantly higher cannabis and tobacco use severity, and lower alcohol use severity, at baseline and over a 1-year period compared with controls. CHR youth had higher lifetime prevalence and frequency of cannabis, and were significantly younger upon first use, and were more likely to use alone and during the day. Baseline substance use did not differentiate participants who later transitioned to psychosis (n = 90) from those who did not transition (n = 272). Controls had lower tobacco use than CHR participants with a prodromal progression clinical outcome and lower cannabis use than those with a psychotic clinical outcome at the 2-year assessment.

CONCLUSIONS

In CHR individuals cannabis and tobacco use is higher than in controls and this pattern persists across 1 year. Evaluation of clinical outcome may provide additional information on the longitudinal impact of substance use that cannot be detected through evaluation of transition/non-transition to psychosis alone.

Changes in neurocognitive functioning during transition to manifest disease: comparison of individuals at risk for schizophrenic and bipolar affective psychoses

BACKGROUND

Neurocognitive deficits are important aspects of schizophrenic disorder because they have a strong impact on social and vocational outcomes. Previously it was assumed that cognitive abilities progressively deteriorate with illness onset. However, recent research results have contradicted this with observations of continuous or even improved performance in individuals at risk for psychosis or manifest schizophrenia. The objective of our longitudinal study was to examine neurocognitive functioning in help-seeking individuals meeting basic symptoms or ultra-high-risk criteria for schizophrenic psychosis (HRSchiz) or risk criteria for affective psychosis (HRBip). The progression of cognitive functioning in individuals converting to psychosis was compared with that of at-risk individuals who did not convert during the follow-up period.

METHOD

Data were available from 86 study participants who completed neurocognitive and clinical assessments at baseline and, on average, 12.8 (s.d. = 1.5) months later. Neurocognitive measures were grouped according to their load in factor analysis to five cognitive domains: speed, attention, fluency, learning and memory, and working memory.

RESULTS

Neurocognitive functioning in HRSchiz and HRBip individuals generally improved over time. Subjects converting to manifest psychosis displayed a stable neurocognitive profile from baseline to follow-up. Compared with non-converters, they had already demonstrated a significantly lower level of performance during their baseline examinations.

CONCLUSIONS

Our data provide no evidence for a progressive cognitive decline in individuals at risk of psychosis. In line with the neurodevelopmental model, our findings suggest that cognitive deficits are already present very early, before or during the prodromal stage of the illness.

New Targets for Prevention of Schizophrenia: Is It Time for Interventions in the Premorbid Phase?

A number of influences have converged that make this Special Theme Issue timely: "A New Direction: Considering Developmentally Sensitive Targets for Very Early Intervention in Schizophrenia". These factors include: 1. the substantial knowledge about premorbid developmental vulnerabilities to psychosis, especially regarding schizophrenia; 2. the promising results emerging from interventions during the clinical high-risk (CHR) phase of psychosis and; 3. the recognition that the CHR period is a relatively late phase of developmental derailment. These factors have together led to a perspective that even earlier intervention is warranted. This paper briefly summarizes the articles comprising the Special Theme including new data on early neurocognitive development, proposed potential targets for psychosocial and psychopharmacological interventions during the premorbid period as early as pregnancy, and ethical challenges. These thought experiments must be empirically tested, and the ethical challenges overcome as posed by the various interventions, which range from relatively low risk, supportive, psychosocial to higher risk, experimental, pharmacological interventions. All of the interventions proposed require careful study of ethics, safety, potential stigma, feasibility, efficacy and tolerability, and the meaning to the people involved.

Self-face recognition in the ultra-high risk for psychosis population

AIM

Phenomenological research indicates that disturbance of the basic sense of self may be a core phenotypic marker of schizophrenia spectrum disorders. Self-face recognition (SFR) is an experimental paradigm which can assess the basic sense of self. In this study, we used SFR to determine whether basic self-disturbance is present in the ultra-high risk (UHR) for psychosis population at the perceptual level.

METHODS

Twenty-three UHR individuals and 23 healthy comparison subjects were administered the SFR task. The study consisted of a 2 × 3 × 2 design: two group levels (UHR for psychosis group and the healthy comparison group); three task levels (self-famous task, self-stranger task, famous-stranger task); and two hand levels (left hand and right hand). Threshold limit values in face recognition were analysed.

RESULTS

The analysis indicated effects for group (F(1, 43) = 5.197, P < 0.05) and interaction effects between group and task (F = 4.767, P < 0.05). An independent samples t-test was used to compare the threshold limit values of the same task between the two groups. For self-famous task, the threshold limit values of the UHR group were higher than those of healthy group both in the left and right hands (t = 2.734, P < 0.05; t = 2.864, P < 0.05), but no significant difference was found in self-stranger task and famous-stranger task (P > 0.05).

CONCLUSIONS

This SFR study indicates that basic self-disturbance is present in the UHR for psychosis at the behavioural level in comparison with a healthy comparison group.

Self-awareness of functional impairment in individuals at clinical high-risk for psychosis

AIMS

A major public health concern associated with schizophrenia is the long-term disability that involves an inability to function independently in the community. An individual's self-awareness of functional impairment may be a significant factor contributing to long-term disability. In fact, subjective interpretation of one's illness impacts treatment participation and adherence, and is linked to poor outcomes. However, it remains unclear how illness-related functional impairment is perceived by individuals prior to the onset of psychosis. This study aims to examine the relationship between clinician-based and self-report assessments of functioning, as well as the contribution of clinical symptoms to this relationship in individuals at clinical high-risk for psychosis.

METHODS

The Sheehan Disability Scale, a self-rated instrument, was used to measure disruption in daily functioning in social and role functioning due to symptoms in a sample of 73 treatment-seeking patients at clinical high-risk for psychosis and 50 healthy controls.

RESULTS

Relative to healthy controls, clinical high-risk patients self-reported significant disruptions in social and role functioning. In addition, a specific relationship emerged in that clinician-rated measures of functioning and depression were related to subjective functioning.

CONCLUSIONS

These findings suggest that clinical high-risk patients are significantly disturbed by their illness. Self-reported disruption of daily functioning was associated with clinician-rated functioning and depressive symptoms, further highlighting the impact of functional impairments on the level of distress experienced by patients in the early phases of the illness. Intervention strategies that repair functional impairment before the onset of psychosis may prevent long-term disability.

Intervening early in bipolar disorder in young people: a review of the clinical staging model

Bipolar disorder (BPD) essentially has its onset during adolescence and early adulthood. It has the capacity to be highly disruptive, dislocating individuals from their normal developmental trajectory and potentially causing significant long-term co-morbidity and chronicity. At a societal level the burden created is greater than schizophrenia. This is not helped by the very substantial delays in its diagnosis and appropriate treatment. Thus, there is a clear rationale for intervening earlier and at a younger age. However, the field of early intervention in BPD is in its infancy. One approach that conceptually provides a basis for early intervention is the Clinical Staging Model (used widely in general medicine). This article outlines how this model helps in an understanding of the emerging stages of BPD. It also summarises the interventions that might be appropriately introduced if a person progresses from an early to a late stage of the illness. Early intervention has a well-established record in psychotic disorders. If it can be realised for BPDs, then it may hold out hope of better outcomes for the next generation of young people at risk.

Developing psychosis and its risk states through the lens of schizotypy

Starting from the early descriptions of Kraepelin and Bleuler, the construct of schizotypy was developed from observations of aberrations in nonpsychotic family members of schizophrenia patients. In contemporary diagnostic manuals, the positive symptoms of schizotypal personality disorder were included in the ultra high-risk (UHR) criteria 20 years ago, and nowadays are broadly employed in clinical early detection of psychosis. The schizotypy construct, now dissociated from strict familial risk, also informed research on the liability to develop any psychotic disorder, and in particular schizophrenia-spectrum disorders, even outside clinical settings. Against the historical background of schizotypy it is surprising that evidence from longitudinal studies linking schizotypy, UHR, and conversion to psychosis has only recently emerged; and it still remains unclear how schizotypy may be positioned in high-risk research. Following a comprehensive literature search, we review 18 prospective studies on 15 samples examining the evidence for a link between trait schizotypy and conversion to psychosis in 4 different types of samples: general population, clinical risk samples according to UHR and/or basic symptom criteria, genetic (familial) risk, and clinical samples at-risk for a nonpsychotic schizophrenia-spectrum diagnosis. These prospective studies underline the value of schizotypy in high-risk research, but also point to the lack of evidence needed to better define the position of the construct of schizotypy within a developmental psychopathology perspective of emerging psychosis and schizophrenia-spectrum disorders.

Towards a psychosis risk blood diagnostic for persons experiencing high-risk symptoms: preliminary results from the NAPLS project

INTRODUCTION

A barrier to preventative treatments for psychosis is the absence of accurate identification of persons at highest risk. A blood test that could substantially increase diagnostic accuracy would enhance development of psychosis prevention interventions.

METHODS

The North American Prodrome Longitudinal Study project is a multisite endeavor that aims to better understand predictors and mechanisms for the development of psychosis. In this study, we measured expression of plasma analytes reflecting inflammation, oxidative stress, hormones, and metabolism. A "greedy algorithm" selected analytes that best distinguished persons with clinical high-risk symptoms who developed psychosis (CHR-P; n = 32) from unaffected comparison (UC) subjects (n = 35) and from those who did not develop psychosis during a 2-year follow-up (CHR-NP; n = 40).

RESULTS

The classifier included 15 analytes (selected from 117), with an area under the receiver operating curve for CHR-P vs UC of 0.91 and CHR-P vs CHR-NP of 0.88. Randomly scrambled group membership followed by reconstructions of the entire classifier method yielded consistently weak classifiers, indicating that the true classifier is highly unlikely to be a chance occurrence. Such randomization methods robustly imply the assays contain consistent information distinguishing the groups which was not obscured by the data normalization method and was revealed by classifier construction. These results support the hypothesis that inflammation, oxidative stress, and dysregulation of hypothalamic-pituitary axes may be prominent in the earliest stages of psychosis.

CONCLUSION

If confirmed in other groups of persons at elevated risk of psychosis, a multiplex blood assay has the potential for high clinical utility.