Age matters in the prevalence and clinical significance of ultra-high-risk for psychosis symptoms and criteria in the general population: Findings from the BEAR and BEARS-kid studies

Clinical utility of the at-risk for psychosis state beyond transition: A multidimensional network analysis

To be relevant to healthcare systems, the clinical high risk for psychosis (CHR-P) concept should denote a specific (i.e., unique) clinical population and provide useful information to guide the choice of intervention. The current study applied network analyses to examine the clinical specificities of CHR-P youths compared to general help-seekers and non-CHR-P youth. 146 CHR-P (mean age = 14.32 years) and 103 non-CHR-P (mean age = 12.58 years) help-seeking youth were recruited from a neuropsychiatric unit and assessed using the Structured Interview for Psychosis-Risk Syndromes, Children's Depression Inventory, Multidimensional Anxiety Scale for Children, Global Functioning: Social, Global Functioning: Role, and Wechsler Intelligence Scale for Children/Wechsler Adult Intelligence Scale. The first network structure comprised the entire help-seeking sample (i.e., help-seekers network), the second only CHR-P patients (i.e., CHR-P network), and the third only non-CHR-P patients (i.e., non-CHR-P network). In the help-seekers network, each variable presented at least one edge. In the CHR-P network, two isolated "archipelagos of symptoms" were identified: (a) a subgraph including functioning, anxiety, depressive, negative, disorganization, and general symptoms; and (b) a subgraph including positive symptoms and the intelligence quotient. In the non-CHR-P network, positive symptoms were negatively connected to functioning, disorganization, and negative symptoms. Positive symptoms were less connected in the CHR-P network, indicating a need for specific interventions alongside those treating comorbid disorders. The findings suggest specific clinical characteristics of CHR-P youth to guide the development of tailored interventions, thereby supporting the clinical utility of the CHR-P concept.

[Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders]

Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders Abstract: As a vulnerable group, minors require special protection in studies. For this reason, researchers are often reluctant to initiate studies, and ethics committees are reluctant to authorize such studies. This often excludes minors from participating in clinical studies. This exclusion can lead to researchers and clinicians receiving only incomplete data or having to rely on adult-based findings in the treatment of minors. Using the example of the study "Computer-Assisted Risk Evaluation in the Early Detection of Psychotic Disorders" (CARE), which was conducted as an 'other clinical investigation' according to the Medical Device Regulation, we present a line of argumentation for the inclusion of minors which weighs the ethical principles of nonmaleficence (especially regarding possible stigmatization), beneficence, autonomy, and fairness. We show the necessity of including minors based on the development-specific differences in diagnostics and early intervention. Further, we present specific protective measures. This argumentation can also be transferred to other disorders with the onset in childhood and adolescence and thus help to avoid excluding minors from appropriate evidence-based care because of insufficient studies.

Clinical and neurodevelopmental predictors of psychotic disorders in children and adolescents at clinical high risk for psychosis: the CAPRIS study

BACKGROUND

The neurodevelopmental hypothesis of schizophrenia represents the disorder as an expression of an alteration during the brain development process early in life. Neurodevelopmental variables could become a trait marker, and the study of these variables in children and adolescents at clinical high risk for psychosis (CHR) could identify a specific cluster of patients who later developed psychosis. The aim of this study is to describe clinical and neurodevelopment predictors of transition to psychosis in child and adolescent participants at CHR. Naturalistic longitudinal two-center study of 101 CHR and 110 healthy controls (HC) aged 10-17. CHR participants were children and adolescents aged 10-17, meeting one or more of the CHR criteria assessed at baseline and at 18 months' follow-up. Neurodevelopmental variables assessed were obstetric complications, delay in principal development milestones, and presence of a neurodevelopment diagnosis. Pairwise comparisons, linear regressions, and binary logistic regression were performed.A transition rate of 23.3% at 1.5 years was observed. Participants who developed psychosis (CHR-P) showed higher rates of grandiosity and higher proportions of antipsychotic medication intake at baseline compared to participants who did not develop a psychotic disorder (CHR-NP). In terms of neurodevelopment alterations, CHR-P group showed a higher proportion of participants reporting delay in language development than the CHR-NP and HC groups. The odds of psychosis increased by 6.238 CI 95% [1.276-30.492] for a one-unit increase in having a positive score in grandiosity; they increased by 4.257 95% CI [1.293-14.023] for a one-unit increase in taking antipsychotic medication, and by 4.522 95% [1.185-64.180] for showing language development delay. However, the p-values did not reach significance after adjusting for multiple comparisons.A combination of clinical and neurodevelopmental alterations could help predict the transition to psychotic disorder in a CHR child and adolescent sample. Our results suggest the potential utility of collecting information about neurodevelopment and using these variable multifactorial models to predict psychosis disorders.

Prodromal symptoms and the duration of untreated psychosis in first episode of psychosis patients: what differences are there between early vs. adult onset and between schizophrenia vs. bipolar disorder?

To assess the role of age (early onset psychosis-EOP < 18 years vs. adult onset psychosis-AOP) and diagnosis (schizophrenia spectrum disorders-SSD vs. bipolar disorders-BD) on the duration of untreated psychosis (DUP) and prodromal symptoms in a sample of patients with a first episode of psychosis. 331 patients with a first episode of psychosis (7-35 years old) were recruited and 174 (52.6%) diagnosed with SSD or BD at one-year follow-up through a multicenter longitudinal study. The Symptom Onset in Schizophrenia (SOS) inventory, the Positive and Negative Syndrome Scale and the structured clinical interviews for DSM-IV diagnoses were administered. Generalized linear models compared the main effects and group interaction. 273 AOP (25.2 ± 5.1 years; 66.5% male) and 58 EOP patients (15.5 ± 1.8 years; 70.7% male) were included. EOP patients had significantly more prodromal symptoms with a higher frequency of trouble with thinking, avolition and hallucinations than AOP patients, and significantly different median DUP (91 [33-177] vs. 58 [21-140] days; Z = - 2.006, p = 0.045). This was also significantly longer in SSD vs. BD patients (90 [31-155] vs. 30 [7-66] days; Z = - 2.916, p = 0.004) who, moreover had different profiles of prodromal symptoms. When assessing the interaction between age at onset (EOP/AOP) and type of diagnosis (SSD/BD), avolition was significantly higher (Wald statistic = 3.945; p = 0.047), in AOP patients with SSD compared to AOP BD patients (p = 0.004). Awareness of differences in length of DUP and prodromal symptoms in EOP vs. AOP and SSD vs. BD patients could help improve the early detection of psychosis among minors.

Cognitive predictors of transition and remission of psychosis risk syndrome in a child and adolescent sample: longitudinal findings from the CAPRIS study

Cognitive impairments are proposed as predictors in the differentiation between subjects with psychosis risk syndrome (PRS) who will develop a psychotic disorder (PRS-P) and those who will not (PRS-NP). More in-depth study of the PRS-NP group could contribute to defining the role of cognitive alterations in psychosis. This study aims to analyze cognition of children and adolescents with PRS in terms of their clinical outcome at 18-month follow-up (psychosis, remission, and non-remission) and of determinate predictors of transition to psychosis and remission of PRS. The method is two-site, naturalistic, longitudinal study design, with 98 help-seeking adolescents with PRS and 64 healthy controls (HC). PRS-P (n = 24) and PRS-NP (n = 74) participants were clinically and cognitively assessed at baseline, and when full-blown psychotic disorder had developed or at 18-month follow-up. PRS-P subjects showed lower scores at baseline in processing speed, visuospatial memory, attention, and executive function (cognitive flexibility/processing speed) compared to HC. PRS-NP subjects showed lower baseline scores in verbal working memory and verbal fluency compared to HC. This deficit is also observed in the PRS group of participants still presenting attenuated psychotic symptoms at 18-month follow-up, while PRS subjects in remission showed a similar cognitive profile to HC subjects. Baseline score on processing speed, measured with a coding task, appeared to be a predictive variable for the development of a psychotic disorder. Performance in verbal working memory was predictive of remission in the PRS-NP. Post hoc comparisons indicate the need for careful interpretation of cognitive markers as predictors of psychosis. Cognitive impairments are present in both PRS-P and PRS-NP. Those individuals who recover from PRS show baseline cognitive performance comparable to the HC group. Together with sociodemographic variables, this observation could help in the differentiation of a variety of PRS trajectories in children and adolescents.

Childhood Schizotypy and Adolescent Mental Disorder

BACKGROUND AND HYPOTHESIS

Schizotypy provides a framework for understanding the developmental nature of psychotic disorders and a means of identifying "at-risk" individuals early in the lifespan. However, there is a lack of prospective longitudinal research examining the relationship between schizotypy in childhood and later psychotic and other mental disorders. We hypothesized that distinct profiles of schizotypy in childhood would be differentially associated with psychotic and other mental disorders emerging later in adolescence.

STUDY DESIGN

In a large population cohort of Australian young people (n = 26 837), we prospectively examined the relationship between person-centered profiles of schizotypy identified in middle childhood (age ~11 years) and adolescent diagnoses (age ~13-18 years) across 7 types of mental disorders using multinomial logistic regression.

RESULTS

Membership in any of 3 childhood schizotypy profiles (true schizotypy, affective schizotypy, or introverted schizotypy) was associated with an increased likelihood of being diagnosed with any type of mental disorder in adolescence; effects were strongest for the true schizotypy group (aOR = 3.07, 95% CI = 2.64, 3.57), followed by the introverted (aOR = 1.94, 95% CI = 1.75, 2.15) and affective (aOR = 1.29, 95% CI = 1.13, 1.47) schizotypy groups. Six of the 7 types of mental disorders measured (including psychotic disorders) were associated with at least 1 schizotypy group.

CONCLUSIONS

Schizotypy in middle childhood is an important correlate of mental disorders in adolescence; however, it does not appear to be specifically associated with psychotic disorders in this age group.

An ecological momentary assessment study of age effects on perceptive and non-perceptive clinical high-risk symptoms of psychosis

Among individuals with clinical high risk for psychosis (CHR), perceptive symptoms are more frequent but have less clinical significance in children/adolescents compared to adults. However, findings are based on clinical interviews relying on patient's recall capacity. Ecological momentary assessment (EMA) can be used to explore experiences in real-time in the subject's daily life. The aim of this study was to assess frequency and stability of (perceptive and non-perceptive) CHR symptoms and to explore potential age effects. EMA was used in a sample of an early detection for psychosis service in Bern, Switzerland (N = 66; 11-36 years). CHR symptoms were recorded in random time intervals for seven days: eight assessments per day per subject, minimum time between prompts set at 25 min. CHR symptoms were additionally assessed with semi-structured interviews including the 'Structured Interview for Psychosis-Risk Syndromes' and the 'Schizophrenia Proneness Instruments'. Mixed-effects linear regression analysis on the frequency of CHR symptoms revealed a significant effect of age group, and the interaction CHR symptoms x age group for both perceptive and non-perceptive symptoms. Further, regarding stability of CHR symptoms, there was a significant effect of the interaction CHR symptoms x age group for perceptive symptoms only. Based on EMA, perceptive CHR symptoms were more frequently reported but less stable in children/adolescents compared with adults. Together with previous findings, our finding of higher instability/variability of perceptive symptoms in younger persons might suggest that with advancing age and more stability of CHR symptoms, clinical relevance (reduced psychosocial functioning) may increase.

The heterogeneity of attenuated and brief limited psychotic symptoms: association of contents with age, sex, country, religion, comorbidities, and functioning

Introduction

The Attenuated Psychosis Symptoms (APS) syndrome mostly represents the ultra-high-risk state of psychosis but, as does the Brief Intermittent Psychotic Symptoms (BIPS) syndrome, shows a large variance in conversion rates. This may be due to the heterogeneity of APS/BIPS that may be related to the effects of culture, sex, age, and other psychiatric morbidities. Thus, we investigated the different thematic contents of APS and their association with sex, age, country, religion, comorbidity, and functioning to gain a better understanding of the psychosis-risk syndrome.

Method

A sample of 232 clinical high-risk subjects according to the ultra-high risk and basic symptom criteria was recruited as part of a European study conducted in Germany, Italy, Switzerland, and Finland. Case vignettes, originally used for supervision of inclusion criteria, were investigated for APS/BIPS contents, which were compared for sex, age, country, religion, functioning, and comorbidities using chi-squared tests and regression analyses.

Result

We extracted 109 different contents, mainly of APS (96.8%): 63 delusional, 29 hallucinatory, and 17 speech-disorganized contents. Only 20 contents (18.3%) were present in at least 5% of the sample, with paranoid and referential ideas being the most frequent. Thirty-one (28.5%) contents, in particular, bizarre ideas and perceptual abnormalities, demonstrated an association with age, country, comorbidity, or functioning, with regression models of country and obsessive-compulsive disorders explaining most of the variance: 55.8 and 38.3%, respectively. Contents did not differ between religious groups.

Conclusion

Psychosis-risk patients report a wide range of different contents of APS/BIPS, underlining the psychopathological heterogeneity of this group but also revealing a potential core set of contents. Compared to earlier reports on North-American samples, our maximum prevalence rates of contents were considerably lower; this likely being related to a stricter rating of APS/BIPS and cultural influences, in particular, higher schizotypy reported in North-America. The various associations of some APS/BIPS contents with country, age, comorbidities, and functioning might moderate their clinical severity and, consequently, the related risk for psychosis and/or persistent functional disability.

Detection of clinical high risk for psychosis in child and adolescent mental health services: Validation of the first step with the French versions of the Prodromal Questionnaire (fPQ-16) and scale of Perceptual and Cognitive Aberrations (fPCA)

AIM

To validate the French versions of the 16-items Prodromal Questionnaire (PQ-16) and the 9-items scale of Perceptual and Cognitive Aberrations (PCA) to facilitate screening of psychosis risk in native French-speaking young individuals referred to Child and Adolescent Mental Health Services.

METHOD

Participants (N = 87, age range 10-18 years) were diagnosed with a non-psychotic disorder according to the Diagnostic and Statistical Manual of Mental Disorders. The French versions of the PQ-16 and PCA were developed using a forward-backward translation procedure. Psychometric properties were tested including (i) internal validity with Pearson correlations and Cronbach's coefficients, and (ii) external validity by correlations with each other's.

RESULTS

(i) Correlations between fPQ-16 and fPCA total scores and individual items were mostly >.4. Cronbach's coefficients were .80 for the fPQ-16 and .61 for the fPCA. (ii) The fPQ-16 and fPCA total scores were significantly correlated with a large effect size (r_s  = 0.66).

CONCLUSION

The fPQ-16 and the fPCA are psychometrically acceptable instruments for the screening of potential psychotic symptoms in French-speaking children and young adolescents under 18 years old referred to Child and Adolescent Mental Health Services.

Age-related changes in self-reported psychotic experiences in clinical help-seeking population: From 15 to 45 years

AIMS

Psychotic experiences differ with age. It is currently unknown whether there were specific patterns and associations between the presentation of psychotic experiences and age. This study aimed to explore age-related differences (15-45 years) in self-reported psychotic experiences in a large-scale clinical population.

METHODS

A total of 2542 consecutive new patients aged 15-45 years were recruited on their first visit to the Shanghai Mental Health Center and screened with the PRIME Screen-Revised (PS-R). According to the clinical diagnostic information of patients from their outpatient medical records compiled by their clinicians, four diagnostic categories were applied: 1) psychotic disorder; 2) mood disorder; 3) anxiety disorder and 4) others.

RESULTS

The PS-R scores of self-reported psychotic experiences declined with age, except for two age ranges: ≤18 years for overall sample (≤18 vs. 19-34 years: t = 5.531, df = 2202, p < .001) and 37-40 years for female sample (37-40 vs. >40 years: t = 1.985, df = 138, p = .049), which showed upward trends, contrary to those of others. There were no significant differences in self-reported psychotic experiences between age groups in patients with psychotic disorders, while significant age differences were found in all nonpsychotic patients.

CONCLUSION

These findings support the view that frequent PS-R screening demonstrated that psychotic experiences decline with age in the clinical population. Early detection of psychosis should focus on not only adolescents but also women aged >36 years.

A Deeper Dive Into the Relation Between Psychotic-like Experiences and Suicidal Ideation and Behaviors in Children Across the United States

BACKGROUND AND HYPOTHESIS

Children who endorse psychotic-like experiences (PLEs) appear to be at a greater risk for suicidal ideation and behavior (SI/SB) compared to their peers who do not endorse PLEs. Despite evidence of differential relations among subtypes of PLEs and SI/SB, the research on which PLE subtypes produce the strongest associations remains mixed. Further, though there is evidence that general psychological distress may help explain the relation between PLEs and SI/SB, no research has investigated the role of distress specific to PLEs in this association.

STUDY DESIGN

The present study sought to assess the associations among individual Prodromal Questionnaire-Brief Child Version (PQ-BC) items and SI/SB, as well as to explore the role of distress associated with PLEs as a mediator and/or moderator in a demographically diverse sample of children across the United States (N = 11 875).

STUDY RESULTS

Results revealed that individual items of the PQ-BC may be differentially predictive of lifetime SI (ßs = 0.000-0.098) and SB (ßs=0.002-0.059), even when controlling for sociodemographic variables, internalizing symptoms, and traumatic experiences, with particularly strong associations observed among items indexing thought control, auditory hallucinations, suspiciousness, and nihilistic thinking/dissociative experiences. Item 13, nihilistic thinking/dissociative experiences, displayed the strongest effect sizes. Findings from moderation and mediation models provided evidence consistent with distress as both a partial mediator and moderator of the relation between total PLEs and individual PQ-BC items with SI and SB.

CONCLUSIONS

Distress specific to PLEs may be an important modifiable risk factor to target in suicide assessment, prevention, and intervention efforts.

Developmental influences on symptom expression in antipsychotic-naïve first-episode psychosis

BACKGROUND

The neurodevelopmental model of psychosis was established over 30 years ago; however, the developmental influence on psychotic symptom expression - how age affects clinical presentation in first-episode psychosis - has not been thoroughly investigated.

METHODS

Using generalized additive modeling, which allows for linear and non-linear functional forms of age-related change, we leveraged symptom data from a large sample of antipsychotic-naïve individuals with first-episode psychosis (N = 340, 12-40 years, 1-12 visits), collected at the University of Pittsburgh from 1990 to 2017. We examined relationships between age and severity of perceptual and non-perceptual positive symptoms and negative symptoms. We tested for age-associated effects on change in positive or negative symptom severity following baseline assessment and explored the time-varying relationship between perceptual and non-perceptual positive symptoms across adolescent development.

RESULTS

Perceptual positive symptom severity significantly decreased with increasing age (F = 7.0, p = 0.0007; q = 0.003) while non-perceptual positive symptom severity increased with age (F = 4.1, p = 0.01, q = 0.02). Anhedonia severity increased with increasing age (F = 6.7, p = 0.00035; q = 0.0003), while flat affect decreased in severity with increased age (F = 9.8, p = 0.002; q = 0.006). Findings remained significant when parental SES, IQ, and illness duration were included as covariates. There were no developmental effects on change in positive or negative symptom severity (all p > 0.25). Beginning at age 18, there was a statistically significant association between severity of non-perceptual and perceptual symptoms. This relationship increased in strength throughout adulthood.

CONCLUSIONS

These findings suggest that as maturation proceeds, perceptual symptoms attenuate while non-perceptual symptoms are enhanced. Findings underscore how pathological brain-behavior relationships vary as a function of development.

Neural Correlates of Facial Emotion Recognition in Non-help-seeking University Students With Ultra-High Risk for Psychosis

Background

Since the introduction of the neurodevelopmental perspective of schizophrenia research on individuals at ultra-high risk for psychosis (UHR) has gained increasing interest, aiming at early detection and intervention. Results from fMRI studies investigating behavioral and brain functional changes in UHR during facial emotion recognition, an essential component of social cognition, showed heterogenous results, probably due clinical diversity across these investigations. This fMRI study investigated emotion recognition in a sub-group of the UHR spectrum, namely non-help-seeking, drug-naïve UHR with high cognitive functioning to reveal the neurofunctional underpinnings of their social functioning in comparison to healthy controls.

Methods

Two large cohorts of students from an elite University (n 1 = 4,040, n 2 = 4,364) were screened firstly with the Prodromal Questionnaires and by surpassing predefined cut-offs then interviewed with the semi-structured Interview for Psychosis-Risk Syndromes to verify their UHR status. Twenty-one identified non-help-seeking UHR and 23 non-UHR control subjects were scanned with functional magnetic resonance imaging while classifying emotions (i.e., neutral, happy, disgust and fear) in a facial emotion recognition task.

Results

Behaviorally, no group differences were found concerning accuracy, reaction times, sensitivity or specificity, except that non-help-seeking UHR showed higher specificity when recognizing neutral facial expressions. In comparison to healthy non-UHR controls, non-help-seeking UHR showed generally higher activation in the superior temporal and left Heschl's gyrus as well as in the somatosensory, insular and midcingulate cortex than the control subjects during the entire recognition task regardless of the emotion categories. In an exploratory analysis, in the non-help-seeking UHR group, functional activity in the left superior temporal gyrus was significantly correlated with deficits in the ability to experience emotions at uncorrected statistical thresholds.

Conclusions

Compared to healthy controls, non-help-seeking UHR show no behavioral deficits during facial emotion recognition, but functional hyperactivities in brain regions associated with this cognitive process. Our study may inspire future early intervention and provide loci for treatment using neural stimulation.

Dr. Lång et al. Reply

We thank our respected colleagues, Fusar-Poli and Salazar de Pablo,¹ for their interest in our recent systematic review and meta-analysis on psychosis risk in children and adolescents diagnosed with an at-risk mental state (ARMS).² Fusar-Poli and Salazar de Pablo agreed with our call for developmentally sensitive approaches when considering psychosis risk in children and adolescents, recognizing that psychotic experiences (the basis of ARMS assessments) are more prevalent in childhood and adolescence than they are in adulthood,³ with age-varying pathological significance.^4,5 This, however, appears to be contradicted by the authors' suggestion that we should have included adults (age >18 years) in our pediatric analysis.

Turkish Version of Structured Interview of Psychosis-Risk Syndromes (SIPS) and Proposal of a Brief Version of SIPS as a Pretest Risk Enrichment

Introduction

The Structured Interview of Psychosis Risk Syndromes (SIPS) was created to identify patients with Clinical High Risk for psychosis (CHR). This study aimed i) to translate and validate the Scale of Prodromal Syndromes (SOPS) in Turkish adolescents, ii) to explore the factor structure of the SIPS/SOPS in the adolescent population, especially focusing on those under the age of 15, iii) to generate a brief version of SIPS (SIPS-B).

Methods

A total of 150 adolescents aged between 12 and 18 years, were consecutively interviewed using SIPS/SOPS. Patients with psychotic syndrome (n=20), psychosis risk syndrome (PRS) (n=59), and clinical controls (CC) (n=71) were included in the study.

Results

Principal component analysis (PCA) yielded three latent factors, explaining 62.7% of the total variance in the whole clinical sample, including positive symptom factor, disorganized symptom factor, and negative symptom factor. The area under curve calculated in ROC analyses involving PRS and CC supported the four-item form of the SIPS-B (optimal cut-off=12.5, sensitivity=87%, specificity=80%).

Conclusion

Our study results support the notion that the Turkish translation of SIPS/SOPS meets the reliability and validity criteria in Turkish adolescents. The SIPS-B could aid clinicians in their routine clinical practice to expedite referral procedures.

Editorial: Can At-Risk Mental State (ARMS) Diagnosis in Children and Adolescents Predict Transition to a Psychotic Disorder? We Are Not There Yet

Psychosis is one of the most extreme and feared forms of psychopathology. Because early intervention leads to better outcomes for psychotic disorders, our field is highly motivated to identify this problem in its earliest stages. Ideally, early intervention during childhood and adolescence would be optimal to help restore healthy brain development and prevent the onset of a psychotic disorder. Structural clinical interviews have been developed to identify youth who are at high risk for psychosis, based largely on the presence of attenuated and/or transient psychotic symptoms. However, these evaluations are challenging because of vast developmental differences among children, adolescents, and adults in how these experiences are understood and expressed. In the wake of a growing body of literature examining the utility of assessments for At Risk Mental States (ARMS) for predicting later transition to a psychotic disorder, the time is ripe for a systematic review to assess the state of this emerging field.

(Attenuated) hallucinations join basic symptoms in a transdiagnostic network cluster analysis

Hallucinations are considered characteristic symptoms of psychosis and part of the 'psychosis superspectrum' of the Hierarchical Taxonomy Of Psychopathology (HiTOP) initiative. To gain insight into their psychopathological relevance, we studied their dimensional placement within a single dense transdiagnostic network constituting of basic symptoms as well as of attenuated and frank psychotic, and related symptoms. Newman's modularity analysis was used to detect symptom clusters in an earlier generated network (Jimeno, N., et al., 2020. Main symptomatic treatment targets in suspected and early psychosis: New insights from network analysis. Schizophr. Bull. 46, 884-895. https://doi.org/10.1093/schbul/sbz140). The constituting 86 symptoms were assessed with the Schizophrenia Proneness Instrument, Adult version (SPI-A), the Structured Interview for Psychosis-Risk Syndromes (SIPS), and the Positive And Negative Syndrome Scale (PANSS) in three adult samples of an early detection service: clinical high-risk (n = 203), first-episode psychosis (n = 153), and major depression (n = 104). Three clusters were detected: "subjective disturbances", "positive symptoms and behaviors", and "negative and anxious-depressive symptoms". The predominately attenuated hallucinations of both SIPS and PANSS joined the basic symptoms in "subjective disturbances", whereas other positive symptoms entered "positive symptoms and behaviors". Our results underline the importance of insight in separating true psychotic hallucinations from other hallucinatory experiences that, albeit phenomenologically similar are still experienced with some insight, i.e., are present in an attenuated form. We conclude that, strictly, hallucinations held with any degree of insight should not be used to diagnose transition to or presence of frank psychoses and, relatedly, to justify antipsychotic medication.

Systematic Review and Meta-analysis: Psychosis Risk in Children and Adolescents With an At-Risk Mental State

OBJECTIVE

The "At Risk Mental State" (ARMS) approach to psychosis, also called "Clinical/Ultra High Risk," has had a major impact on psychosis services internationally. Despite well-established developmental differences in the prevalence and expression of psychotic symptoms from childhood into adulthood, there has been no systematic review of psychosis transitions specifically in children and adolescents up to age of 18 years. Evidence for this age group is crucial for developmentally appropriate clinical decisions by child and adolescent psychiatrists.

METHOD

Systematic review and meta-analysis of psychosis risk among children diagnosed with ARMS up to age 18 years, with pooled transition rates after 1-year, 2-year and ≥5-year follow-up.

RESULTS

We retrieved 1,107 records and identified 16 articles from 9 studies reporting transition rates on 436 individuals with ARMS aged 9 to 18 years. The pooled transition rate to psychosis at 1 year was 9.5% (95% CI = 5.5%-14.2%, 7 studies included), at 2-years 12.1% (95% CI = 6.7%-18.6%, 4 studies included), and at ≥5 years 16.1% (95% CI = 5.6%-30.0%, 4 studies included). We did not find evidence that the diagnosis of ARMS was associated with increased risk of psychosis once risk-enriching recruitment strategies were taken into account.

CONCLUSION

At 5-year follow-up, 1 in 6 youths diagnosed with an ARMS had transitioned to psychosis, but we did not find evidence that this risk was related to ARMS diagnosis as opposed to sampling/recruitment strategies. Our findings indicate a need for caution in applying ARMS methodology to children and adolescents. and highlight the need for developmentally sensitive approaches when considering psychosis risk.

Clinical high-risk criteria of psychosis in 8–17-year-old community subjects and inpatients not suspected of developing psychosis

BACKGROUND

In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity.

AIM

To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients.

METHODS

In the mainly cross-sectional examinations, 8–17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive–compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ² tests and nonparametric tests with Cramer’s V and Rosenthal’s r as effect sizes, and their association with functioning using correlation analyses.

RESULTS

The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ² (4) = 9.425; P = 0.051, Cramer’s V = 0.132; and Z = -4.281, P < 0.001; Rosenthal’s r = 0.184], and thought pressure [χ² (4) = 11.019; P = 0.026, Cramer’s V = 0.143; and Z = -2.639, P = 0.008; Rosenthal’s r = 0.114], derealization [χ² (4) = 32.380; P < 0.001, Cramer’s V = 0.245; and Z = -3.924, P < 0.001; Rosenthal’s r = 0.169] and visual perception disturbances [χ² (4) = 10.652; P = 0.031, Cramer’s V = 0.141; and Z = -2.822, P = 0.005; Rosenthal’s r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive–compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall’s tau = -0.172, P < 0.001).

CONCLUSION

The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

The Bern Early Recognition and Intervention Centre for mental crisis (FETZ Bern)-An 8-year evaluation

AIM

Early detection of, and intervention for, psychosis during its prodromal phase has the potential to alter the course of the disease and has therefore become a major objective of modern clinical psychiatry. An increasing number of early detection and intervention services have been established in Europe and worldwide. This study aims to describe and evaluate an early detection and intervention service for children, adolescents and adults (FETZ Bern) aged from eight to 40 years with a population catchment area of 1.035 million in Bern, Switzerland.

METHODS

Routine demographic, diagnostic and service usage data were collected upon admission to the service. Using a retrospective, descriptive and naturalistic study design, data was analysed for different age groups (children, adolescents and adults) and where available, outcome data after 12 and 24 months was evaluated.

RESULTS

The FETZ Bern has received 827 referrals with full diagnostic data available for 353 patients. The majority of the assessed patients were young males. While 40% met criteria for a clinical high-risk state of psychosis, 20% were diagnosed with fully manifest psychosis at time of admission, and another 40% had one or more non-psychotic axis-I diagnoses.

CONCLUSIONS

The FETZ Bern is the first early detection centre worldwide assessing children aged younger than 12 years, as well as adolescents and young adults in one service. Given that developmental peculiarities are important in understanding and ultimately treating psychosis, the FETZ Bern, with its emphasis on developmental peculiarities, should be considered as a model for other similar services.

Development of the Korea-Polyenvironmental Risk Score for Psychosis

OBJECTIVE

Comprehensive understanding of polyenvironmental risk factors for the development of psychosis is important. Based on a review of related evidence, we developed the Korea Polyenvironmental Risk Score (K-PERS) for psychosis. We investigated whether the K-PERS can differentiate patients with schizophrenia spectrum disorders (SSDs) from healthy controls (HCs).

METHODS

We reviewed existing tools for measuring polyenvironmental risk factors for psychosis, including the Maudsley Environmental Risk Score (ERS), polyenviromic risk score (PERS), and Psychosis Polyrisk Score (PPS). Using odds ratios and relative risks for Western studies and the "population proportion" (PP) of risk factors for Korean data, we developed the K-PERS, and compared the scores thereon between patients with SSDs and HCs. In addition, correlation was performed between the K-PERS and Positive and Negative Syndrome Scale (PANSS).

RESULTS

We first constructed the "K-PERS-I," comprising five factors based on the PPS, and then the "K-PERS-II" comprising six factors based on the ERS. The instruments accurately predicted participants' status (case vs. control). In addition, the K-PERS-I and -II scores exhibited significant negative correlations with the negative symptom factor score of the PANSS.

CONCLUSION

The K-PERS is the first comprehensive tool developed based on PP data obtained from Korean studies that measures polyenvironmental risk factors for psychosis. Using pilot data, the K-PERS predicted patient status (SSD vs. HC). Further research is warranted to examine the relationship of K-PERS scores with clinical outcomes of psychosis and schizophrenia.

Reward Processing in Children With Psychotic-Like Experiences

Alterations to striatal reward pathways have been identified in individuals with psychosis. They are hypothesized to be a key mechanism that generate psychotic symptoms through the production of aberrant attribution of motivational salience and are proposed to result from accumulated childhood adversity and genetic risk, making the striatal system hyper-responsive to stress. However, few studies have examined whether children with psychotic-like experiences (PLEs) also exhibit these alterations, limiting our understanding of how differences in reward processing relate to hallucinations and delusional ideation in childhood. Consequently, we examined whether PLEs and PLE-related distress were associated with reward-related activation in the nucleus accumbens (NAcc). The sample consisted of children (N = 6718) from the Adolescent Brain Cognitive Development (ABCD) study aged 9-10 years who had participated in the Monetary Incentive Delay (MID) task in functional MRI. We used robust mixed-effects linear regression models to investigate the relationship between PLEs and NAcc activation during the reward anticipation and reward outcome stages of the MID task. Analyses were adjusted for gender, household income, ethnicity, depressive symptoms, movement in the scanner, pubertal development, scanner ID, subject and family ID. There was no reliable association between PLEs and alterations to anticipation- or outcome-related striatal reward processing. We discuss the implications for developmental models of psychosis and suggest a developmental delay model of how PLEs may arise at this stage of development.

Toward Generalizable and Transdiagnostic Tools for Psychosis Prediction: An Independent Validation and Improvement of the NAPLS-2 Risk Calculator in the Multisite PRONIA Cohort

BACKGROUND

Transition to psychosis is among the most adverse outcomes of clinical high-risk (CHR) syndromes encompassing ultra-high risk (UHR) and basic symptom states. Clinical risk calculators may facilitate an early and individualized interception of psychosis, but their real-world implementation requires thorough validation across diverse risk populations, including young patients with depressive syndromes.

METHODS

We validated the previously described NAPLS-2 (North American Prodrome Longitudinal Study 2) calculator in 334 patients (26 with transition to psychosis) with CHR or recent-onset depression (ROD) drawn from the multisite European PRONIA (Personalised Prognostic Tools for Early Psychosis Management) study. Patients were categorized into three risk enrichment levels, ranging from UHR, over CHR, to a broad-risk population comprising patients with CHR or ROD (CHR|ROD). We assessed how risk enrichment and different predictive algorithms influenced prognostic performance using reciprocal external validation.

RESULTS

After calibration, the NAPLS-2 model predicted psychosis with a balanced accuracy (BAC) (sensitivity, specificity) of 68% (73%, 63%) in the PRONIA-UHR cohort, 67% (74%, 60%) in the CHR cohort, and 70% (73%, 66%) in patients with CHR|ROD. Multiple model derivation in PRONIA-CHR|ROD and validation in NAPLS-2-UHR patients confirmed that broader risk definitions produced more accurate risk calculators (CHR|ROD-based vs. UHR-based performance: 67% [68%, 66%] vs. 58% [61%, 56%]). Support vector machines were superior in CHR|ROD (BAC = 71%), while ridge logistic regression and support vector machines performed similarly in CHR (BAC = 67%) and UHR cohorts (BAC = 65%). Attenuated psychotic symptoms predicted psychosis across risk levels, while younger age and reduced processing speed became increasingly relevant for broader risk cohorts.

CONCLUSIONS

Clinical-neurocognitive machine learning models operating in young patients with affective and CHR syndromes facilitate a more precise and generalizable prediction of psychosis. Future studies should investigate their therapeutic utility in large-scale clinical trials.

[Identifying cognitive and emotional markers in relation to auditory-verbal hallucinations in pediatric population: Physalis study]

OBJECTIVES

Auditory-verbal hallucinatory experiences (AVH) represent a prevalence of 12% in the general pediatric population. They are most often considered as a transient and benign developmental phenomenon, associated with mood and anxiety disorders. The persistence of AVHs for several years and into adolescence would represent a poor prognosis of progression into a psychiatric disorder, and more particularly psychotic disorder. The alteration of social and emotional cognitive markers are described as prodromal of this unfavorable progression which should be considered within the continuum between subclinical and clinical signs of the "psychosis phenotype". The objective of this study was to assess these markers in children and adolescents with AVH and their correlation with the presence and persistence of hallucinations.

METHODS

Multicenter prospective case-control study, longitudinal over 6months. Patients were included based on the presence of HAV on clinical examination. Forty subjects aged 8 to 16years from a clinical pediatric population were included. They were divided into two groups according to the Diagnostic Interview Schedule for Children-Child version (DISC-C): a group with AVH ("AVH+"), and a group without HAV ("AVH-"). A diagnosis of schizophrenia spectrum disorder was a non-inclusion criterion according to the criteria of DSM-5 (K-SADS-PL). This group was matched to the control group without AVH (AVH-) according to sex, age (±6months) and associated psychiatric diagnoses assessed by the MINI-Kid. The marker of social cognition was assessed with the NEPSY II test. The emotional marker was assessed with the self-questionnaires: EED IV, which highlights the emotions currently being felt by the subject, and the BAVQ-R, which categorizes the child's emotions in reaction to AVH.

RESULTS

No significant link was found between the social and emotional cognition markers and the presence of AVH at T0. At 6months, 50% of subjects in the AVH+ group suffered from persistent AVH and 18% progressed to a diagnosis of schizophrenia spectrum disorder. The persistence of AVH was not significantly correlated with the marker of social cognition, but it was significantly correlated with the presence of negative emotions (sadness, fear, hostility and anger) and inversely correlated with emotions of joy.

CONCLUSION

In this study, AVH experiences in the pediatric population are not linked to markers of social cognition, but negative emotions appear as early markers of AVH persistence. CLINICALTRIALS.

GOV IDENTIFIER

NCT02567500.

Predictors of help-seeking behaviour in people with mental health problems: a 3-year prospective community study

BACKGROUND

The majority of people with mental illness do not seek help at all or only with significant delay. To reduce help-seeking barriers for people with mental illness, it is therefore important to understand factors predicting help-seeking. Thus, we prospectively examined potential predictors of help-seeking behaviour among people with mental health problems (N = 307) over 3 years.

METHODS

Of the participants of a 3-year follow-up of a larger community study (response rate: 66.4%), data of 307 (56.6%) persons with any mental health problems (age-at-baseline: 16-40 years) entered a structural equation model of the influence of help-seeking, stigma, help-seeking attitudes, functional impairments, age and sex at baseline on subsequent help-seeking for mental health problems.

RESULTS

Functional impairment at baseline was the strongest predictor of follow-up help-seeking in the model. Help-seeking at baseline was the second-strongest predictor of subsequent help-seeking, which was less likely when help-seeking for mental health problems was assumed to be embarrassing. Personal and perceived stigma, and help-seeking intentions had no direct effect on help-seeking.

CONCLUSIONS

With only 22.5% of persons with mental health problems seeking any help for these, there was a clear treatment gap. Functional deficits were the strongest mediator of help-seeking, indicating that help is only sought when mental health problems have become more severe. Earlier help-seeking seemed to be mostly impeded by anticipated stigma towards help-seeking for mental health problems. Thus, factors or beliefs conveying such anticipated stigma should be studied longitudinally in more detail to be able to establish low-threshold services in future.

Recent stressful life events and stress sensitivity in children and adolescents at clinical risk for psychosis

Although psychosocial stress is consistently described as a casual factor for psychosis, the role of recent stressful life events (SLEs) is inconclusive. Studies with subjects with psychosis risk syndrome (PRS), fail to show a large number of SLEs but suggest greater stress sensitivity in these populations. We evaluate the presence of recent SLEs and stress sensitivity, and their relationship with symptoms and functionality in a sample consisting exclusively of help-seeking children and adolescents. Seventy-two 10- to 17-year-old help-seeking subjects who met PRS criteria and forty-two healthy control (HC) subjects participated in a naturalistic multi-site study. Measures of stress included the Stressful Life Events Schedule (SLES) and the G4 item of the Scale for Prodromal Syndromes (SOPS) scale. Child and adolescent PRS subjects presented greater number of SLEs during the previous year, greater total accumulated stress, greater sensitivity to stress, and more impaired tolerance to normal stress than did HC subjects. Stress measures showed a relationship with positive and negative attenuated symptoms, clinical variables and functionality. Our results support the role of stress in the PRS status. It reinforces the suggested differences for clinical presentation of PRS in terms of age, highlighting the importance of gathering data on the under-18 population.

Cortical gray matter reduction precedes transition to psychosis in individuals at clinical high-risk for psychosis: A voxel-based meta-analysis

Gray matter and cortical thickness reductions have been documented in individuals at clinical high-risk for psychosis and may be more pronounced in those who transition to psychosis. However, these findings rely on small samples and are inconsistent across studies. In this review and meta-analysis we aimed to investigate neuroanatomical correlates of clinical high-risk for psychosis and potential predictors of transition, using a novel meta-analytic method (Seed-based d Mapping with Permutation of Subject Images) and cortical mask, combining data from surface-based and voxel-based morphometry studies. Individuals at clinical high-risk for psychosis who later transitioned to psychosis were compared to those who did not and to controls, and included three statistical maps. Overall, individuals at clinical high-risk for psychosis did not differ from controls, however, within the clinical high-risk for psychosis group, transition to psychosis was associated with less cortical gray matter in the right temporal lobe (Hedges' g = -0.377), anterior cingulate and paracingulate (Hedges' g = -0.391). These findings have the potential to help refine prognostic and etiopathological research in early psychosis.

Annual Research Review: Prevention of psychosis in adolescents - systematic review and meta-analysis of advances in detection, prognosis and intervention

BACKGROUND

The clinical high-risk state for psychosis (CHR-P) paradigm has facilitated the implementation of psychosis prevention into clinical practice; however, advancements in adolescent CHR-P populations are less established.

METHODS

We performed a PRISMA/MOOSE-compliant systematic review of the Web of Science database, from inception until 7 October 2019, to identify original studies conducted in CHR-P children and adolescents (mean age <18 years). Findings were systematically appraised around core themes: detection, prognosis and intervention. We performed meta-analyses (employing Q statistics and I ² test) regarding the proportion of CHR-P subgroups, the prevalence of baseline comorbid mental disorders, the risk of psychosis onset and the type of interventions received at baseline. Quality assessment and publication bias were also analysed.

RESULTS

Eighty-seven articles were included (n = 4,667 CHR-P individuals). Quality of studies ranged from 3.5 to 8 (median 5.5) on a modified Newcastle-Ottawa scale. Detection: Individuals were aged 15.6 ± 1.2 years (51.5% males), mostly (83%) presenting with attenuated positive psychotic symptoms. CHR-P psychometric accuracy improved when caregivers served as additional informants. Comorbid mood (46.4%) and anxiety (31.4%) disorders were highly prevalent. Functioning and cognition were impaired. Neurobiological studies were inconclusive.

PROGNOSIS

Risk for psychosis was 10.4% (95%CI: 5.8%-18.1%) at 6 months, 20% (95%CI: 15%-26%) at 12 months, 23% (95%CI: 18%-29%) at 24 months and 23.3% (95%CI: 17.3%-30.7%) at ≥36 months.

INTERVENTIONS

There was not enough evidence to recommend one specific treatment (including cognitive behavioural therapy) over the others (including control conditions) to prevent the transition to psychosis in this population. Randomised controlled trials suggested that family interventions, cognitive remediation and fish oil supplementation may improve cognition, symptoms and functioning. At baseline, 30% of CHR-P adolescents were prescribed antipsychotics and 60% received psychotherapy.

CONCLUSIONS

It is possible to detect and formulate a group-level prognosis in adolescents at risk for psychosis. Future interventional research is required.

Genetic and clinical analyses of psychosis spectrum symptoms in a large multiethnic youth cohort reveal significant link with ADHD

Psychotic symptoms are not only an important feature of severe neuropsychiatric disorders, but are also common in the general population, especially in youth. The genetic etiology of psychosis symptoms in youth remains poorly understood. To characterize genetic risk for psychosis spectrum symptoms (PS), we leverage a community-based multiethnic sample of children and adolescents aged 8-22 years, the Philadelphia Neurodevelopmental Cohort (n = 7225, 20% PS). Using an elastic net regression model, we aim to classify PS status using polygenic scores (PGS) based on a range of heritable psychiatric and brain-related traits in a multi-PGS model. We also perform univariate PGS associations and evaluate age-specific effects. The multi-PGS analyses do not improve prediction of PS status over univariate models, but reveal that the attention deficit hyperactivity disorder (ADHD) PGS is robustly and uniquely associated with PS (OR 1.12 (1.05, 1.18) P = 0.0003). This association is driven by subjects of European ancestry (OR = 1.23 (1.14, 1.34), P = 4.15 × 10^-7) but is not observed in African American subjects (P = 0.65). We find a significant interaction of ADHD PGS with age (P = 0.01), with a stronger association in younger children. The association is independent of phenotypic overlap between ADHD and PS, not indirectly driven by substance use or childhood trauma, and appears to be specific to PS rather than reflecting general psychopathology in youth. In an independent sample, we replicate an increased ADHD PGS in 328 youth at clinical high risk for psychosis, compared to 216 unaffected controls (OR 1.06, CI(1.01, 1.11), P = 0.02). Our findings suggest that PS in youth may reflect a different genetic etiology than psychotic symptoms in adulthood, one more akin to ADHD, and shed light on how genetic risk can be investigated across early disease trajectories.

Establishing a clinical service to prevent psychosis: What, how and when? Systematic review

The first rate-limiting step to successfully translate prevention of psychosis in to clinical practice is to establish specialised Clinical High Risk for Psychosis (CHR-P) services. This study systematises the knowledge regarding CHR-P services and provides guidelines for translational implementation. We conducted a PRISMA/MOOSE-compliant (PROSPERO-CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Fifty-six studies (1998-2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12-35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, and unemployment in one third (36.6%). Most services provided up to 2-years (72.4%), of clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group (18.9%) psychotherapy, physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%), and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%), and functional status (48.8%). We provide ten practical recommendations for implementation of CHR-P services. Health service knowledge summarised by the current study will facilitate translational efforts for implementation of CHR-P services worldwide.

Neurocognition and Social Cognition- Possibilities for Diagnosis and Treatment in Ultra-High Risk for Psychosis State

In recent decades, clinicians have developed the construct of ultra-high risk (UHR) for psychosis to characterize the prodromal phase of psychosis or classify people with weakly expressed psychotic symptoms. In this conceptual analysis, we have gathered up-to-date data about the clinical picture of neurocognition and social cognition in people at UHR for psychosis. We also discuss treatment options. A well-chosen therapeutic approach can help to deal with difficulties and delay or even prevent the development of full-blown psychotic disorders in the UHR group. Despite much evidence supporting the benefits of therapy, early interventions are still not as widely used as they should be. Thus, a better understanding of the UHR state is very important for all healthcare workers.

Neuropsychological profile of children and adolescents with psychosis risk syndrome: the CAPRIS study

Neuropsychological underperformance is well described in young adults at clinical high risk for psychosis, but the literature is scarce on the cognitive profile of at-risk children and adolescents. The aim of this study is to describe the neuropsychological profile of a child and adolescent sample of patients with psychosis risk syndrome (PRS) compared to healthy controls and to analyze associations between attenuated psychotic symptoms and cognitive impairment. Cross-sectional baseline data analysis from a longitudinal, naturalistic, case-control, two-site study is presented. Eighty-one help-seeking subjects with PRS and 39 healthy controls (HC) aged between 10 and 17 years of age were recruited. PRS was defined by: positive or negative attenuated symptoms, Brief Limited Intermittent Psychotic Symptoms (BLIPS), genetic risk (first- or second-degree relative), or schizotypal personality disorder plus impairment in functioning. A neuropsychological battery was administered to assess general intelligence, verbal and visual memory, visuospatial abilities, speed processing, attention, and executive functions. The PRS group showed lower general neuropsychological performance scores at a multivariate level and lower scores than controls in general intelligence and executive functions. Lower scores on executive function and poorer attention were associated with high scores of positive attenuated psychotic symptoms. No association with attenuated negative symptoms was found. This study provides evidence of cognitive impairment in PRS children and adolescents and shows a relationship between greater cognitive impairment in executive functions and attention tasks and severe attenuated positive symptoms. However, longitudinal studies are needed to clarify the nature of cognitive impairment as a possible vulnerability marker.

Markers of Psychosis Risk in the General Population

The categorical approach to defining schizophrenia spectrum disorders requires meeting established criteria. To advance early identification and intervention in young people, the field has progressed to studying help-seeking individuals who are at clinical high risk based on subthreshold psychosis spectrum symptoms, and criteria have been articulated for qualifying individuals as at risk. A broader dimensional examination of psychosis has been applied to population-based studies on non-help seekers. This review highlights the ascertainment and assessment approaches to such population-based studies. Most studies are cross-sectional and rely on questionnaires with limited overlap of tools. However, several consistent findings emerge on symptoms, neurocognitive deficits, and neuroimaging parameters and other biomarkers associated with emergence and persistence of psychotic features. The findings are consistent with the literature on abnormalities associated with schizophrenia, including the presence of neurocognitive deficits; abnormalities in brain structure, function, and connectivity that are related to distress; impairment; and functional outcome. These findings support the validity of studying psychosis experiences during development in a way that can chart the emergence of psychosis in the context of general psychopathology. Such studies are necessary for establishing developmental trajectories that characterize this emergence and for identifying risk and resilience biomarkers moderating or modulating the full range of schizophrenia-related manifestations. More community-based studies are needed, with better standardization and harmonization of measures and incorporating longitudinal follow-up, to establish mechanistic links between cellular-molecular aberrations and specific manifestations of psychosis as envisioned by the precision medicine agenda.

An attachment perspective on the risk for psychosis: Clinical correlates and the predictive value of attachment patterns and mentalization

BACKGROUND

In a longitudinal design, the present study examined: (a) the nature of attachment patterns and reflective functioning (RF) in individuals at ultra-high risk for psychosis (UHR); (b) the association between RF and subclinical psychotic symtoms; and (c) the psychosis-predictive value of attachment patterns, RF, and the interaction between these factors.

METHOD

The sample comprised 57 UHR subjects and 53 clinical controls (non-UHR). UHR subjects were followed over a mean period of 14 months (SD = 2.7; range 11-19), during which time 11.5% developed psychosis. Attachment patterns and RF were measured. Hierarchical logistic regression was used to examine the predictive value of variables in the transition to psychosis.

RESULTS

At baseline, significant differences were found between groups in secure attachment patterns and RF. RF was negatively associated with the attenuated psychotic symptoms described by the Unusual Thought Content/Delusional Ideas, Suspiciousness/Persecutory Ideas, and Disorganized Communication subscales. Moreover, poor mentalization was related to an increased likelihood of developing a psychotic disorder (OR = 0.427, 95% CI [0.188, 0.970]); conversely, no predictive effects of the attachment variables and their interaction with RF on the transition to psychosis were found. Notably, an optimal threshold value of RF = 1.25 was found to distinguish UHR subjects who made the transition to psychosis from those who did not develop this pathology.

CONCLUSION

The results suggest that aberrant mentalizing patterns can predict the development of psychosis. Clinical implications of these results for the development of preventive treatments are discussed.

Sex differences in symptomatology of psychosis-risk patients and in prediction of psychosis

Sex differences may be important for understanding underlying pathophysiological mechanisms and developing effective preventions and treatments of mental disorders. Despite sex differences in the onset of psychosis, patients at clinical high risk for psychosis (CHR) are underinvestigated for sex effects, especially with respect to models for prediction of conversion to psychosis. We studied psychopathological sex differences in referrals to a German early detection service and in its subgroup of converters and examined sex-specific psychopathological prediction models. In 152 male and 90 female referrals (88% at CHR; 35% converters), symptoms assessed with the Structured Interview for Psychosis-Risk Syndromes were investigated for sex differences using effect sizes. Sex-specific prediction models of psychosis were separately generated using Cox regressions with a LASSO operator. We found different small sex effects (0.10 < Rosenthal's r < 0.30) in the referral and in the converter sample. In the referral sample, exclusively, males showed more pronounced symptoms (all negative symptoms incl. reduced stress tolerance, grandiosity, and disorganized communication); in converters, females experienced more pronounced perceptual abnormalities, bizarre thinking, and odd behaviors, while males expressed and experienced emotions to a lower degree. Furthermore, sexes differed in psychosis-predictive symptoms: "suspiciousness" and "disorganized communication" were prominent in prediction of psychosis in males, whereas "trouble with focus and attention" was so in females. While most sex differences in patients attending an early detection service seem to reflect general differences that are not specifically related to psychosis, others might be psychosis-specific. These results can inform the development of more individualized and effective interventions for CHR patients based on more precise sex-specific prediction models.

Clinical profile, conversion rate, and suicidal thinking and behaviour in children and adolescents at ultra-high risk for psychosis: a theoretical perspective

Over the past years there has been substantial growing interest in the prodromes of psychosis to identify individuals at risk for psychosis prior to their first psychotic episode. Researchers have proposed criteria to detect young adults at Ultra-High Risk (UHR) for psychosis, and these criteria have also been applied to children and adolescents, though few clinical studies have examined this population. This theoretical perspective presents some of the crucial issues in the assessment and treatment of UHR children and adolescents: the presence of a specific clinical profile (i.e., different to that of healthy controls and UHR young adults), the predictive value of UHR criteria, and the presence and clinical significance of suicidal thinking and behaviour. In UHR children and adolescents, like UHR young adults, the presence of Attenuated Psychotic Symptoms (APS) is the most frequently reported inclusion criterion at baseline, with a prevalence of approximately 89–100%. In addition, there are frequently non-psychotic comorbid diagnoses of depressive and anxiety disorders. In contrast to the UHR adult population, UHR children and adolescents demonstrate a lower conversion rate to frank psychosis, most likely due to their high rate of APS. Finally, UHR adolescents report a high prevalence of suicidal ideation and self-injurious behaviour (67.5%), as well as a significantly greater frequency of attempted suicide, relative to adolescents with frank psychosis. On this basis, UHR children and adolescents report a clinical complexity that should be carefully monitored and considered for specific and targeted therapeutic interventions to be planned and developed.

Effects of age and sex on clinical high-risk for psychosis in the community

BACKGROUND

Recent reports of both heightened prevalence rates and limited clinical relevance of clinical high-risk (CHR) criteria and their relevant symptoms in children and adolescents indicate an important role of neurodevelopment in the early detection of psychoses. Furthermore, sex effects in CHR symptoms have been reported, though studies were inconclusive. As sex also impacts on neurodevelopment, we expected that sex might have an additional contribution to age in the prevalence and clinical relevance of CHR symptoms and criteria.

AIM

To investigate age and sex effects on CHR criteria and symptoms and their association with psychosocial impairment and mental disorder.

METHODS

In this cross-sectional cohort study, n = 2916 8- to 40-year-olds, randomly drawn from the population register of the Swiss canton Bern, were assessed in semi-structured interviews by phone or face-to-face for CHR symptoms and criteria using the Structured Interview for Psychosis-Risk Syndromes and the Schizophrenia Proneness Instrument in its child and youth, and adult version, respectively. Furthermore, social and occupational functioning and DSM-IV axis I disorders were assessed. Simple and interaction effects of age and sex on CHR symptoms and criteria, and interaction effects of age, sex, and CHR symptoms and criteria on presentation of functional impairment and of non-psychotic disorder were investigated using logistic regression analyses.

RESULTS

Altogether, 542 (18.6%) participants reported any CHR symptom; of these, 261 (9.0%) participants reported any one of the 11 criteria relevant cognitive and perceptual basic symptoms, and 381 (13.1%) any one of the five attenuated or transient psychotic symptoms (attenuated psychotic symptoms/brief intermittent psychotic symptoms). Fewer participants met any one of the CHR criteria (n = 82, 2.8%) or any one of the three recently recommended CHR criteria (n = 38, 1.3%). Both age and sex were significantly (P < 0.05) associated with CHR symptoms and criteria, mostly by younger age and female sex. Though slightly differing between symptom groups, age thresholds were detected around the turn from adolescence to adulthood; they were highest for cognitive basic symptoms and CHR criteria. With the exception of the infrequent speech disorganization attenuated psychotic symptom, the interaction of age with CHR symptoms and criteria predicted functional impairment; whereas, independent of each other, sex and CHR symptoms mostly predicted mental disorders.

CONCLUSION

Age and sex differentially impact on CHR symptoms and criteria; these differences may support better understanding of causal pathways. Thus, future CHR studies should consider effects of sex and age.

Validation of the Korean Version of the 15-Item Community Assessment of Psychic Experiences in a College Population

OBJECTIVE

To investigate the reliability and validity of the Korean version of the Community Assessment of Psychic Experiences-15 item positive scale (CAPE-15) in college students.

METHODS

This study had two stages: initial screening with self-report questionnaires including the CAPE-15, and semi-structured interviews to investigate the instrument's diagnostic validity. The initial screening involved 1,749 college students. The modified Korean version of Prodromal Questionnaire-16 item (mKPQ-16) was also administered. The criteria for ultra-high risk (UHR) of psychosis in the Comprehensive Assessment of At-Risk Mental States (CAARMS) were the gold standard for diagnosis.

RESULTS

Twelve of the interviewed subjects met the CAARMS criteria for UHR of psychosis. The area under the receiver operating characteristic curve was highest (0.936) for the CAPE-15 distress score (p<0.001). The use of 6 as the cutoff for the CAPE-15 distress score resulted in the best balance of sensitivity (91.7%) and specificity (85.2%), with a favorable positive predictive value of 32.4%. The coefficients of correlation between the CAPE-15 and mKPQ-16 were significant.

CONCLUSION

The Korean version of the CAPE-15 is a good instrument for screening for psychosis risk in collegiate settings. The validation of this scale could contribute to the early identification of psychosis in the Korean community.

Basic Symptoms Are Associated With Age in Patients With a Clinical High-Risk State for Psychosis: Results From the PRONIA Study

In community studies, both attenuated psychotic symptoms (APS) and basic symptoms (BS) were more frequent but less clinically relevant in children and adolescents compared to adults. In doing so, they displayed differential age thresholds that were around age 16 for APS, around age 18 for perceptive BS, and within the early twenties for cognitive BS. Only the age effect has previously been studied and replicated in clinical samples for APS. Thus, we examined the reported age effect on and age thresholds of 14 criteria-relevant BS in a patient sample at clinical-high risk of psychosis (N = 261, age 15-40 yrs.), recruited within the European multicenter PRONIA-study. BS and the BS criteria, "Cognitive Disturbances" (COGDIS) and "Cognitive-perceptive BS" (COPER), were assessed with the "Schizophrenia Proneness Instrument, Adult version" (SPI-A). Using logistic regressions, prevalence rates of perceptive and cognitive BS, and of COGDIS and COPER, as well as the impact of social and role functioning on the association between age and BS were studied in three age groups (15-18 years, 19-23 years, 24-40 years). Most patients (91.2%) reported any BS, 55.9% any perceptive and 87.4% any cognitive BS. Furthermore, 56.3% met COGDIS and 80.5% COPER. Not exhibiting the reported differential age thresholds, both perceptive and cognitive BS, and, at trend level only, COPER were less prevalent in the oldest age group (24-40 years); COGDIS was most frequent in the youngest group (15-18 years). Functional deficits did not better explain the association with age, particularly in perceptive BS and cognitive BS meeting the frequency requirement of BS criteria. Our findings broadly confirmed an age threshold in BS and, thus, the earlier assumed link between presence of BS and brain maturation processes. Yet, age thresholds of perceptive and cognitive BS did not differ. This lack of differential age thresholds might be due to more pronounced the brain abnormalities in this clinical sample compared to earlier community samples. These might have also shown in more frequently occurring and persistent BS that, however, also resulted from a sampling toward these, i.e., toward COGDIS. Future studies should address the neurobiological basis of CHR criteria in relation to age.

Spontaneous discontinuation of distressing auditory verbal hallucinations in a school-based sample of adolescents: a longitudinal study

Auditory verbal hallucinations (AVH) can be transiently present in both clinical and healthy adolescent populations. It is not yet fully understood why AVH discontinue in some adolescents and persist in others. The aim of this explorative study is to investigate predictors of spontaneous discontinuation of distressing AVH in a school-based sample of adolescents. 1841 adolescents (mean age 12.4 years, 58% female) completed self-report questionnaires at baseline. The current study included 123 adolescents (7%; 63% female) who reported at least mild distressing AVH at baseline and completed follow-up measurements. LASSO analyses were used to uncover predictors of spontaneous discontinuation of distressing AVH. During follow-up, 43 adolescents (35%) reported having experienced distressing AVH during the last 12 months, while 80 adolescents did not. Spontaneous discontinuation of distressing AVH was predicted by never having used cannabis, parents not being divorced in the past year, never having been scared by seeing a deceased body, less prosocial behaviour, school grade repetition, having the feeling that others have it in for you, having anxiety when meeting new people, having lived through events exactly as if they happened before and having the feeling as if parts of the body have changed. No associations between spontaneous discontinuation of distressing AVH and age or ethnicity were found. Distressing AVH in non-clinical adolescents are mostly transient. Discontinuation was predicted up to a certain extent. However, several predictors were difficult to interpret and do not provide leads for preventive measures, except for discouraging cannabis use.

Brain-Wide Functional Dysconnectivity in Schizophrenia: Parsing Diathesis, Resilience, and the Effects of Clinical Expression

BACKGROUND

The functional dysconnectivity observed from functional magnetic resonance imaging (fMRI) studies in schizophrenia is also seen in unaffected siblings indicating its association with the genetic diathesis. We intended to apportion resting-state dysconnectivity into components that represent genetic diathesis, clinical expression or treatment effect, and resilience.

METHODS

fMRI data were acquired from 28 schizophrenia patients, 28 unaffected siblings, and 60 healthy controls. Based on Dosenbach's atlas, we extracted time series of 160 regions of interest. After constructing functional network, we investigated between-group differences in strength and diversity of functional connectivity and topological properties of undirected graphs.

RESULTS

Using analysis of variance, we found 88 dysconnectivities. Post hoc t tests revealed that 62.5% were associated with genetic diathesis and 21.6% were associated with clinical expression. Topologically, we observed increased degree, clustering coefficient, and global efficiency in the sibling group compared to both patients and controls.

CONCLUSION

A large portion of the resting-state functional dysconnectivity seen in patients represents a genetic diathesis effect. The most prominent network-level disruption is the dysconnectivity among nodes of the default mode and salience networks. Despite their predisposition, unaffected siblings show a pattern of resilience in the emergent connectomic topology. Our findings could potentially help refine imaging genetics approaches currently used in the pursuit of the pathophysiology of schizophrenia.

DSM-5 Attenuated Psychosis Syndrome in Adolescents Hospitalized With Non-psychotic Psychiatric Disorders

Introduction: Although attenuated psychotic symptoms often occur for the first time during adolescence, studies focusing on adolescents are scarce. Attenuated psychotic symptoms form the criteria to identify individuals at increased clinical risk of developing psychosis. The study of individuals with these symptoms has led to the release of the DSM-5 diagnosis of Attenuated Psychosis Syndrome (APS) as a condition for further research. We aimed to characterize and compare hospitalized adolescents with DSM-5-APS diagnosis vs. hospitalized adolescents without a DSM-5-APS diagnosis. Methods: Interviewing help-seeking, hospitalized adolescents (aged 12-18 years) and their caregivers independently with established research instruments, we (1) evaluated the presence of APS among non-psychotic adolescents, (2) characterized and compared APS and non-APS individuals regarding sociodemographic, illness and intervention characteristics, (3) correlated psychopathology with levels of functioning and severity of illness and (4) investigated the influence of individual clinical, functional and comorbidity variables on the likelihood of participants to be diagnosed with APS. Results: Among 248 consecutively recruited adolescents (age=15.4 ± 1.5 years, females = 69.6%) with non-psychotic psychiatric disorders, 65 (26.2%) fulfilled APS criteria and 183 (73.8%) did not fulfill them. Adolescents with APS had higher number of psychiatric disorders than non-APS adolescents (3.5 vs. 2.4, p < 0.001; Cohen's d = 0.77), particularly, disruptive behavior disorders (Cramer's V = 0.16), personality disorder traits (Cramer's V = 0.26), anxiety disorders (Cramer's V = 0.15), and eating disorders (Cramer's V = 0.16). Adolescents with APS scored higher on positive (Cohen's d = 1.5), negative (Cohen's d = 0.55), disorganized (Cohen's d = 0.51), and general symptoms (Cohen's d = 0.84), and were more severely ill (Cohen's d = 1.0) and functionally impaired (Cohen's d = 0.31). Negative symptoms were associated with lower functional levels (Pearson ρ = -0.17 to -0.20; p = 0.014 to 0.031). Global illness severity was associated with higher positive, negative, and general symptoms (Pearson ρ = 0.22 to 0.46; p = 0.04 to p < 0.001). APS status was independently associated with perceptual abnormalities (OR = 2.0; 95% CI = 1.6-2.5, p < 0.001), number of psychiatric diagnoses (OR = 1.5; 95% CI = 1.2-2.0, p = 0.002), and impaired stress tolerance (OR = 1.4; 95% CI = 1.1-1.7, p = 0.002) (r ² = 0.315, p < 0.001). Conclusions: A considerable number of adolescents hospitalized with non-psychotic psychiatric disorders meet DSM-5-APS criteria. These help-seeking adolescents have more comorbid disorders and more severe symptoms, functional impairment, and severity of illness than non-APS adolescents. Thus, they warrant high intensity clinical care.

Assessing Youth with Psychotic Experiences: A Phenomenological Approach

Psychotic experiences may be part of normal development or indicate a wide range of mental disorders. This article shows how a systematic, domain-based, phenomenological approach to assessing psychotic symptoms in youth facilitates the gathering of the nuanced clinical information necessary to understand a child's specific experience. Mapping this information onto a narrative timeline, while understanding the evolution and developmental context of psychotic experiences, is essential in making an accurate diagnostic formulation and appropriate treatment plan for youth presenting with psychotic experiences.

Prevalence and correlates of psychotic-like experiences in the general population

BACKGROUND

To what extent Psychotic Like Experiences (PLEs) are associated with nonpsychotic psychiatric disorders and whether the number of PLEs is associated with higher rates of psychiatric disorders remains unclear.

METHODS

The sample was composed of 34,653 civilian participants, aged 18 years and older from wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). This was a representative sample of the non-institutionalized U.S.

POPULATION

Twenty-two PLEs were assessed. Lifetime prevalence of psychiatric disorders (any mood, anxiety, substance use and personality disorders, PTSD, ADHD, and suicide attempts) according to the number of PLEs were calculated.

RESULTS

Almost a third (26.69%) of respondents reported experiencing at least one type of PLEs. There was a gradual association between the number of PLEs and the presence of a nonpsychotic psychiatric disorder (ranging from 5.68%in participants with no PLEs up to 99.53% in those with five or more PLEs). This association with PLE was significant for each of the 25 psychiatric disorders examined regardless of the number of PLEs. Lifetime prevalence of PLEs were significantly higher among the younger respondents, women, non-married, unemployed, high educational level and those with low family income.

CONCLUSION

There is a gradual increase in the magnitude of the association of the numbers of PLEs for each of the 25 nonpsychotic psychiatric disorders examined. Having at least one PLE is strongly associated with the presence of a psychiatric disorder.

Age effects on basic symptoms in the community: A route to gain new insight into the neurodevelopment of psychosis?

Reports of limited clinical significance of attenuated psychotic symptoms before age 15/16 indicate an important role of neurodevelopment in the early detection of psychoses. Therefore, we examined if age also exerts an influence on the prevalence and clinical significance of the 14 cognitive and perceptive basic symptoms (BS) used in psychosis-risk criteria and conceptualized as the most direct self-experienced expression of neurobiological aberrations. A random representative general population sample of the Swiss canton Bern (N = 689, age 8-40 years, 06/2011-05/2014) was interviewed for BS, psychosocial functioning, and current mental disorder. BS were reported by 18% of participants, mainly cognitive BS (15%). In regression analyses, age affected perceptive and cognitive BS differently, indicating an age threshold for perceptive BS in late adolescence (around age 18) and for cognitive BS in young adulthood (early twenties)-with higher prevalence, but a lesser association with functional deficits and the presence of mental disorder in the below-threshold groups. Thereby, interaction effects between age and BS on functioning and mental disorder were commonly stronger than individual effects of age and BS. Indicating support of the proposed "substrate-closeness" of BS, differential age effects of perceptual and cognitive BS seem to follow normal brain maturation processes, in which they might occur as infrequent and temporary non-pathological disturbances. Their persistence or occurrence after conclusion of main brain maturation processes, however, might signify aberrant maturation or neurodegenerative processes. Thus, BS might provide important insight into the pathogenesis of psychosis and into differential neuroprotective or anti-inflammatory targets.

Associations of psychosis-risk symptoms with quality of life and self-rated health in the Community

BACKGROUND

Understanding factors related to poor quality of life (QoL) and self-rated health (SRH) in clinical high-risk (CHR) for psychosis is important for both research and clinical applications. We investigated the associations of both constructs with CHR symptoms, axis-I disorders, and sociodemographic variables in a community sample.

METHODS

In total, 2683 (baseline) and 829 (3-year follow-up) individuals of the Swiss Canton of Bern (age-at-baseline: 16-40 years) were interviewed by telephone regarding CHR symptoms, using the Schizophrenia Proneness Instrument for basic symptoms, the Structured Interview for Psychosis-Risk Syndromes for ultra-high risk (UHR) symptoms, the Mini-International Neuropsychiatric Interview for current axis-I disorders, the Brief Multidimensional Life Satisfaction Scale for QoL, and the 3-level EQ-5D for SRH.

RESULTS

In cross-sectional structural equation modelling, lower SRH was exclusively significantly associated with higher age, male gender, lower education, and somatoform disorders. Poor QoL was exclusively associated only with eating disorders. In addition, both strongly interrelated constructs were each associated with affective, and anxiety disorders, UHR and, more strongly, basic symptoms. Prospectively, lower SRH was predicted by lower education and anxiety disorders at baseline, while poorer QoL was predicted by affective disorders at baseline.

CONCLUSIONS

When present, CHR, in particular basic symptoms are already distressful for individuals of the community and associated with poorer subjective QoL and health. Therefore, the symptoms are clinically relevant by themselves, even when criteria for a CHR state are not fulfilled. Yet, unlike affective and anxiety disorders, CHR symptoms seem to have no long-term influence on QoL and SRH.