Shades of vulnerability: latent structures of clinical caseness in prodromal and early phases of schizophrenia

Development and validation of a short version of the questionnaire of stressful life events (QSLE)

Stressful life events (SLE) tend to occur before the onset of psychosis, this highlights the importance of its detection and evaluation in these patients. The need to have instruments that assess SLE easily and quickly underpins the objective of this study, which is to validate a short version of the questionnaire of stressful life events (QSLE). 124 patients with first-episode psychosis and 218 healthy controls aged between 11 and 52 years were recruited. The QSLE scale underwent discrimination analysis, which revealed 18 items had good SLEs discriminability between the two samples. These 18 items were then used to create the shorter QSLE-SV. The QSLE-SV showed good internal consistency (Cronbach's alpha = 0.749). An AUC of 0.830 was observed, suggesting that the predictor was good. Using 2 as the cut-off score to predict an individual as a patient would yield a sensitivity of 91.1% and a specificity of 51.6%, and using a cut-off point of 3, the sensitivity was 77.4% and the specificity was 72.5%. QSLE-SV displayed satisfactory psychometric properties in a Spanish population. The QSLE-SV allows for investigating childhood, adolescent and adult life events by measuring current stress and age on a continuous scale in a quick and easy way.

Impact of traumatic life events on clinical variables of individuals with first-episode psychosis and healthy controls

BACKGROUND

Traumatic life events (TLEs) are one of the most robust environmental risk factors for the onset of first-episode psychosis (FEP).

AIMS

To explore TLEs in FEP patients and healthy controls (HC), to analyze gender differences and to examine whether TLEs were associated with sociodemographic, clinical and psychofunctional variables in all FEP sample and split by age.

METHODS

Descriptive and cross-sectional study. Three hundred and thirty-five FEP and 253 HC were recruited at 16 Spanish mental health research centers. The Traumatic Experiences in Psychiatric Outpatients Questionnaire was administered.

RESULTS

We found a higher number of TLEs in FEP than in HC, and the proportion of individuals with three or more TLEs was significantly higher in the FEP group. No differences were found in terms of gender and age. There was no relationship between total number of TLEs and psychotic symptomatology and functional outcomes.

CONCLUSIONS

The number and cumulative TLEs should be taken into account in the detection, epidemiology and process of recovery in FEP.

Antipsychotic prescription, assumption and conversion to psychosis: resolving missing clinical links to optimize prevention through precision

The current concept of clinical high-risk(CHR) of psychosis relies heavily on “below-threshold” (i.e. attenuated or limited and intermittent) psychotic positive phenomena as predictors of the risk for future progression to “above-threshold” positive symptoms (aka “transition” or “conversion”). Positive symptoms, even at attenuated levels are often treated with antipsychotics (AP) to achieve clinical stabilization and mitigate the psychopathological severity. The goal of this study is to contextually examine clinicians’ decision to prescribe AP, CHR individuals’ decision to take AP and psychosis conversion risk in relation to prodromal symptoms profiles. CHR individuals (n = 600) were recruited and followed up for 2 years between 2016 and 2021. CHR individuals were referred to the participating the naturalistic follow-up study, which research procedure was independent of the routine clinical treatment. Clinical factors from the Structured Interview for Prodromal Syndromes (SIPS) and global assessment of function (GAF) were profiled via exploratory factor analysis (EFA), then the extracted factor structure was used to investigate the relationship of prodromal psychopathology with clinicians’ decisions to AP-prescription, CHR individuals’ decisions to AP-taking and conversion to psychosis. A total of 427(71.2%) CHR individuals were prescribed AP at baseline, 532(88.7%) completed the 2-year follow-up, 377(377/532, 70.9%) were taken AP at least for 2 weeks during the follow-up. EFA identified six factors (Factor-1-Negative symptoms, Factor-2-Global functions, Factor-3-Disorganized communication & behavior, Factor-4-General symptoms, Factor-5-Odd thoughts, and Factor-6-Distorted cognition & perception). Positive symptoms (Factor-5 and 6) and global functions (Factor-2) factors were significant predictors for clinicians’ decisions to AP-prescription and CHR individuals’ decisions to assume AP, whereas negative symptoms (Factor-1) and global functions (Factor-2) factors predicted conversion. While decisions to AP-prescription, decisions to AP-taking were associated to the same factors (positive symptoms and global functions), only one of those was predictive of conversion, i.e. global functions. The other predictor of conversion, i.e. negative symptoms, did not seem to be contemplated both on the clinician and patients’ sides. Overall, the findings indicated that a realignment in the understanding of AP usage is warranted.

Antipsychotics are related to psychometric conversion to psychosis in ultra-high-risk youth

BACKGROUND

The prescription of antipsychotics outside overt psychotic conditions remains controversial, especially in youth where it is relatively widespread. Furthermore, some studies seem to indicate that antipsychotic exposure in individuals at ultra-high-risk (UHR) for psychosis is associated with higher conversion rates. This study was set up to test whether the inter-current prescription of antipsychotics in UHR patients was related to the psychometric threshold for a diagnosis of psychosis.

METHODS

The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 125 UHR participants. Standard psychometric criteria were used to quantify conversion to psychosis. Kaplan-Mayer and Cox proportional hazard survival analysis were applied to determine the impact of having or not received the prescription of an antipsychotic drug.

RESULTS

Over the study period 30 (24%) subjects received the prescription of an antipsychotic. In the sample, there were 31 participants (25%) who had reached the psychometric threshold for conversion to psychosis after 2 years of treatment. UHR people who received a prescription of antipsychotics during the first 2 years of treatment were statistically more likely to reach the psychometric threshold for conversion to psychosis on the BPRS: Hazard ratio = 3.03 (95%CI: 1.49-6.16); p = .003.

CONCLUSION

This finding supports the hypothesis that the prescription of antipsychotics within UHR cohorts is to be considered a red flag for higher incipient risk of conversion to psychosis.

Duration of Untreated Disorder and Cannabis Use: An Observational Study on a Cohort of Young Italian Patients Experiencing Psychotic Experiences and Dissociative Symptoms

BACKGROUND

The Duration of Untreated Psychosis (DUP) is the time between the first-episode psychosis (FEP) and the initiation of antipsychotic treatment. It is an important predictor of several disease-related outcomes in psychotic disorders. The aim of this manuscript is investigating the influence of cannabis on the DUP and its clinical correlates.

METHODS

During years 2014-2019, sixty-two FEP patients with and without cannabis use disorder (CUD) were recruited from several Italian psychiatric hospitals. The subjects were then divided into two groups based on the duration of the DUP and assessed at the beginning of the antipsychotic treatment and after 3 and 6 months, using the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF) scale, and the Dissociative Experiences Scale (DES-II).

RESULTS

As expected, a longer DUP was associated with worse symptoms and cannabis use did not seem to affect the DUP, but both were related with more dissociative symptoms at onset and over time.

DISCUSSION

According to our study, cannabis use can be a predictor of FEP and DUP, and of disease outcome. However, several factors might influence the relationship between cannabis use and DUP. Preventing cannabis use and early diagnosis of psychotic disorders might impact the disease by reducing the persistence of symptoms and limiting dissociative experiences.

Outcome at 2-year of treatment in first-episode psychosis patients who were enrolled in a specialized early intervention program

Treatment in early intervention services (EIS) seems superior to treatment as usual on several outcomes, but the extent of heterogeneity in response is unclear. In this study, treatment response trajectories up to 2 years in first-episode psychosis (FEP) patients enrolled in an Italian early intervention service (EIS) have been quantified. The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 129 participants. Conditional growth modeling and latent class growth analysis were used to test changes over time in the BPRS and separation into independent classes over time. Group differences were tested on socio-demographic and clinical variables known to be related to outcome in psychosis. Scores on the BPRS showed a statistically significant decrease in overall scores across all tested models. Four trajectories were identified across 2 years. Most patients showed a progressive decrease in the BPRS scores; a scant fraction showed a more stepped decrease from very high levels of psychopathology. No potential predictor was statistically related to the time course of BPRS scores. Most patients that undergo treatment within an EIS are characterized by amelioration, but patients that have higher baseline scores of psychopathology require more intensive treatment.

Anhedonia in adolescents at ultra-high risk (UHR) of psychosis: findings from a 1-year longitudinal study

Previous findings suggested deficits in pleasure experience in schizophrenia, but little is known in psychosis risk prodrome, especially in adolescence. Aim of this study was (1) to assess anhedonia in distinct help-seeking subgroups of adolescents identified through the ultra-high risk (UHR) criteria, (2) to explore any association of anhedonia with other psychopathological aspects in the UHR group, and (3) to monitor longitudinally the stability of anhedonia in UHR individuals across 1-year follow-up period. 123 participants (13-18 years) completed the Comprehensive Assessment of At-Risk Mental States (CAARMS), the Beck Depression Inventory-II, the Schizotypal Personality Questionnaire-Brief version, the Brief-O-LIFE questionnaire (BOL), and the Brief version of the World Health Organization Quality of Life scale (WHOQOL-BREF). Two different indexes of anhedonia were used: CAARMS "Anhedonia" item 4.3 and BOL "Introvertive Anhedonia" subscale scores. No difference in anhedonia levels between UHR and First Episode Psychosis (FEP) groups was found. UHR adolescents showed higher CAARMS and BOL anhedonia scores than non-UHR/FEP. After 1-year follow-up period, UHR adolescents had a significant decrease in severity only in CAARMS anhedonia subscores. In UHR subgroup, CAARMS anhedonia measures showed significant correlations with impaired role functioning and negative symptoms, while BOL anhedonia was significantly correlated with specific schizotypal personality traits concerning interpersonal deficits. Anhedonia is prominent in the psychosis prodrome, also in adolescence. Its severity is not statistically different from that of FEP adolescents and is related to more severe functioning impairment and a worse quality of life.

Duration of the psychosis prodrome

The recognition of a prodromal period preceding the onset of frank psychosis dates back to its first descriptions. Despite insights gained from a prospective approach to the study of the Clinical High Risk syndrome for psychosis (CHR-P), a prospectively-based understanding of the duration of the psychosis prodrome and the factors that may influence is not well-established. Here we analyze data from the second North American Prodrome Longitudinal Study (NAPLS-2) to characterize prodrome duration in those who converted to psychosis. Of the 764 participants identified as being at CHR-P, 94 converted to psychosis and 92 of these had recorded estimates of prodrome onset. Estimates of prodrome duration were derived from CHR-P syndrome onset and conversion dates from the Structured Interview for Psychosis-risk Syndromes. Results identified a mean prodrome duration of 21.6 months. Neither CHR-P sub-syndrome nor medication exposure was found to significantly influence prodrome duration in this sample. These results provide the most precise estimate of prodrome duration to date, although results are limited to prodromes identified by ascertainment as being at CHR-P. Our findings also suggest a rule of thirds with regard to prodrome duration in those followed for two years: one third of CHR-P patients who convert will do so by 1 year after CHR-P syndrome onset, another third 1-2 years after onset, and the final third more than 2 years after onset.

Tracking salience in young people: A psychometric field test of the Aberrant Salience Inventory (ASI)

AIM

To explore the prevalence of Aberrant Salience (AS, an alleged experiential feature of psychosis-proneness) in Italian young people and corroborate the transcultural validity of the Aberrant Salience Inventory (ASI).

METHODS

Young adults attending an Italian university (n = 649) underwent serial evaluations with the ASI together with psychometric proxies for help seeking General Health Questionnaire and attenuated positive and negative symptoms Schizotypal Personality Questionnaire (SPQ). The distribution of ASI scores was explored with latent class analysis (LCA).

RESULTS

Reliability of the Italian version of the ASI (I-ASI) was acceptable for all subscales (ordinal alpha >.70). Concurrent validity was in the expected direction, with higher correlations with measures of attenuated positive symptoms vs negative symptoms of psychosis (Steigers' z test, P < .005 in all comparisons). LCA identified three classes, with 217 (33.4%) participants in the "high aberrant salience" class. Gender and age were not related to class membership. Compared to the baseline class, SPQ scores in the schizotypy range were more likely in the "high aberrant salience" class (OR = 39.1; 95%confidence interval: 5.30-288.1).

CONCLUSION

AS is a relatively common experience among Italian young people. The study also confirmed the validity of field-testing ASI as a tool for the real-world characterization of people with vulnerability to psychosis, such as symptomatic help seekers with clinical high-risk states.

Developmental vulnerability to psychosis: Selective aggregation of basic self-disturbance in early onset schizophrenia

Trait-like anomalies of subjective experience (aka, Basic Self-disturbance or Self-disorder, SD) have been empirically identified as schizophrenia-specific markers of vulnerability in several clinical and genetic high-risk populations. However, such specificity is still to be tested in developmental years, where emerging psychopathology is less crystallized and diagnostic boundaries more blurred. Thus, the current study explores the distribution of SD in adolescent help-seekers (age range 14 to 18) and tests the specificity of SD with respect to the severity of their diagnostic staging (Early Onset schizophrenia-spectrum psychosis [EOP], ultra high-risk [UHR] and clinical help-seeking controls [CHSC]). For this purpose, 96 help-seeking adolescents consecutively referred to specialized Child and Adolescent Units for diagnostic evaluation, underwent a comprehensive psychopathological examination including the specific interview for SD (i.e. the Examination of Anomalous Self-Experience, EASE). One-way ANOVA was used to test the diagnostic distribution of SD (EASE score), whereas multinomial logistic regression was used to test the effect of SD on the diagnostic outcome. SD frequency (both in terms of EASE total score and domain sub-scores) was decreasing progressively from EOP to CHSC, with intermediate levels in UHR. The EASE total score increased the risk of belonging to the more severe diagnostic stages (i.e, UHR and EOP vs CHSC as reference class) and allowed the correct reclassification of the 75% of the sample. The results confirm the schizophrenia-spectrum specificity of SD in adolescence, highlighting their potential value for early differential diagnosis and risk stratification.

The Italian version of the 16-item prodromal questionnaire (iPQ-16): Field-test and psychometric features

OBJECTIVE

Among current early screeners for psychosis-risk states, the Prodromal Questionnaire-16 items (PQ-16) is often used. We aimed to assess validity and reliability of the Italian version of the PQ-16 in a young adult help-seeking population.

METHODS

We included 154 individuals aged 18-35years seeking help at the Reggio Emilia outpatient mental health services in a large semirural catchment area (550.000 inhabitants). Participants completed the Italian version of the PQ-16 (iPQ-16) and were subsequently evaluated with the Comprehensive Assessment of At-Risk Mental States (CAARMS). We examined diagnostic accuracy (i.e. specificity, sensitivity, negative and positive likelihood ratios, and negative and positive predictive values) and content, convergent, and concurrent validity between PQ-16 and CAARMS using Cronbach's alpha, Spearman's rho, and Cohen's kappa, respectively. We also tested the validity of the adopted PQ-16 cut-offs through Receiver Operating Characteristic (ROC) curves plotted against CAARMS diagnoses and the 1-year predictive validity of the PQ-16.

RESULTS

The iPQ-16 showed high internal consistency and acceptable diagnostic accuracy and concurrent validity. ROC analyses pointed to a cut-off score of ≥5 as best cut-off. After 12months of follow-up, 8.7% of participants with a PQ-16 symptom total score of ≥5 who were below the CAARMS psychosis threshold at the baseline, developed a psychotic disorder.

CONCLUSIONS

Psychometric properties of the iPQ-16 were satisfactory.

The early recognition inventory ERIraos assesses the entire spectrum of symptoms through the course of an at-risk mental state

AIM

Functional disability and social consequences frequently occur at the prodromal stage of schizophrenia. Efforts to recognize an increasing risk of psychosis onset have thus become a topical issue worldwide. This is to introduce the English version of the ERIraos early-recognition inventory.

METHODS

The ERIraos, developed in a systematic, empirical approach from the Instrument for the Retrospective Assessment of the Onset of Schizophrenia, incorporates basic symptoms from the Cologne Early Recognition Study. The research version also includes as further predictive items so-called brief limited intermittent psychotic symptoms and attenuated psychotic symptoms from the Comprehensive Assessment of At-Risk Mental States instrument.

RESULTS

The ERIraos with its 15-item screening Checklist and 50-item Symptom List permits early recognition of psychosis risk in three steps of decreasing sensitivity and increasing specificity. Step 1 relies on patients' self-perception of symptoms, which prompt them to contact a primary health service. There, in Step 2, at-risk individuals are identified using the Checklist, characterized by a low-risk threshold, and referred to further examination using the Symptom List (Step 3). Information on symptom accumulation and increasing symptom severity enhances the instrument's predictive power. In a validation test, psychotic transitions increased linearly up to 50% over 2 years. Compared with other instruments and on the prodromal stage of depressive disorder, the ERIraos has shown good predictive capacity.

CONCLUSIONS

The ERIraos has been successfully employed as a two-step tool for the early recognition of psychosis risk in several German studies and translated into several foreign languages.

Current and potential pharmacological and psychosocial interventions for anxiety symptoms and disorders in patients with schizophrenia: structured review

OBJECTIVE

Between 30% and 62% of patients with schizophrenia present with co-morbid anxiety disorders that are associated with increased overall burden. Our aim was to summarize current and potential interventions for anxiety in schizophrenia.

DESIGN

Structured review, summarizing pharmacological and psychosocial interventions used to reduce anxiety in schizophrenia and psychosis.

RESULTS

Antipsychotics have been shown to reduce anxiety, increase anxiety, or have no effect. These may be augmented with another antipsychotic, anxiolytic, or antidepressant. Novel agents, such as L-theanine, pregabalin, and cycloserine, show promise in attenuating anxiety in schizophrenia. Psychosocial therapies have been developed to reduce the distress of schizophrenia. Cognitive behavioural therapy (CBT) has shown that benefit and refinements in the therapy have been successful, for example, for managing worry in schizophrenia. CBT usually involves more than 16 sessions, as short courses of CBT do not attenuate the presentation of anxiety in schizophrenia. To address time and cost, the development of manualized CBT to address anxiety in schizophrenia is being developed.

CONCLUSIONS

The presence of coexisting anxiety symptoms and co-morbid anxiety disorders should be ascertained when assessing patients with schizophrenia or other psychoses as a range of pharmacological and psychosocial treatments are available.

Vulnerability, Stress, and Support in the Disease Trajectory from Prodrome to Diagnosed Schizophrenia: Diathesis-Stress-Support Model

Schizophrenia is a debilitating psychiatric disorder seen across the world. The goal of current research is to provide a more comprehensive understanding of prodrome, the initial period before the disease manifests as schizophrenia. Unfortunately, there is little information to comprehensively understand the indicators that later lead to schizophrenia. This has resulted in a lack of scientific knowledge to aid in early identification and intervention by psychiatric nurses or school nurses. Such information could inform nursing assessment and care plan development. The purpose of this paper is to construct a conceptual model for describing the important factors relating to the schizophrenia prodrome process in human developmental manner by critically synthesizing empirical evidence and reviewing the strengths and limitations of current conceptual models.

Early intervention in psychosis: a feasibility study financed by the Italian Center on Control of Maladies

AIM

In November 2005 the Italian Center on Control of Maladies, a department operating under the Ministry of Health, financed a project aimed at evaluating the feasibility of a protocol of intervention based on the early intervention in psychosis (EIP) model within the Italian public mental health-care network.

METHODS

The study was carried out between March 2007 and December 2009. It involved five centres operating under the Departments of Mental Health of Milan (Programma 2000), Rome (area D), Grosseto, Salerno (Nocera) and Catanzaro (Soverato).

RESULTS

Enrolment lasted 12 months, at the end of which 43 patients were enrolled as first-episode psychosis (FEP), and 24 subjects as ultra high-risk (UHR) patients. Both FEP and UHR samples included a preponderance of male patients. A family history of psychosis was rarely reported in both samples. The FEP incidence rate was lower than expected on the basis of international estimates of the incidence of schizophrenia but within the expected figure for the estimated Italian rates in three centres out of five.

CONCLUSIONS

Overall, the study proved that an EIP centre can be established within the public Department of Mental Health to reach a good fraction of the cases in need of treatment. Since then, several studies have been set up to assess the feasibility of EIP in the Italian public mental health sector in Lombardy and Tuscany, and in 2012 the Emilia-Romagna Regional Authority started an educational plan aimed at implementing the EIP model in all the Mental Health Departments in the region.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Patients With First-Episode Psychosis are Not a Homogeneous Population: Implications for Treatment

Objective: This study aimed at defining the characteristics of a population of patients diagnosed with first-episode psychosis (FEP), and accessing for the first time a center for early intervention in psychosis in the health district of Milan and its surroundings. Methods: Patients were included in the study from January 2007 to December 2008; criteria: first contact with any public mental health service of the catchment area for a first episode of schizophrenia or related syndromes according to the ICD-10 criteria. Cluster analysis was used to divide patients into groups based on the main socio-demographic and clinical characteristics at presentation. Results: Overall, 91 FEP patients were enrolled in the study. Two clusters were identified, which differed principally by symptom profile. Patients in cluster 1 (n=36) had severe agitation, and a history of alcohol and/or substance abuse at presentation more often than those in cluster 2 (n=55), who were more likely to suffer at presentation from severe depression or apathy, anxiety, poor self-care, functional or work impairment and severe social withdrawal. After six months of treatment patients improved on almost all symptomatic dimensions on the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale, with greater improvement in cluster 1 than in cluster 2. Conclusions: The findings of this study need replication in larger samples and on a wider severity scale. Nevertheless, the heterogeneity of patients with FEP might impact on treatment. Policymakers should recognize the importance of the diagnostic and outcome assessment in the treatment of severe mental disorders.