The impact of subclinical psychosis on the transition from subclinicial mania to bipolar disorder

Exploring the effects of family and life events on genetic and environmental architecture of schizotypal and hypomanic dimensions: Insights from a twin study

BACKGROUND

Strategies of prevention for psychiatric disorders need a deep understanding of the aetiological factors involved in the psychopathological processes. Our twin study aims at disentangling the contributions of genes and environment to schizotypal and hypomanic dimensions, considering the role of stressful life events (LEs) and the quality of family relationships.

METHODS

The Magical Ideation Scale (MIS) and Perceptual Aberration Scale (PAS) were used to assess positive schizotypy, while Hypomanic Personality Scale (HPS) and its sub-scales were used to investigate proneness to affective disorders. 268 twins (54.5 % female; aged 18.0 ± 6.68) were included. Participants filled out a questionnaire on LEs and their parents provided an evaluation of intra-family relationship (Relationship Quality Index, RQI). Classic univariate twin models for quantitative traits were fitted for scales, and the effects of covariates (LEs and RQI) were assessed.

RESULTS

For MIS, HPS and its sub-scales, significant common and unique environmental effects were detected, with genetic factors affecting only HPS Social Vitality sub-scale. Unique environment was the only source of variance of PAS score. The number of recent LEs influenced MIS and PAS models, while RQI score affected MIS model.

LIMITATIONS

The main limitation of the study is the small sample size, which reduces statistical power and may potentially lead to an underestimation of heritability. Additionally, the cross-sectional design limits the possibility to draw causal considerations.

CONCLUSIONS

Findings provide preliminary evidence for a significant environmental role in modulating states of vulnerability. Moreover, the expression of positive schizotypy resulted influenced by recent stressors and intra-family relationships.

Predicting bipolar disorder I/II in individuals at clinical high-risk: Results from a systematic review

INTRODUCTION

No systematic review has estimated the consistency and the magnitude of the risk of developing bipolar disorder I-II (BD-I/II) in individuals at clinical high risk for bipolar disorder (CHR-BD).

METHODS

PubMed and Web of Science databases were searched until April 2022 in this pre-registered (PROSPERO CRD42022346515) PRISMA-compliant systematic review to identify longitudinal studies in individuals meeting pre-defined CHR-BD criteria. The risk of bias was assessed using the Newcastle-Ottawa Scale, and results were systematically synthesized around CHR-BD criteria across follow-up periods and different subgroups.

RESULTS

Altogether, 13 studies were included reporting on nine prospective independent cohorts (n = 678 individuals at CHR-BD). The mean age of participants was 15.7 years (range 10.1-22.6 years), and 54.2 % were females. The most common CHR-BD subgroup was subthreshold mania (55.5 %), followed by BD-Not Otherwise Specified (BD-NOS: 33.3 %). Development of BD I/II ranged from 7.1 % to 23.4 % after 2 years. Development of BD-I ranged from 3.4 % at 4 years to 23 % at 8 years. Development of BD-II ranged from 10 % at 2 years to 63.8 % at 4 years. The risk of developing BD-I appeared highest in those meeting BD-NOS criteria (23 % at eight years). Predictors of development of BD were identified but remained mostly unreplicated. The quality of the included studies was moderate (NOS = 5.2 ± 1.1).

CONCLUSIONS

Emerging data from research studies point towards the promising utility of CHR-BD criteria. These studies may pave the way to the next generation of research, implementing detection, prognostication, and preventive interventions in individuals at CHR-BD identified and followed in clinical practice.

Predicting the emergence of full-threshold bipolar I, bipolar II and psychotic disorders in young people presenting to early intervention mental health services

BACKGROUND

Predictors of new-onset bipolar disorder (BD) or psychotic disorder (PD) have been proposed on the basis of retrospective or prospective studies of 'at-risk' cohorts. Few studies have compared concurrently or longitudinally factors associated with the onset of BD or PDs in youth presenting to early intervention services. We aimed to identify clinical predictors of the onset of full-threshold (FT) BD or PD in this population.

METHOD

Multi-state Markov modelling was used to assess the relationships between baseline characteristics and the likelihood of the onset of FT BD or PD in youth (aged 12-30) presenting to mental health services.

RESULTS

Of 2330 individuals assessed longitudinally, 4.3% (n = 100) met criteria for new-onset FT BD and 2.2% (n = 51) met criteria for a new-onset FT PD. The emergence of FT BD was associated with older age, lower social and occupational functioning, mania-like experiences (MLE), suicide attempts, reduced incidence of physical illness, childhood-onset depression, and childhood-onset anxiety. The emergence of a PD was associated with older age, male sex, psychosis-like experiences (PLE), suicide attempts, stimulant use, and childhood-onset depression.

CONCLUSIONS

Identifying risk factors for the onset of either BD or PDs in young people presenting to early intervention services is assisted not only by the increased focus on MLE and PLE, but also by recognising the predictive significance of poorer social function, childhood-onset anxiety and mood disorders, and suicide attempts prior to the time of entry to services. Secondary prevention may be enhanced by greater attention to those risk factors that are modifiable or shared by both illness trajectories.

What makes the psychosis 'clinical high risk' state risky: psychosis itself or the co-presence of a non-psychotic disorder?

AIMS

Although attenuated psychotic symptoms in the psychosis clinical high-risk state (CHR-P) almost always occur in the context of a non-psychotic disorder (NPD), NPD is considered an undesired 'comorbidity' epiphenomenon rather than an integral part of CHR-P itself. Prospective work, however, indicates that much more of the clinical psychosis incidence is attributable to prior mood and drug use disorders than to psychosis clinical high-risk states per se. In order to examine this conundrum, we analysed to what degree the 'risk' in CHR-P is indexed by co-present NPD rather than attenuated psychosis per se.

METHODS

We examined the incidence of early psychotic experiences (PE) with and without NPD (mood disorders, anxiety disorders, alcohol/drug use disorders), in a prospective general population cohort (n = 6123 at risk of incident PE at baseline). Four interview waves were conducted between 2007 and 2018 (NEMESIS-2). The incidence of PE, alone (PE-only) or with NPD (PE + NPD) was calculated, as were differential associations with schizophrenia polygenic risk score (PRS-Sz), environmental, demographical, clinical and cognitive factors.

RESULTS

The incidence of PE + NPD (0.37%) was lower than the incidence of PE-only (1.04%), representing around a third of the total yearly incidence of PE. Incident PE + NPD was, in comparison with PE-only, differentially characterised by poor functioning, environmental risks, PRS-Sz, positive family history, prescription of antipsychotic medication and (mental) health service use.

CONCLUSIONS

The risk in 'clinical high risk' states is mediated not by attenuated psychosis per se but specifically the combination of attenuated psychosis and NPD. CHR-P/APS research should be reconceptualised from a focus on attenuated psychotic symptoms with exclusion of non-psychotic DSM-disorders, as the 'pure' representation of a supposedly homotypic psychosis risk state, towards a focus on poor-outcome NPDs, characterised by a degree of psychosis admixture, on the pathway to psychotic disorder outcomes.

Precursors of self-reported subclinical hypomania in adolescence: A longitudinal general population study

Symptoms of subclinical hypomania (SHM) are common in the general population of adolescents and young adults. SHM are most often transient yet might be risk markers of later bipolar disorder. The current study aimed to assess the clinical correlates of SHM at age 11 in the general population, examine the continuity of SHM from age 11-age 16 and explore the clinical precursors of age 16 SHM. As part of the Copenhagen Child Cohort 2000, 1,632 preadolescents participated in the examination of SHM and various clinical correlates at age 11, 893 were re-assessed for SHM at age 16 years. At age 11, SHM, psychotic experiences and depressive symptoms were assessed by semi-structured psychopathological interviews. Furthermore, the participants were diagnostically assessed by the Development and Well-Being Assessment and interviewed about sleep length. At age 16, SHM was assessed by self-report, using the Hypomania Checklist-32. Cannabis use occurring at age 15 or earlier was assessed at age 16. At age 11, SHM was associated with depressive disorders (Relative Risk [RR] = 2.96 [95% CI 1.26–6.96]), interview-based depressive symptoms (RR = 9.22 [5.93–14.34]), neurodevelopmental disorders (RR = 2.94 [1.66–5.20]), psychotic experiences (RR = 4.51 [2.90–7.01]) and insufficient sleep (RR = 2.10 [1.28–3.43]. In the longitudinal analyses, age 16 SHM was preceded by age 11 SHM (RR = 1.89 [1.02–3.49]), psychotic experiences (RR = 2.06, [1.28–3.33]), emotional disorders (RR = 1.77, [1.02–3.09]) and cannabis use (RR = 3.14, [1.93–5.10]), after mutual adjustment and adjustment for sex, and sociodemographic factors. In conclusion, age 11 SHM was statistically significantly associated with other types of psychopathology in cross-sectional analyses and showed some continuity with later self-reported SHM at age 16. Particularly early psychotic experiences and cannabis use stood out as independent precursors of self-reported SHM and might constitute important risk markers for the development of future SHM and bipolar disorder. An important potential caveat of the current study includes the self-report assessment of SHM.

A Latent Class Analysis of Manic and Psychotic Symptoms

Bipolar spectrum disorders encompass heterogeneous clinical manifestations and comorbidities. A latent class analysis (LCA) was performed in 1846 subjects who experienced an episode of abnormally elevated or irritable mood to identify homogeneous groups of subjects, based on the distribution of 11 manic and 7 psychotic symptoms. LCA identified five classes: 1) two classes with irritability and with low and high level of psychosis (respectively "irritable," 29.1% of the sample, and "irritable-psychotic," 16.2%); 2) a class with expansive mood and hyperactivity ("expansive-hyperactive," 12.7%); and 3) two classes with manic symptoms and high and low level of psychosis ("manic-psychotic," 15.0%, and "manic," 27.2%). "Irritable" displayed lower rates of depressive episode, panic, and substance use disorders. Manic-psychotic displayed higher rates of depressive episode, panic, generalized anxiety, and substance use disorders. Use of mental health treatment more frequent in manic-psychotic and manic classes. Five classes of bipolar spectrum disorders were characterized by different sociodemographic and clinical patterns.

Applying a Transdiagnostic Cognitive-Behavioral Treatment to Adolescents at High Risk for Serious Mental Illness: Rationale and Preliminary Findings

Given the chronic and deleterious course of serious mental illness (SMI; schizophrenia and bipolar disorder), significant efforts have been undertaken to improve prediction of SMI and provide treatment for adolescents in the early, putatively prodromal stage of these illnesses. While risk assessments and disorder-specific treatments for adolescents at risk for SMI have shown some efficacy, significant issues remain around disorder-specific treatments for these youth. There is substantial heterogeneity of psychopathology within adolescents at high risk for SMI that leads to many false-positives and varying diagnostic outcomes. As a result, initial treatment focusing on broad symptoms and skills has been proposed in place of disorder-specific treatments. We discuss the rationale for providing an already-developed and empirically supported transdiagnostic treatment for emotional disorders (termed the Unified Protocol) as a first-line staging of treatment for adolescents experiencing early SMI symptoms. Additionally, we outline the open trial we are piloting using this transdiagnostic treatment in adolescents between the ages of 13 - 17 who have begun experiencing distressing yet subsyndromal psychosis or bipolar mood symptoms. Preliminary findings suggest feasibility and acceptability as well as initial efficacy in improving psychiatric symptoms, quality of life, and difficulties regulating emotions. We also present case studies from our open trial. A unified, cognitive-behavioral treatment for early presentations of SMI has important clinical and public health benefits, including streamlining treatment and providing broad skills that are applicable to a wide range of psychopathology.

An International Society of Bipolar Disorders task force report: Precursors and prodromes of bipolar disorder

OBJECTIVES

To clarify the clinical features preceding the onset of bipolar disorder (BD) has become a public health priority for the prevention of high morbidity and mortality. BD remains frequently under- or misdiagnosed, and under- or mistreated, often for years.

METHODS

We assessed the predictive value of precursors and prodromes of BD. We assessed precursors of first-lifetime manic or hypomanic episodes with/without mixed features in retrospective and prospective studies. The task force evaluated and summarized separately assessments of familial risk, premorbid personality traits, retrospective, and prospective studies.

RESULTS

Cyclothymic features, a family history of BD, retrospectively reported attenuated manic symptoms, prospectively identified subthreshold symptoms of hypomania, recurrence of depression, panic anxiety and psychotic features, have been identified as clinical precursors of BD. The prodromal symptoms like [hypo]mania often appears to be long enough to encourage early identification and timely intervention.

CONCLUSIONS

The predictive value of any risk factor identified remains largely unknown. Prospective controlled studies are urgently needed for prevention and effective treatment.

The Critical Need for Help-Seeking Controls in Clinical High-Risk Research

Despite rapidly growing knowledge of the clinical high-risk (CHR) state for psychosis, the vast majority of case-control studies have relied on healthy volunteers as a reference point for drawing inferences about the CHR construct. Researchers have long recognized that results generated from this design are limited by significant interpretive concerns, yet little attention has been given to how these concerns affect the growing field of CHR research. We argue that overreliance on healthy controls in CHR research threatens the validity of inferences concerning group differences, hinders advances in understanding the development of psychosis, and limits clinical progress. We suggest that the combined use of healthy and help-seeking (i.e., psychiatric) controls is a necessary step for the next generation of CHR research. We then evaluate methods for help-seeking control studies, identify the available CHR studies that have used such designs, discuss select findings in this literature, and offer recommendations for research.

Clinical and Environmental Risk Factors for Bipolar Disorder: Review of Prospective Studies

After participating in this activity, learners should be better able to:• Evaluate factors that have been identified in prospective studies as predicting the onset of bipolar disorder ABSTRACT: The prodromal phase of bipolar disorder (BD) remains incompletely characterized, limiting early detection of BD and delaying interventions that might limit future morbidity and disability. Retrospective and family-risk studies have consistently found evidence of prodromal psychopathology in subjects later diagnosed with BD. Here, we review prospective studies of clinical risk factors and exposures identified before diagnosis of BD: our findings are consistent with those from retrospective and family-risk studies. Affective psychopathology often precedes diagnosis to suggest a homotypic trajectory in developing BD. Early non-affective (heterotypic) psychopathological disturbances, including anxiety and disruptive behavior disorders, as well as environmental factors and exposures, have been found in prospective studies to increase the risk of BD, but tend to lack specificity in predicting BD. Findings from prospective studies are encouragingly similar to those of retrospective and family-risk studies.

White matter alterations in individuals experiencing attenuated positive psychotic symptoms

AIM

Diffusion tensor imaging (DTI) studies suggest that reduced fractional anisotropy (FA) in the inferior longitudinal fasciculus (ILF) and superior longitudinal fasciculus (SLF) occurs among schizophrenia patients and those at risk for psychosis. Nevertheless, there is a dearth of knowledge investigating white matter fibre pathways in non-help-seeking individuals who endorse attenuated positive psychotic symptoms (APPS) across a range of mental disorders. The aim of the current study was to determine if alterations in ILF and SLF microstructures were specific to distressing APPS related to risk for psychosis or to APPS symptoms occurring in multiple mental disorders, which would suggest a shared phenotype among disorders.

METHOD

Twenty-six non-help-seeking young adults were administered the Prodromal Questionnaire. DTI was conducted on participants (n = 13) who endorsed eight or more distressing APPS (D-APPS, a potentially clinically relevant group) and those who endorsed three or fewer distressing APPS (low-APPS; n = 13). Semistructured interviews were administered to determine diagnoses, as well as clinical risk for psychosis status.

RESULTS

Results indicated that the D-APPS group exhibited decreased FA in the left ILF compared with the low-APPS group, even after removing four D-APPS participants who were considered at risk for psychosis.

CONCLUSION

Findings suggest that white matter microstructure is altered in individuals experiencing APPS across a range of disorders, independent of clinical high risk for psychosis status. Reduced FA in the left ILF may not be specific to psychosis risk, but rather for APPS that occur in a number of mental disorders.

Evidence That Environmental and Familial Risks for Psychosis Additively Impact a Multidimensional Subthreshold Psychosis Syndrome

BACKGROUND

The observed link between positive psychotic experiences (PE) and psychosis spectrum disorder (PSD) may be stronger depending on concomitant presence of PE with other dimensions of psychopathology. We examined whether the effect of common risk factors for PSD on PE is additive and whether the impact of risk factors on the occurrence of PE depends on the co-occurrence of other symptom dimensions (affective dysregulation, negative symptoms, and cognitive alteration).

METHOD

Data from the Netherlands Mental Health Survey and Incidence Study 2 were used. Risk factors included childhood adversity, cannabis use, urbanicity, foreign born, hearing impairment, and family history of affective disorders. Logistic regression models were applied to test (1) the additive effect of risk factors (4 levels) on PE and (2) the moderating effects of symptom dimensions on the association between risk factors (present/absent) and PE, using additive interaction, expressed as the interaction contrast ratio.

RESULTS

Risk factors were additive: the greater the number of risk factors, the greater the odds of PE. Furthermore, concomitant presence of the other symptom dimensions all increased the impact of risk factors on PE. After controlling for age, sex, and education, only affective dysregulation and negative symptoms remained significant moderators; only affective dysregulation remained a significant moderator if all dimensions were adjusted for each other.

CONCLUSIONS

Risk factors may not be directly associated with PE but additively give rise to a multidimensional subthreshold state anticipating the multidimensional clinical syndrome. Early motivational and cognitive impairments in the context of PE may be reducible to affective dysregulation.

Semistructured Interview for Bipolar At Risk States (SIBARS)

The external prognostic accuracy of Bipolar At Risk (BAR) criteria is undetermined and no psychometric tools are available to measure them. We present here three studies that overcome these limitations. Study 1 and 2 investigated the prognostic accuracy (Harrell's C) of the original BAR and revised Bipolar At Risk States (BARS) criteria respectively for the prediction of bipolar disorders, using a retrospective cohort of individuals at Clinical High Risk for Psychosis (CHR-P). Study 3 validated externally the prognostic accuracy of a newly developed Semistructured Interview of At Risk Bipolar States (SIBARS) in an independent prospective CHR-P cohort. In study 1 (n = 205), those meeting BAR criteria had an increased risk of developing bipolar disorders (HR = 5.30) relative to those not meeting them, but the prognostic accuracy was poor (Harrell's C = 0.659). In study 2 (n = 205), those meeting the refined BARS criteria had a higher risk of developing bipolar disorders than those not meeting them (HR = 12.364), with an adequate prognostic accuracy (Harrell's C = 0.777). Study 3 (n = 71) confirmed that SIBARS criteria had an adequate prognostic accuracy (Harrell's C = 0.742) and clinical utility. Overall, these findings suggest that the SIBARS could be used for the detection of individuals at risk of developing bipolar disorders in CHR-P services.

The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum

The concept of schizophrenia only covers the 30% poor outcome fraction of a much broader multidimensional psychotic syndrome, yet paradoxically has become the dominant prism through which everything 'psychotic' is observed, even affective states with mild psychosis labelled 'ultra-high risk' (for schizophrenia). The inability of psychiatry to frame psychosis as multidimensional syndromal variation of largely unpredictable course and outcome - within and between individuals - hampers research and recovery-oriented practice. 'Psychosis' remains firmly associated with 'schizophrenia', as evidenced by a vigorous stream of high-impact but non-replicable attempts to 'reverse-engineer' the hypothesized biological disease entity, using case-control paradigms that cannot distinguish between risk for illness onset and risk for poor outcome. In this paper, the main issues surrounding the concept of schizophrenia are described. We tentatively conclude that with the advent of broad spectrum phenotypes covering autism and addiction in DSM5, the prospect for introducing a psychosis spectrum disorder - and modernizing psychiatry - appears to be within reach.

Cannabis use in first-treatment bipolar I disorder: relations to clinical characteristics

AIMS

The aim of this study was to investigate the associations between recent cannabis use, current symptomatology and age at onset of first manic, depressive and psychotic episodes in a large sample with first-treatment bipolar I disorder (BD I).

METHODS

One hundred one patients with first-treatment Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) bipolar I disorder were included as part of the Thematically Organized Psychosis study. The Structural Clinical Interview for DSM-IV was used for DSM-IV diagnosis and identification of episodes of illness. Earlier suicide attempts were recorded. Manic, depressive and psychotic symptoms were rated using the Young Mania Rating Scale, Inventory of Depressive Symptoms and Positive and Negative Syndrome Scale correspondingly. Cannabis use within the six last months was recorded.

RESULTS

After controlling for confounders, recent cannabis use was significantly associated with lower age at onset of first manic and psychotic episode, but not with onset of first depressive episode (both P < 0.05). Recent use was also associated with more lifetime suicide attempts (P < 0.01). No group differences were found on symptom levels.

CONCLUSIONS

The present study confirms earlier findings of an association between cannabis use and a lower age at onset. Recent cannabis use was also associated with more lifetime suicide attempts. The current findings suggest that recent cannabis use is associated with a more severe course of illness in the early phase of BD I.

Hallucinations and inhibitory functioning in healthy young adults with high and low levels of hypomanic personality traits

INTRODUCTION

Hallucinations in schizophrenia and hallucination proneness in healthy young adults are associated with a common cognitive mechanism, namely impaired inhibitory control. Hallucinatory-like experiences also seem related to hypomanic symptoms in non-clinical participants; however, the mechanisms involved are unknown. We sought to examine self-reported hallucinatory/anomalous perceptual experiences in students selected for high versus low levels of hypomanic personality traits, and whether hypomania is characterised by deficient inhibitory control.

METHOD

Undergraduate students with either high (n = 26) or low (n = 28) scores on the Hypomanic Personality Scale-Revised (HPS-20) were compared on: (1) the Launay Slade Hallucination Scale-Revised (LSHS-R), a measure of hallucination proneness, (2) the Cardiff Anomalous Perceptions Scale (CAPS) and (3) the Inhibition of Currently Irrelevant Memories (ICIM) task, an index of intentional inhibition.

RESULTS

The high HPS group had higher total scores, as well as higher frequency (on CAPS only), intrusiveness and distress (CAPS) scores compared to the low HPS group. They also produced significantly more false alarms on the second run of the ICIM task than the low hypomania traits group.

CONCLUSIONS

Frequent, intrusive and distressing perceptual anomalies and proneness to hallucinations tend to occur in healthy individuals with hypomanic personality traits and may be associated with transient difficulties with inhibitory control. Inhibitory control may be a cognitive marker of vulnerability to hallucinations across diagnostic boundaries.

Why are help-seeking subjects at ultra-high risk for psychosis help-seeking?

In addition to attenuated psychotic symptoms, individuals at high clinical risk of developing psychosis display a wide range of psychopathological features. Some of these may be subjectively perceived as more troubling than others and may therefore be more likely to trigger help-seeking behavior. We aimed at investigating the nature and prevalence of symptoms subjectively considered most distressing by high-risk individuals at the time of their presentation to early recognition services and to determine their impact on baseline and longitudinal functional and clinical outcomes. The clinical records of 221 clients meeting ultra-high risk (UHR) criteria and receiving care at a specialized early intervention service ("Outreach and Support in South London") between 2001 and 2011 were reviewed. Main outcome measures were reason to seek help as subjectively reported by the clients, comorbid DSM-IV SCID diagnoses, transition to psychosis, psychosocial functioning at baseline and after a median follow-up period of 4.5 years. Affective symptoms, i.e., depression and/or anxiety, were the most commonly reported subjective reasons to seek help (47.1%). Sub-threshold psychotic symptoms were reported by 39.8%. There was no significant association between subjective complaints at presentation and transition to psychosis. However, the group reporting affective symptoms as their main subjective reason to seek help at baseline had a significantly poorer longitudinal outcome in psychosocial functioning relative to the group reporting sub-threshold psychotic symptoms. Assessment of subjective complaints in UHR individuals at initial presentation may help to identify predictors of future functional outcome and tailor treatments accordingly.

Evidence that the presence of psychosis in non-psychotic disorder is environment-dependent and mediated by severity of non-psychotic psychopathology

BACKGROUND

Evidence suggests that in affective, non-psychotic disorders: (i) environmental exposures increase risk of subthreshold psychotic experiences (PEs) and strengthen connectivity between domains of affective and subthreshold psychotic psychopathology; and (ii) PEs are a marker of illness severity.

METHOD

In 3021 adolescents from the Early Developmental Stages of Psychopathology cohort, we tested whether the association between PEs and presence of DSM-IV mood disorder (MD)/obsessive-compulsive disorder (OCD) would be moderated by risk factors for psychosis (cannabis use, childhood trauma and urbanicity), using the interaction contrast ratio (ICR) method. Furthermore, we analysed whether the interaction between environment and PEs was mediated by non-psychotic psychopathology.

RESULTS

The association between PEs and MD/OCD was moderated by urbanicity (ICR = 2.46, p = 0.005), cannabis use (ICR = 3.76, p = 0.010) and, suggestively, trauma (ICR = 1.91, p = 0.063). Exposure to more than one environmental risk factor increased the likelihood of co-expression of PEs in a dose-response fashion. Moderating effects of environmental exposures were largely mediated by the severity of general non-psychotic psychopathology (percentage explained 56-68%, all p < 0.001). Within individuals with MD/OCD, the association between PEs and help-seeking behaviour, as an index of severity, was moderated by trauma (ICR = 1.87, p = 0.009) and urbanicity (ICR = 1.48, p = 0.005), but not by cannabis use.

CONCLUSIONS

In non-psychotic disorder, environmental factors increase the likelihood of psychosis admixture and help-seeking behaviour through an increase in general psychopathology. The findings are compatible with a relational model of psychopathology in which more severe clinical states are the result of environment-induced disturbances spreading through a psychopathology network.

The transdiagnostic dimension of psychosis: implications for psychiatric nosology and research

If psychosis is a transdiagnostic dimension, the expression of which is governed by a dynamic set of contextual and emotional factors that are amenable to treatment, current approaches in psychiatric nosology and therapeutic research may need to be revised. The dominant approach to date is to clinically and conceptually situate psychotic symptoms in the construct of schizophrenia. However, schizophrenia, which has a lifetime prevalence of 1%, only represents the poor outcome fraction of a much broader spectrum of psychotic disorders which have a lifetime prevalence of 3.5%. Therefore, research findings in schizophrenia may reflect mechanisms of prognosis rather than fundamental associations with psychosis and other symptom domains per se. Similarly, the discovery that up to 30% of individuals with non-psychotic common mental disorders have subthreshold psychotic symptoms that situate them on the transdiagnostic dimension of psychosis - and which impact clinical severity and treatment response - indicates that the rigid separation between 'psychotic' and 'non-psychotic' hampers both clinical practice and research. Diagnostic manuals in psychiatry would benefit from a system of transdiagnostic dimensions, including a transdiagnostic dimension of psychosis. Introduction of transdiagnostic dimensions allows for a system combining a nomothetic (i.e., group-specific) categorical diagnosis with an idiographic (i.e., person-specific) combination of dimensional scores. The advantage of such a system is that it encourages consideration of how symptoms dynamically interact with each other in a network of psychopathology, and of how this network is impacted by the social world.

The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust

The negative implications of living in a socially unequal society are now well documented. However, there is poor understanding of the pathways from specific environmental risk to symptoms. Here we examine the associations between social deprivation, depression, and psychotic symptoms using the 2007 Adult Psychiatric Morbidity Survey, a cross-sectional dataset including 7,353 individuals. In addition we looked at the mediating role of stress, discrimination, trust and lack of social support. We found that the participants' neighbourhood index of multiple deprivation (IMD) significantly predicted psychosis and depression. On inspection of specific psychotic symptoms, IMD predicted paranoia, but not hallucinations or hypomania. Stress and trust partially mediated the relationship between IMD and paranoid ideation. Stress, trust and a lack of social support fully mediated the relationship between IMD and depression. Future research should focus on the role deprivation and social inequalities plays in specific manifestations of psychopathology and investigate mechanisms to explain those associations that occur. Targeting the mediating mechanisms through appropriate psychological intervention may go some way to dampen the negative consequences of living in an unjust society; ameliorating economic injustice may improve population mental health.

Indications of a dose-response relationship between cannabis use and age at onset in bipolar disorder

Cannabis use seems to play a causal role in the development of psychotic disorders. Recent evidence suggests that it may also precipitate onset in bipolar disorder. We here investigate if there is a dose-response relationship between cannabis use and age at onset in bipolar disorder, and whether there are interactions between cannabis use and illness characteristics (presenting polarity and presence of psychosis). Consecutively recruited patients with a DSM-IV, SCID verified diagnosis of bipolar I, II or NOS disorder (n=324) participated. Two-way ANCOVAS were used to investigate the effect of levels of cannabis use (<10 times during one month lifetime, >10 times during one month lifetime or a cannabis use disorder) on age at onset, including interaction effects with illness characteristics, while controlling for possible confounders. There was a significant association indicating a dose-response relationship between cannabis use and age at onset, which remained statistically significant after controlling for possible confounders (gender, bipolar subtype, family history of severe mental illness and alcohol or other substance use disorders). There were no interaction effects between cannabis use and presenting polarity or presence of psychosis. Doses of cannabis used may affect the age at onset of bipolar disorder.

Lessons learned from the psychosis high-risk state: towards a general staging model of prodromal intervention

BACKGROUND

The past two decades have seen exponential clinical and research interest in help-seeking individuals presenting with potentially prodromal symptoms for psychosis. However, the epidemiological validity of this paradigm has been neglected, limiting future advancements in the field.

METHOD

We undertook a critical review of core epidemiological issues underlying the clinical high-risk (HR) state for psychosis and which model of prodromal intervention is best suited for mental health.

RESULTS

The HR state for psychosis model needs refining, to bring together population-based findings of high levels of psychotic experiences (PEs) and clinical expression of risk. Traditionally, outcome has been attributed to 'HR criteria' alone rather than taking into account sampling strategies. Furthermore, the exclusive focus on variably defined 'transition' obscures true variation in the slow and non-linear progression across stages of psychopathology. Finally, the outcome from HR states is variable, indicating that the underlying paradigm of 'schizophrenia light progressing to schizophrenia' is inadequate.

CONCLUSIONS

In the general population, mixed and non-specific expression of psychosis, depression, anxiety and subthreshold mania is common and mostly transitory. When combined with distress, it may be considered as the first, diagnostically neutral stage of potentially more severe psychopathology, which only later may acquire a degree of diagnostic specificity and possible relative resistance to treatment. Therefore, rather than creating silos of per-disorder ultra-HR syndromes, an early intervention focus on the broad syndrome of early mental distress, requiring phase-specific interventions, may be more profitable.

An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders

BACKGROUND

The psychosis-proneness-persistence-impairment model of psychotic disorder incorporates notions of both phenomenological and temporal continuity (persistence) of psychotic experiences (PE), but not structural continuity. Specific testable propositions of phenomenological continuity and persistence are identified. Method Propositions are tested by systematic reviews of the epidemiology of PE, persistence of PE and disorder outcomes, and meta-analyses (including Monte Carlo permutation sampling, MCPS) of reported rates and odds ratios (ORs).

RESULTS

Estimates of the incidence and prevalence of PE obtained from 61 cohorts revealed a median annual incidence of 2.5% and a prevalence of 7.2%. Meta-analysis of risk factors identified age, minority or migrant status, income, education, employment, marital status, alcohol use, cannabis use, stress, urbanicity and family history of mental illness as important predictors of PE. The mode of assessment accounted for significant variance in the observed rates. Across cohorts, the probability of persistence was very strongly related to the rate of PE at baseline. Of those who report PE, ∼20% go on to experience persistent PE whereas for ∼80%, PE remit over time. Of those with baseline PE, 7.4% develop a psychotic disorder outcome.

CONCLUSIONS

Compelling support is found for the phenomenological and temporal continuity between PE and psychotic disorder and for the fundamental proposition that this relationship is probabilistic. However, imprecision in epidemiological research design, measurement limitations and the epiphenomenological nature of PE invite further robust scrutiny of the continuity theory.

Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity--implications for diagnosis and ultra-high risk research

BACKGROUND

It is commonly assumed that there are clear lines of demarcation between anxiety and depressive disorders on the one hand and psychosis on the other. Recent evidence, however, suggests that this principle may be in need of updating.

METHODS

Depressive and/or anxiety disorders, with no previous history of psychotic disorder, were examined for the presence of psychotic symptoms in a representative community sample of adolescents and young adults (Early Developmental Stages of Psychopathology study; n = 3021). Associations and consequences of psychotic symptomatology in the course of these disorders were examined in terms of demographic distribution, illness severity, onset of service use, and risk factors.

RESULTS

Around 27% of those with disorders of anxiety and depression displayed one or more psychotic symptoms, vs 14% in those without these disorders (OR 2.23, 95% CI 1.89-2.66, P < .001). Presence as compared with nonpresence of psychotic symptomatology was associated with younger age (P < .0001), male sex (P < .0058), and poorer illness course (P < .0002). In addition, there was greater persistence of schizotypal (P < .0001) and negative symptoms (P < .0170), more observable illness behavior (P < .0001), greater likelihood of service use (P < .0069), as well as more evidence of familial liability for mental illness (P < .0100), exposure to trauma (P < .0150), recent and more distant life events (P < .0006-.0244), cannabis use (P < .0009), and any drug use (P < .0008).

CONCLUSION

Copresence of psychotic symptomatology in disorders of anxiety and depression is common and a functionally and etiologically highly relevant feature, reinforcing the view that psychopathology is represented by a network or overlapping and reciprocally impacting dimensional liabilities.

Evidence that bipolar disorder is the poor outcome fraction of a common developmental phenotype: an 8-year cohort study in young people

BACKGROUND

Reported rates of bipolar syndromes are highly variable between studies because of age differences, differences in diagnostic criteria, or restriction of sampling to clinical contacts.

METHOD

In 1395 adolescents aged 14-17 years, DSM-IV (hypo)manic episodes (manic and hypomanic episodes combined), use of mental health care, and five ordinal subcategories representing the underlying continuous score of (hypo)manic symptoms ('mania symptom scale') were measured at baseline and approximately 1.5, 4 and 10 years later using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI).

RESULTS

Incidence rates (IRs) of both (hypo)manic episodes and (hypo)manic symptoms (at least one DSM-IV core symptom) were far higher (714/105 person-years and 1720/10(5) person-years respectively) than traditional estimates. In addition, the risk of developing (hypo)manic episodes was very low after the age of 21 years [hazard ratio (HR) 0.031, 95% confidence interval (CI) 0.0050-0.19], independent of childhood disorders such as attention deficit hyperactivity disorder (ADHD). Most individuals with hypomanic and manic episodes were never in care (87% and 62% respectively) and not presenting co-morbid depressive episodes (69% and 60% respectively). The probability of mental health care increased linearly with the number of symptoms on the mania symptom scale. The incidence of the bipolar categories, in particular at the level of clinical morbidity, was strongly associated with previous childhood disorders and male sex.

CONCLUSIONS

This study showed, for the first time, that experiencing (hypo)manic symptoms is a common adolescent phenomenon that infrequently predicts mental health care use. The findings suggest that the onset of bipolar disorder can be elucidated by studying the pathway from non-pathological behavioural expression to dysfunction and need for care.

The proximal prodrome to first episode mania--a new target for early intervention

OBJECTIVE

Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention.

METHODS

Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature.

RESULTS

Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified.

CONCLUSIONS

In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

Dimensions and the psychosis phenotype

In this paper, we discuss the conceptual background for including a dimensional component to the DSM V diagnoses for psychoses. We review the evidence for a continuous distribution of psychosis like symptoms in the general population and summarise the research validating the clinical usefulness of psychopathological dimensions. We conclude that diagnostic models using both categorical and dimensional representations of psychosis have better predictive validity than either model independently. Dimensions do not appear to be diagnosis specific so a flexible scoring of dimensions across all psychotic and major affective disorders may be potentially more informative than a system where categorical diagnoses are kept artificially dimension-specific.