What causes the onset of psychosis?

Factorial structure of the Comprehensive Assessment of At-Risk Mental States in help-seeking individuals: mapping the structure and the prediction of subsequent transition to psychosis

Objectives

The aim of the current study was 3-fold: 1) to examine the factorial structure of the Comprehensive Assessment of At-Risk Mental States (CAARMS) in help-seeking individuals undergoing an assessment on suspicion of psychosis risk; 2) to investigate the association of CAARMS factors with functioning; 3) and to test the association of any derived factors with the longitudinal outcome of transition to psychosis.

Methods

The study included 101 patients. First, a principal component analysis (PCA) was conducted using the Varimax rotation method. A minimum initial eigenvalues of greater than or equal to 1.0, analysis of Scree plots, percentage of variance explained by each component, reliability (Cronbach's alpha) of factors above 0.7 and Parallel Analysis were the criteria used to determine the appropriate number of factors Second, Spearman correlations were run to analyze the relationship between CAARMS factors and sociodemographic and functional variables (i.e. age, schooling, Social and Occupational Functioning Assessment Scale-SOFAS- and Health of the Nation Outcome Scales-HoNOS- scores). Third, we performed a Logistic regression analysis to evaluate the association between baseline CAARMS factors and the risk of transition to psychosis at the 6-month follow-up.

Results

A total of 101 consecutive patiens were recruited. We found that: 1) a 6 factor model solution as the most appropriate, jointly accounting for 65% of the variance; 2) factors 1 ("negative-interpersonal"), 2 ("cognitive-disorganization"), 3 ("positive"), and 4 ("motor-physical changes") were negatively correlated with SOFAS total score; factors 1, 2, and 3 showed positive correlations with HoNOS total score; factors 2 and 3 present similar patterns of correlations, factor 3 manifesting the strongest association with HoNOS symptoms, HONOS and SOFAS total score. Both factors 5 and 6 show significant associations with HoNOS behavioral impairment; 3) after 6 months 28 participants (30.1%) converted to psychosis. Factors 2 and 3 were positively associated with the risk of transition to psychosis; whereas, the factor 5 ("affective factor") was negatively associated with the outcome variable.

Conclusions

It is thus crucial to recognize the type and severity of psychopathology in help-seeking individuals in order to intensive clinical monitoring of subclinical psychopathology risk profiles, and design specific care pathways.

A systematic review of dramatherapy interventions used to support adults with psychosis

BACKGROUND

Psychiatric treatment of psychosis often comprises therapeutic and psychotropic combinations. Dramatherapy is often utilised in health services with this population, particularly when clients struggle to engage with talking therapies because of complex presentations, experience preverbal trauma, neurodiversity challenges and/or communication difficulties. Dramatherapy as a therapeutic intervention is recognised by health regulating bodies but as yet has not yet been systematically reviewed.

AIMS

To synthesise existing peer-reviewed empirical research literature and gather evidence regarding dramatherapy used to support adults with psychosis; To collate and understand the intervention methods of dramatherapy as a treatment to support adults experiencing psychosis; To assess the effect of dramatherapy on adults with psychosis, by collating qualitative and quantitative outcome measures, where reported in included research.

METHODS

Literature was sourced through database searches (CINAHL, EMBASE, COCHRANE, PsycINFO, PubMed, Scopus, and APA PsycNet) and hand searches. 8541 papers were screened, and 11 met inclusion criteria for synthesis. Findings related to aims were narratively synthesised, before being thematically analysed.

RESULTS

Participant characteristics of age, gender, ethnicity, and socio-economic background were heterogeneous. Participants across studies often had multiple diagnoses, and unknown complexities making recovery through standard treatment unachievable. Presentations included episodes of psychosis, schizophrenia, and dual-diagnoses of mental health challenges and intellectual difficulties. Positive effects found the use of dramatherapy include: New perspectives; Improved relationships; Ability to make choices with reduced anxiety; Understanding of self; Reduced psychotic symptoms. Quantitative data substantiated qualitative findings, and effect indicated changes in social functioning, behaviours, and symptoms following dramatherapy intervention.

IMPLICATIONS

Systematic findings will support practitioners to implement evidence-based practice and to improve treatment provision for adults with psychosis. Further methodologically sound research into the field is encouraged to advance understanding of dramatherapy interventions for adults with psychosis.

The relationship between climate change anxiety and psychotic experiences is mediated by death anxiety

BACKGROUND

As climate change persists, accelerates, and intensifies, and since mitigating factors are absent, mental health impacts are expected to follow the same patterns. Therefore, it appears of utmost importance to deepen and broaden the knowledge and understanding of how and through which mechanisms climate change anxiety (CCA) may interplay with mental health outcomes. Based on the stress-vulnerability model of psychosis, the present study proposed to examine the relationship between CCA and psychotic experiences (PEs), and to test the theoretically-driven hypothesis that death anxiety acts as a mediator in this relationship.

METHOD

This study adopted a cross-sectional approach involving a sample of young adults aged 18 to 35 years (mean age = 24.56 ± 22.49 years; 63.9% females) originating from, and residing in Lebanon.

RESULTS

The results of the mediation analysis showed that death anxiety partially mediated the association between CCA and PEs. Higher CCA was significantly associated with higher death anxiety; higher death anxiety was significantly associated with more PEs. Finally, higher CCA was directly and significantly associated with more PEs.

CONCLUSION

Drawing from the present preliminary findings, the key tentative recommendation is that addressing death anxiety might alleviate the association between CCA and PEs. In addition, government decision-makers need to recognize the necessity of considering climate change implications on mental health in policy and decision-making.

Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data

BACKGROUND

Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect.

METHOD

We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality.

RESULTS

In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms.

CONCLUSIONS

Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis.

Moment-to-moment affective dynamics in schizophrenia and bipolar disorder

BACKGROUND

Affective disturbances in schizophrenia and bipolar disorder may represent a transdiagnostic etiological process as well as a target of intervention. Hypotheses on similarities and differences in various parameters of affective dynamics (intensity, successive/acute changes, variability, and reactivity to stress) between the two disorders were tested.

METHODS

Experience sampling method was used to assess dynamics of positive and negative affect, 10 times a day over 6 consecutive days. Patients with schizophrenia (n = 46) and patients with bipolar disorder (n = 46) were compared against age-matched healthy controls (n = 46).

RESULTS

Compared to controls, the schizophrenia group had significantly more intense momentary negative affect, a lower likelihood of acute changes in positive affect, and reduced within-person variability of positive affect. The bipolar disorder group was not significantly different from either the schizophrenia group or the healthy control group on any affect indexes. Within the schizophrenia group, level of depression was associated with weaker reactivity to stress for negative affect. Within the bipolar disorder group, level of depression was associated with lower positive affect.

CONCLUSIONS

Patients with schizophrenia endured a more stable and negative affective state than healthy individuals, and were less likely to be uplifted in response to happenings in daily life. There is little evidence that these affective constructs characterize the psychopathology of bipolar disorder; such investigation may have been limited by the heterogeneity within group. Our findings supported the clinical importance of assessing multiple facets of affective dynamics beyond the mean levels of intensity.

Primary states of consciousness: A review of historical and contemporary developments

Primary states of consciousness are conceived as phylogenetically older states of consciousness as compared to secondary states governed by sociocultural inhibition. The historical development of the concept in psychiatry and neurobiology is reviewed, along with its relationship to theories of consciousness. We suggest that primary states of consciousness are characterized by a temporary breakdown of self-control accompanied by a merging of action, communication, and emotion (ACE fusion), ordinarily segregated in human adults. We examine the neurobiologic basis of this model, including its relation to the phenomenon of neural dedifferentiation, the loss of modularity during altered states of consciousness, and increased corticostriatal connectivity. By shedding light on the importance of primary states of consciousness, this article provides a novel perspective on the role of consciousness as a mechanism of differentiation and control. We discuss potential differentiators underlying a gradient from primary to secondary state of consciousness, suggesting changes in thalamocortical interactions and arousal function. We also propose a set of testable, neurobiologically plausible working hypotheses to account for their distinct phenomenological and neural signatures.

Social Isolation and Psychosis: Perspectives from People with Psychosis, Family Caregivers and Mental Health Professionals

This paper explores the subjective experiences of mental health practitioners, people with psychosis and carers, on social isolation and community integration of people with psychosis. Focus groups and one-to-one interviews with 80 adult participants across three sites in the UK were conducted. Audio recordings were transcribed and analysed using thematic analysis. Participants commented on various aspects that may cause social isolation or enable community integration, including institutional factors (lack of resources, hospitalisation impact), illness symptoms (e.g., paranoia; over-pathologising vs individual choice), stigma (particularly the psychosis label), and the importance of communities that foster agency and embrace change. Hospitalisation maybe be a cause for isolation and psychiatric wards should consider allowing for socialisation as a therapeutic tool. Initiatives should consider the social fabric of our communities, socioeconomic inequalities and stigmatisation. Building communities that are accepting, kind and flexible can create opportunities that could lead to independence from mental health services.

You read my mind: fMRI markers of threatening appraisals in people with persistent psychotic experiences

Anomalous perceptual experiences are relatively common in the general population. Evidence indicates that the key to distinguishing individuals with persistent psychotic experiences (PEs) with a need for care from those without is how they appraise their anomalous experiences. Here, we aimed to characterise the neural circuits underlying threatening and non-threatening appraisals in people with and without a need for care for PEs, respectively. A total of 48 participants, consisting of patients with psychosis spectrum disorder (clinical group, n = 16), non-need-for-care participants with PEs (non-clinical group, n = 16), and no-PE healthy control participants (n = 16), underwent functional magnetic resonance imaging while completing the Telepath task, designed to induce an anomalous perceptual experience. Appraisals of the anomalous perceptual experiences were examined, as well as functional brain responses during this window, for significant group differences. We also examined whether activation co-varied with the subjective threat appraisals reported in-task by participants. The clinical group reported elevated subjective threat appraisals compared to both the non-clinical and no-PE control groups, with no differences between the two non-clinical groups. This pattern of results was accompanied by reduced activation in the superior and inferior frontal gyri in the clinical group as compared to the non-clinical and control groups. Precuneus activation scaled with threat appraisals reported in-task. Resilience in the context of persistent anomalous experiences may be explained by intact functioning of fronto-parietal regions, and may correspond to the ability to contextualise and flexibly evaluate psychotic experiences.

Neural mechanisms of psychosis vulnerability and perceptual abnormalities in the ALS-FTD spectrum

OBJECTIVE

The aims of this study were to (i) explore psychotic experiences across the entire amyotrophic lateral sclerosis-frontotemporal dementia (ALS-FTD) spectrum from a clinical and genetic perspective, (ii) determine the rate of abnormal perceptual experiences across the five sensory modalities and (iii) explore the neurobiological factors that lead to psychosis vulnerability in ALS-FTD.

METHODS

In a prospective case-controlled study design, 100 participants were enrolled including ALS (n = 37, 24% satisfied criteria for ALS-Plus), ALS-FTD (n = 11), bvFTD (n = 27) and healthy controls (n = 25). Psychotic experiences, perceptual abnormalities and psychosocial factors were determined by means of the clinical interview and carer and patient reports. Voxel-based morphometry analyses determined atrophy patterns in patients experiencing psychosis-like experiences and other perceptual abnormalities.

RESULTS

The rates of psychotic experiences and abnormalities of perception in each sensory modality were high across the entire ALS-FTD continuum. The rate was highest in those with C9orf72 expansions. Rates were also high in patients with pure ALS including psychosis measured by carer-based reports (18%) and self-report measures of psychotic-like experiences (21%). In an ENTER regression model, social anxiety and ACE-III scores were the best predictors of psychosis proneness, accounting for 44% of the score variance. Psychosis-like experiences and perceptual abnormalities were associated with a predominantly frontal and temporal pattern of atrophy that extended to the cerebellum and centred on the anterior thalamus.

INTERPRETATION

The model for psychosis proneness in ALS-FTD likely includes complex interactions between cognitive, social and neurobiological factors that determine vulnerability to psychosis and that may have relevance for individualised patient management.

Moment-to-moment dynamics between auditory verbal hallucinations and negative affect and the role of beliefs about voices

BACKGROUND

Negative affect (NA) has been suggested to be both an antecedent and a consequence of auditory verbal hallucinations (AVH). Furthermore, negative appraisals of voices have been theorized to contribute to the maintenance of AVH. Using the experience sampling method (ESM), this study examined the bi-directional relationship between NA and AVH, and the moderating effect of negative beliefs about voices.

METHODS

Forty-seven patients diagnosed with schizophrenia spectrum disorders with frequent AVH completed a clinical interview, followed by ESM for 10 times a day over 6 days on an electronic device. Time-lagged analyses were conducted using multilevel regression modeling. Beliefs about voices were assessed at baseline.

RESULTS

A total of 1654 data points were obtained. NA predicted an increase in AVH in the subsequent moment, and AVH predicted an increase in NA in the subsequent moment. Baseline beliefs about voices as malevolent and omnipotent significantly strengthened the association between NA and AVH within the same moment. In addition, the belief of omnipotence was associated with more hallucinatory experiences in the moment following NA. However, beliefs about voices were not associated directly with momentary levels of NA or AVH.

CONCLUSIONS

Experiences of NA and AVH drove each other, forming a feedback loop that maintained the voices. The associations between NA and AVH, either within the same moment or across moments, were exacerbated by negative beliefs about voices. Our results suggest that affect-improving interventions may stop the feedback loop and reduce AVH frequency.

Lifetime prevalence and potential determinants of psychotic experiences in the general population of Qatar

BACKGROUND

To estimate the lifetime prevalence and potential determinants of psychotic experience(s) (PEs) in the general population of Qatar - a small non-war afflicted, conservative, high-income, middle-eastern country with recent rapid urbanization including an influx of migrants.

METHODS

A probability-based sample (n = 1353) of non-migrants and migrants were interviewed face-to-face and administered a 7-item psychosis screener adapted from the Composite International Diagnostic Interview, the Kessler 6-item psychological distress scale, and the 5 items assessing odd (paranormal) beliefs and magical thinking (OBMT) from the Schizotypal Personality Questionnaire. Using bivariate and logistic regression analyses, lifetime prevalence rates of PEs were estimated then compared before and after adjustment for socio-demographics, Arab ethnicity, psychological distress, and OBMT.

RESULTS

Prevalence of PEs was 27.9%. Visual hallucinations were most common (12.8%), followed by persecutory delusions (6.7%) and auditory hallucinations (6.9%). Ideas of reference (3.6%) were least prevalent. PEs were significantly higher in Arabs (34.7%) compared with non-Arabs (16.4%, p < 0.001) with the exception of ideas of reference and paranoid delusions. Female gender was associated with a higher prevalence of PEs in the Arab group only (p < 0.001). Prevalence of PEs was significantly higher among Arabs (48.8% v. 15.8%, p < 0.001) and non-Arabs (35.2% v. 7.3%, p < 0.001) with OBMT. Arab ethnicity (OR = 2.10, p = 0.015), psychological distress (OR = 2.29 p = 0.003), and OBMT (OR = 6.25, p < 0.001) were independently associated with PEs after adjustment for all variables.

CONCLUSIONS

Ethnicity, but not migration was independently associated with PEs. Evidence linking Arab ethnicity, female gender, and psychological distress to PEs through associations with OBMT was identified for future prospective investigations.

Delusional ideation, manic symptomatology and working memory in a cohort at clinical high-risk for psychosis: A longitudinal study

We followed up a cohort (n = 35) of clients with an “At Risk Mental State” (ARMS) for almost 2 years (mean 21.3 months). At baseline, these clients had taken part in research looking at the relationship between reasoning biases, memory, personality styles and delusional ideation. During the follow-up period, clients underwent a package of intervention from a specialist early detection team. Eighty percent (n = 28) of these clients were successfully re-interviewed. There was improvement across the cohort as a whole, however five participants (17.9%) had made the transition to psychosis at follow-up. Those who had become psychotic had lower levels of manic symptomatology at baseline than those who did not enter the first episode. Further, across the cohort, impaired working memory and delusional ideation at baseline combined to predict 45% of the delusional ideation at follow-up. These preliminary findings suggest that working memory impairments may be linked to the persistence of delusional ideation and that manic symptoms in someone with an ARMS may suggest that such an individual is less likely to develop a frank psychotic episode.

Links between psychotic and neurotic symptoms in the general population: an analysis of longitudinal British National Survey data using Directed Acyclic Graphs

BACKGROUND

Non-psychotic affective symptoms are important components of psychotic syndromes. They are frequent and are now thought to influence the emergence of paranoia and hallucinations. Evidence supporting this model of psychosis comes from recent cross-fertilising epidemiological and intervention studies. Epidemiological studies identify plausible targets for intervention but must be interpreted cautiously. Nevertheless, causal inference can be strengthened substantially using modern statistical methods.

METHODS

Directed Acyclic Graphs were used in a dynamic Bayesian network approach to learn the overall dependence structure of chosen variables. DAG-based inference identifies the most likely directional links between multiple variables, thereby locating them in a putative causal cascade. We used initial and 18-month follow-up data from the 2000 British National Psychiatric Morbidity survey (N = 8580 and N = 2406).

RESULTS

We analysed persecutory ideation, hallucinations, a range of affective symptoms and the effects of cannabis and problematic alcohol use. Worry was central to the links between symptoms, with plausible direct effects on insomnia, depressed mood and generalised anxiety, and recent cannabis use. Worry linked the other affective phenomena with paranoia. Hallucinations were connected only to worry and persecutory ideation. General anxiety, worry, sleep problems, and persecutory ideation were strongly self-predicting. Worry and persecutory ideation were connected over the 18-month interval in an apparent feedback loop.

CONCLUSIONS

These results have implications for understanding dynamic processes in psychosis and for targeting psychological interventions. The reciprocal influence of worry and paranoia implies that treating either symptom is likely to ameliorate the other.

The relationship between ethnicity and service access, treatment uptake and the incidence of psychosis among people at ultra high risk for psychosis

Black ethnicity is associated with increased risk for psychosis in South London. This study explored the distribution of ethnicity among services users at ultra high risk for psychosis (UHR) and examined the influence of ethnicity on service access, treatment uptake and incidence of psychosis. The ethnic distribution of 228 people at UHR for psychosis, seen in an early detection clinical service over 10 years, was compared with 146 people with first episode psychosis from the same geographic region and census figures for the local population. Black service users were significantly over-represented in the UHR group compared to the background population (34% vs 21%; p < 0.05); but less so than in the first episode sample (58% vs 19%; p < 0.05). Within the UHR sample, there was no strong evidence of differences between ethnic groups in the types of treatment provided, nor in the rate of transition to psychosis over 2 years. The absence of differences between ethnic groups in rates of transition to psychosis raises the possibility that access to mental health care at the high risk stage might have reduced the influence of ethnicity on the incidence of psychosis in this sample. This would need to be replicated in a larger sample.

Bullying victimisation and psychosis: The interdependence and independence of risk trajectories

A number of studies have noted an association between being the victim of bullying and psychotic symptoms. We offer an overview of the topic, focusing especially on a developmental perspective. We highlight the results of the latest studies on psychosis across the continuum and its relationship with bullying. Then we summarise the three main explanatory models investigated: developmental, biological and cognitive. We recommend that bullying in psychosis requires careful study of the developmental trajectories involved, and that research should now focus on how personal, social and biological factors interact.

LEARNING OBJECTIVES

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Influence of depressive symptoms on distress related to positive psychotic-like experiences in women

The Community Assessment of Psychic Experiences (CAPE) is an effective instrument for detection of the presence of psychotic symptoms and associated distress in the general population. However, little research has studied distress associated with positive psychotic-like experiences (PLEs). Our aim is to study PLE-related distress using the CAPE. In this study we analysed factors associated with differences in PLE-related distress in a sample of 200 non-clinical participants recruited by snowball sampling. Presence of PLEs and related psychological distress was measured using the CAPE questionnaire. The influence of age, gender, educational level and drug use was studied. In univariate analysis we found that gender and CAPE positive, depressive and negative scores, were associated with CAPE positive distress. Using multiple linear regression, we found that only the effect of gender, and the interaction between frequency of depression and gender, remained statistically significant. In our sample interaction between gender and depressive symptoms is a determining factor in distress associated with positive PLEs. The results of this study may be useful for the implementation of prevention programs.

Rethinking Social Cognition in Light of Psychosis: Reciprocal Implications for Cognition and Psychopathology

The positive symptoms of psychosis largely involve the experience of illusory social actors and yet our current measures of social cognition, at best, only weakly predict their presence. We review evidence to suggest that the range of current approaches in social cognition is not sufficient to explain the fundamentally social nature of these experiences. We argue that social agent representation is an important organising principle for understanding social cognition and that alterations in social agent representation may be a factor in the formation of delusions and hallucination in psychosis. We evaluate the feasibility of this approach in light of clinical and non-clinical studies, developmental research, cognitive anthropology and comparative psychology. We conclude with recommendations for empirical testing of specific hypotheses and how studies of social cognition could more fully capture the extent of social reasoning and experience in both psychosis and more prosaic mental states.

Aging of cerebral white matter

White matter (WM) occupies a large volume of the human cerebrum and is mainly composed of myelinated axons and myelin-producing glial cells. The myelinated axons within WM are the structural foundation for efficient neurotransmission between cortical and subcortical areas. Similar to neuron-enriched gray matter areas, WM undergoes a series of changes during the process of aging. WM malfunction can induce serious neurobehavioral and cognitive impairments. Thus, age-related changes in WM may contribute to the functional decline observed in the elderly. In addition, aged WM becomes more susceptible to neurological disorders, such as stroke, traumatic brain injury (TBI), and neurodegeneration. In this review, we summarize the structural and functional alterations of WM in natural aging and speculate on the underlying mechanisms. We also discuss how age-related WM changes influence the progression of various brain disorders, including ischemic and hemorrhagic stroke, TBI, Alzheimer's disease, and Parkinson's disease. Although the physiology of WM is still poorly understood relative to gray matter, WM is a rational therapeutic target for a number of neurological and psychiatric conditions.

The Impact of CB2 Receptor Ligands on the MK-801-Induced Hyperactivity in Mice

It has been known that there is a relationship between cannabis use and schizophrenia-related symptoms; however, it can be a subject of controversy. The involvement of CB1 receptor ligands in the schizophrenia has already been revealed and confirmed. However, there is still lack of information concerning the role of CB2 receptors in the psychosis-like effects in mice and the further studies are needed.The aim of the present research was to study the role of the CB2 receptor ligands in the symptoms typical for schizophrenia. We provoked hyperlocomotion in mice which is analogous to positive psychosis-like effects in humans, by an acute administration of a NMDA receptor antagonist, MK-801 (0.3 and 0.6 mg/kg), a pharmacological model of schizophrenia. An acute administration of MK-801 induced the increase in locomotor activity (hyperactivity) in rodents, measured in actimeters.We revealed that an acute injection of CB2 receptor agonist JWH 133 at the dose range (0.05-1.0 mg/kg) and CB2 receptor antagonist, AM 630 at the dose range (0.1-1.0 mg/kg) decreased locomotion of mice. An acute injection of JWH 133 (2.0 mg/kg) and AM 630 (2.0 mg/kg) had no statistical significant influence on the locomotor activity of mice. However, an acute injection of both CB2 receptor ligands (agonist and antagonist), JWH 133, at the non-effective dose of 2.0 mg/kg and AM 630 at the non-effective dose of 2.0 mg/kg, potentiated the MK-801-induced hyperactivity.The present findings have confirmed that endocannabinoid system, not only via CB1, but also via CB2 receptors, may be involved in the schizophrenia-like responses, including hyperlocomotion in mice.

Epistemic Benefits of Elaborated and Systematized Delusions in Schizophrenia

In this article I ask whether elaborated and systematized delusions emerging in the context of schizophrenia have the potential for epistemic innocence. Cognitions are epistemically innocent if they have significant epistemic benefits that could not be attained otherwise. In particular, I propose that a cognition is epistemically innocent if it delivers some significant epistemic benefit to a given agent at a given time, and if alternative cognitions delivering the same epistemic benefit are unavailable to that agent at that time. Elaborated and systematized delusions in schizophrenia are typically false and exemplify failures of rationality and self-knowledge. Empirical studies suggest that they may have psychological benefits by relieving anxiety and enhancing meaningfulness. Moreover, these delusions have been considered as adaptive in virtue of the fact that they enable automated learning to resume after a significant disruption caused by incorrect prediction-error signalling. I argue that such psychological benefits and adaptive features also have positive epistemic consequences. More precisely, delusions can be a means to restoring epistemic functionality in agents who are overwhelmed by hypersalient experiences in the prodromal stage of psychosis. The analysis leads to a more complex view of the epistemic status of delusions than is found in the contemporary philosophical literature and has some implications for clinical practice. 1 Introduction2 Types of Delusions3 What Is Wrong with Elaborated and Systematized Delusions?4 Finding Life Meaningful5 Learning Resumed6 Epistemic Innocence7 Epistemic Benefit8 No Alternatives9 Conclusions and Implications.

The Influence of the CB1 Receptor Ligands on the Schizophrenia-Like Effects in Mice Induced by MK-801

A growing body of psychiatric research has emerged, focusing on the role of endocannabinoid system in psychiatric disorders. For example, the endocannabinoid system, via cannabinoid CB (CB1 and CB2) receptors, is able to control the function of many receptors, such as N-methyl-d-aspartate (NMDA) receptors connected strictly with psychosis or other schizophrenia-associated symptoms. The aim of the present research was to investigate the impact of the CB1 receptor ligands on the symptoms typical for schizophrenia. We provoked psychosis-like effects in mice by an acute administration of NMDA receptor antagonist, MK-801 (0.1–0.6 mg/kg). An acute administration of MK-801 induced psychotic symptoms, manifested in the increase in locomotor activity (hyperactivity), measured in actimeters, as well as the memory impairment, assessed in the passive avoidance task. We revealed that an acute injection of CB1 receptor agonist, oleamide (5–20 mg/kg), had no influence on the short- and long-term memory-related disturbances, as well as on the hyperlocomotion in mice, provoking by an acute MK-801. In turn, an amnestic effects or hyperactivity induced by an acute MK-801 was attenuated by an acute administration of AM 251 (0.25–3 mg/kg), a CB1 receptor antagonist. The present findings confirm that endocannabinoid system is able to modify a variety of schizophrenia-like responses, including the cognitive disturbances and hyperlocomotion in mice. Antipsychotic-like effects induced by CB1 receptor antagonist, obtained in our research, confirm the potential effect of CB1 receptor blockade and could have important therapeutic implications on clinical settings, in the future.

Risk of psychosis and internal migration: Results from the Bologna First Episode Psychosis study

BACKGROUND

Incidence of psychotic disorders is higher in many migrant groups; however little is known about internal migrants (IM). This study aims to describe the IR in natives (NA), IM and external migrants (EM).

METHOD

All patients aged 18-64years, with First Episode Psychosis (FEP), who made contact with the Bologna West psychiatric services, between 2002 and 2010, were included.

RESULTS

187 cases were included. Age and sex adjusted IR of psychosis per 100,000per year were: 12.6 for NA, 25.3 for IM and 21.4 for EM. The IRR was 1.93 (1.19-3.13, P=0.007) for IM and 1.79 (1.06-3.02, P=0.03) for EM compared to NA.

CONCLUSION

Rates of psychosis were significantly elevated in IM as well as in EM. This result adds evidence as to the role of migration itself (versus ethnicity) on the risk of psychosis.

How anxiety induces verbal hallucinations

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Anxiety both triggers verbal hallucinations (VHs) and shapes their content.

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A current model that accounts for this in terms of failed anticipation is critiqued.

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An important subset of VHs arise from a particular anxious style of anticipation.

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This anxious anticipation makes an experience of thinking more like one of perceiving.

Verbal hallucinations are often associated with pronounced feelings of anxiety, and it has also been suggested that anxiety somehow triggers them. In this paper, we offer a phenomenological or ‘personal-level’ account of how it does so. We show how anxious anticipation of one’s own thought contents can generate an experience of their being ‘alien’. It does so by making an experience of thinking more like one of perceiving, resulting in an unfamiliar kind of intentional state. This accounts for a substantial subset of verbal hallucinations, which are experienced as falling within one’s psychological boundaries and lacking in auditory qualities.

A frame of mind from psychiatry

A distinctive characteristic of psychiatry is that it is a discipline that deals with both the physical and the mental lives of individuals. Largely because of this characteristic, different models are used for different disorders, however, there is still a remnant tendency towards reductionist views in the field. In this paper I argue that the available empirical evidence from psychiatry gives us reasons to question biological reductionism and that, in its place, we should adopt a pluralistic explanatory model that is more suited to the needs of the discipline and to the needs of the patients it is meant to help. This will allow us to retain psychiatry as an autonomous science that can productively co-exist with neuroscience while also giving patients the kind of attention they need. I further argue that this same evidence supports a view of the mind that is anti-reductive and that allows that causation can be both bottom-up and top-down and that such a view is available in emergentism coupled with an interventionist model of causation.

Bullying victimisation and risk of psychotic phenomena: analyses of British national survey data

BACKGROUND

Being bullied is an aversive experience with short-term and long-term consequences, and is incorporated in biopsychosocial models of psychosis. We used the 2000 and the 2007 British Adult Psychiatric Morbidity Surveys to test the hypothesis that bullying is associated with individual psychotic phenomena and with psychosis, and predicts the later emergence of persecutory ideation and hallucinations.

METHODS

We analysed two nationally representative surveys of individuals aged 16 years or older in Great Britain (2000) and England (2007). Respondents were presented with a card listing stressful events to identify experiences of bullying over the entire lifespan. We assessed associations with the dependent variables persecutory ideation, auditory and visual hallucinations, and diagnosis of probable psychosis. All analyses were controlled for sociodemographic confounders, intelligence quotient (IQ), and other traumas.

FINDINGS

We used data for 8580 respondents from 2000 and 7403 from 2007. Bullying was associated with presence of persecutory ideation and hallucinations, remaining so after adjustment for sociodemographic factors, IQ, other traumas, and childhood sexual abuse. Bullying was associated with a diagnosis of probable psychosis. If reported at baseline, bullying predicted emergence and maintenance of persecutory ideation and hallucinations during 18 months of follow-up in the 2000 survey. Controlling for other traumas and childhood sexual abuse did not affect the association between bullying and psychotic symptoms, but reduced the significance of the association with diagnosis of probable psychosis. Bullying was most strongly associated with the presence of concurrent persecutory ideation and hallucinations.

INTERPRETATION

Bullying victimisation increases the risk of individual psychotic symptoms and of a diagnosis of probable psychosis. Early detection of bullying and use of treatments oriented towards its psychological consequences might ameliorate the course of psychosis.

FUNDING

None.

Psychotic experiences in the population: Association with functioning and mental distress

Psychotic experiences are far more common in the population than psychotic disorder. They are associated with a number of adverse outcomes but there has been little research on associations with functioning and distress. We wished to investigate functioning and distress in a community sample of adolescents with psychotic experiences. Two hundred and twelve school-going adolescents were assessed for psychotic experiences, mental distress associated with these experiences, global (social/occupational) functioning on the Children's Global Assessment Scale, and a number of candidate mediator variables, including psychopathology, suicidality, trauma (physical and sexual abuse and exposure to domestic violence) and neurocognitive functioning. Seventy five percent of participants who reported psychotic experiences reported that they found these experiences distressing (mean score for severity of distress was 6.9 out of maximum 10). Participants who reported psychotic experiences had poorer functioning than participants who did not report psychotic experiences (respective means: 68.6, 81.9; OR=0.25, 95% CI=0.14-0.44). Similarly, participants with an Axis-1 psychiatric disorder who reported psychotic experiences had poorer functioning than participants with a disorder who did not report psychotic experiences (respective means: 61.8, 74.5; OR=0.28, 95% CI=0.12-0.63). Candidate mediator variables explained some but not all of the relationship between psychotic experiences and functioning (OR=0.48, 95% CI=0.22-1.05, P<0.07). Young people with psychotic experiences have poorer global functioning than those who do not, even when compared with other young people with psychopathology (but who do not report psychotic experiences). A disclosure of psychotic experiences should alert treating clinicians that the individual may have significantly more functional disability than suggested by the psychopathological diagnosis alone.

The calcium-sensitive Sigma-1 receptor prevents cannabinoids from provoking glutamate NMDA receptor hypofunction: implications in antinociception and psychotic diseases

Through the cannabinoid receptor 1 (CB1), the endocannabinoid system plays a physiological role in maintaining the activity of glutamate N-methyl-D-aspartate (NMDA) receptor within harmless limits. The influence of cannabinoids must be proportional to the stimulus in order to prevent NMDAR overactivation or exaggerated hypofunction that may precipitate symptoms of psychosis. In this framework, the recently reported association of CB1s with NMDARs, which mediates the reduction of cannabinoid analgesia promoted by NMDAR antagonism, could also support the precipitation of schizophrenia brought about by the abuse of smoked cannabis, mostly among vulnerable individuals. Accordingly, we have investigated this possibility using neuroprotection and analgesia as reporters of the CB1-NMDAR connection. We found that the Sigma 1 receptor (σ1R) acts as a safety switch, releasing NMDARs from the influence of CB1s and thereby avoiding glutamate hypofunction. In σ1R(-/-) mice the activity of NMDARs increases and cannot be regulated by cannabinoids, and NMDAR antagonism produces no effect on cannabinoid analgesia. In wild-type mice, ligands of the σ1R did not affect the CB1-NMDAR regulatory association, however, experimental NMDAR hypofunction enabled σ1R antagonists to release NMDARs from the negative control of CB1s. Of the σ1R antagonists tested, their order of activity was: S1RA > BD1047 ≫ NE100 = BD1063, although SKF10047, PRE-084 and (+)pentazocine were inactive yet able to abolish the effect of S1RA in this paradigm. Thus, the σ1R controls the extent of CB1-NMDAR interaction and its failure might constitute a vulnerability factor for cannabis abuse, potentially precipitating schizophrenia that might otherwise be induced later in time by the endogenous system.

Abnormal effective connectivity and psychopathological symptoms in the psychosis high-risk state

BACKGROUND

Recent evidence has revealed abnormal functional connectivity between the frontal and parietal brain regions during working memory processing in patients with schizophrenia and first-episode psychosis. However, it still remains unclear whether abnormal frontoparietal connectivity during working memory processing is already evident in the psychosis high-risk state and whether the connection strengths are related to psychopathological outcomes.

METHODS

Healthy controls and antipsychotic-naive individuals with an at-risk mental state (ARMS) performed an n-back working memory task while undergoing functional magnetic resonance imaging. Effective connectivity between frontal and parietal brain regions during working memory processing were characterized using dynamic causal modelling.

RESULTS

Our study included 19 controls and 27 individuals with an ARMS. In individuals with an ARMS, we found significantly lower task performances and reduced activity in the right superior parietal lobule and middle frontal gyrus than in controls. Furthermore, the working memory-induced modulation of the connectivity from the right middle frontal gyrus to the right superior parietal lobule was significantly reduced in individuals with an ARMS, while the extent of this connectivity was negatively related to the Brief Psychiatric Rating Scale total score.

LIMITATIONS

The modest sample size precludes a meaningful subgroup analysis for participants with a later transition to psychosis.

CONCLUSION

This study demonstrates that abnormal frontoparietal connectivity during working memory processing is already evident in individuals with an ARMS and is related to psychiatric symptoms. Thus, our results provide further insight into the pathophysiological mechanisms of the psychosis high-risk state by linking functional brain imaging, computational modelling and psychopathology.

Psychosis, agnosia, and confabulation: an alternative two-factor account

INTRODUCTION

Theories of delusions which rely on a combination of abnormal experience and defective belief evaluation and/ or cognitive bias are the subject of an emerging consensus. This paper challenges the validity of these theories and constructs a two factor alternative.

METHODS

The paper starts by identifying the difficulty the current theories have explaining the complex delusions of schizophrenia and then, by considering, first, the aetiology of somatopsychotic symptoms, and second, the literature on the relationship between confabulation and allopsychotic symptoms, demonstrates that the natural solution is to retain the experiential factor whilst replacing the second factor with confabulation.

RESULTS

The paper is then able to demonstrate that the resultant two-factory theory can clarify recent work on the aetiological role of autonoetic agnosia and on the relationships between confabulation, delusion, and thought disorder.

CONCLUSIONS

The theory supersedes currently available theories in terms of its simplicity, fruitfulness, scope and conservatism and represents an advance in the search for unified theory of psychosis.

Mood instability and psychosis: analyses of British national survey data

BACKGROUND

We used British national survey data to test specific hypotheses that mood instability (1) is associated with psychosis and individual psychotic phenomena, (2) predicts the later emergence of auditory hallucinations and paranoid ideation, and (3) mediates the link between child sexual abuse and psychosis.

METHODS

We analyzed data from the 2000 and 2007 UK national surveys of psychiatric morbidity (N = 8580 and 7403, respectively). The 2000 survey included an 18-month follow-up of a subsample (N = 2406). Mood instability was assessed from the Structured Clinical Interview for DSM-IV Axis II (SCID-II) questionnaire. Our dependent variables comprised auditory hallucinations, paranoid ideation, the presence of psychosis overall, and a 15-item paranoia scale.

RESULTS

Mood instability was strongly associated in cross-sectional analyses with psychosis (2000: OR: 7.5; 95% CI: I 4.1-13.8; 2007: OR: 21.4; CI: 9.7-41.2), paranoid ideation (2000: OR: 4.7; CI: 4.1-5.4; 2007: OR: 5.7; CI: 4.9-6.7), auditory hallucinations (2000: OR: 3.4; CI: 2.6-4.4; 2007: OR 3.5; CI: 2.7-4.7), and paranoia total score (2000: Coefficient: 3.6; CI: 3.3-3.9), remaining so after adjustment for current mood state. Baseline mood instability significantly predicted 18-month inceptions of paranoid ideation (OR: 2.3; CI: 1.6-3.3) and of auditory hallucinations (OR: 2.6; CI: 1.5-4.4). Finally, it mediated a third of the total association of child sexual abuse with psychosis and persecutory ideation and a quarter of that with auditory hallucinations.

CONCLUSIONS

Mood instability is a prominent feature of psychotic experience and may have a role in its genesis. Targeting mood instability could lead to innovative treatments for psychosis.

Schizophrenia and alcohol dependence: diverse clinical effects of oxytocin and their evolutionary origins

Beginning in 1979 with the first report that central administration of oxytocin stimulates maternal behavior in virgin rats, decades of animal research and more recent human studies have demonstrated that oxytocin has many pro-social effects. These many findings suggest that oxytocin may be an effective treatment for social deficits that are hallmark features of disorders such as autism and schizophrenia. Effects in preclinical animal models also imply that oxytocin may be an efficacious pharmacotherapy in a wide range of psychiatric disorders including psychoses and addictions. To date, 3 small clinical trials found that daily intranasal oxytocin treatment for 2-8 weeks significantly reduced psychotic symptoms in schizophrenia. Two of these trials also found improvement in social cognition or neurocognition, areas in which patients have significant deficiencies that do not respond to conventional antipsychotic treatment and contribute to disability. In another small trial, intranasal oxytocin potently blocked alcohol withdrawal. After reviewing the rationale for these trials, they are described in more detail. Questions are then asked followed by discussions of the large gaps in our knowledge about brain oxytocin systems in humans. The hope is to highlight important directions for future investigations of the role of oxytocin in the pathophysiology of psychotic disorders and addictions and to extend clinical research in these areas. Heretofore unrecognized roles for which oxytocin may have been selected during the evolution of placental mammalian maternal-infant and other social attachments are considered as possible origins of oxytocin antipsychotic and antiaddiction effects.This article is part of a Special Issue entitled Oxytocin and Social Behav.

The cannabinoid receptor 1 associates with NMDA receptors to produce glutamatergic hypofunction: implications in psychosis and schizophrenia

The endocannabinoid system is widespread throughout the central nervous system and its type 1 receptor (CB1) plays a crucial role in preventing the neurotoxicity caused by activation of glutamate N-methyl-D-aspartate receptors (NMDARs). Indeed, it is the activity of NMDARs themselves that provides the demands on the endogenous cannabinoids in order to control their calcium currents. Therefore, a physiological role of this system is to maintain NMDAR activity within safe limits, thereby protecting neural cells from excitotoxicity. Thus, cannabinoids may be able to control NMDAR overactivation-related neural dysfunctions; however, the major obstacles to the therapeutic utilization of these compounds are their psychotropic effects and negative influence on cognitive performance. Studies in humans have indicated that abuse of smoked cannabis can promote psychosis and even circumstantially precipitate symptoms of schizophrenia, although the latter appears to require a prior vulnerability in the individual. It is possible that cannabinoids provoke psychosis/schizophrenia reflecting a mechanism common to neuroprotection: the reduction of NMDAR activity. Cannabinoids are proposed to produce such effect by reducing the pre-synaptic release of glutamate or interfering with post-synaptic NMDAR-regulated signaling pathways. The efficacy of such control requires the endocannabinoid system to apply its negative influence in a manner that is proportional to the strength of NMDAR signaling. Thus, cannabinoids acting at the wrong time or exerting an inappropriate influence on their receptors may cause NMDAR hypofunction. The purpose of the present review is to draw the attention of the reader to the newly described functional and physical CB1-NMDAR association, which may elucidate the scenario required for the rapid and efficacious control of NMDAR activity. Whether alterations in these mechanisms may increase NMDAR hypofunction leading to vulnerability to schizophrenia will be outlined.

Latent structure of psychosis in the general population: results from the Singapore mental health study

BACKGROUND

Few studies have examined the latent construct of psychotic symptoms or distinguished between the latent construct and its manifest indicators. The current study aimed to investigate the latent structure of psychotic symptoms using factor mixture modeling (FMM) and to use the best-fitting model to examine its sociodemographic and clinical correlates.

METHOD

The Singapore Mental Health Study (SMHS) was based on an adult representative sample of the Singapore population. Psychotic symptoms were assessed by using the Psychosis Screen section of the Composite International Diagnostic Interview version 3.0 (CIDI 3.0). FMM analyses were applied to determine the latent construct of psychotic symptoms. Sociodemographic and clinical correlates of the latent structure of psychosis symptoms were examined using multiple linear and logistic regression analyses.

RESULTS

The overall weighted lifetime prevalence of any psychotic experience was 3.8% in the SMHS after excluding subthreshold experiences. The FMM analysis clearly supported the dimensional model of the latent structure of psychotic symptoms. On deriving the total score for 'psychosis symptoms' in accordance with the one latent trait model, and correlating it with sociodemographic factors, we found that female gender, vocational education, current and past smokers were positively associated with the 'psychosis' total score.

CONCLUSIONS

There is a need for an increased understanding of, and research into, this intermediate state of 'psychosis symptoms' that do not meet diagnostic criteria for psychosis. It is also important to learn more about the group of individuals in the community who may have preserved functioning to elucidate the protective factors that prevent transition to psychosis.

Predictors of methamphetamine psychosis: history of ADHD-relevant childhood behaviors and drug exposure

The goal of this study was to extend our previous research that reported a significant association between Attention Deficit Hyperactivity Disorder (ADHD)-relevant childhood behaviors and the frequency of methamphetamine (MA)-induced psychotic symptoms in an expanded sample. 190 participants who met DSM-IV criteria for MA dependence were administered the Methamphetamine Experience Questionnaire that assessed MA-induced psychosis. Data related to MA exposure, comorbid drug use, education, familial psychiatric history and assessments of ADHD-relevant childhood behaviors as measured by the Wender Utah Rating Scale (WURS) were collected. Although WURS scores did not differ between 145 MAP+ and 45 MAP- subjects, MAP+ subjects with higher WURS scores were significantly more likely to report more frequent psychosis. Although mean daily MA dosage did not differ between the MAP+ and MAP- subjects, MAP+ subjects who consumed larger doses of MA were significantly more likely to experience frequent psychosis. These data suggest that ADHD-relevant childhood behaviors may interact with MA exposure to reflect a neurobiological vulnerability related to the emergence of frequent MA-induced psychotic symptoms. These results may elucidate factors that contribute to the psychiatric sequelae of MA abuse.

What can we learn about schizophrenia from studying the human model, drug-induced psychosis?

When drug-induced psychoses were first identified in the mid-20th century, schizophrenia was considered a discrete disease with a likely genetic cause. Consequently, drug-induced psychoses were not considered central to understanding schizophrenia as they were thought to be phenocopies rather than examples of the illness secondary to a particular known cause. However, now that we know that schizophrenia is a clinical syndrome with multiple component causes, then it is clear that the drug-induced psychoses have much to teach us. This article shows how the major neuropharmacological theories of schizophrenia have their origins in studies of the effects of drugs of abuse. Research into the effects of LSD initiated the serotonergic model; amphetamines the dopamine hypothesis, PCP and ketamine the glutamatergic hypothesis, while most recently the effects of cannabis have provoked interest in the role of endocannabinoids in schizophrenia. None of these models account for the complete picture of schizophrenia; rather the various drug models mimic different aspects of the illness. Determining the different molecular effects of those drugs whose pharmacological effects do and do not mimic the various aspects of schizophrenia has much to teach us concerning the pathogenesis of the illness.

Opposite effects of neonatal hypoxia on acute amphetamine-induced hyperlocomotion in adult and adolescent mice

We investigated whether the effect of neonatal hypoxia on amphetamine-induced hyperlocomotion can reproduce the ontogenic (age of onset) properties of schizophrenia. Neonatal hypoxia enhanced amphetamine-induced hyperlocomotion in adult mice and decreased it in adolescent mice. These findings provide ontogenic validity for this very simple animal model of schizophrenia.

Brain-wide functional inter-hemispheric disconnection is a potential biomarker for schizophrenia and distinguishes it from depression

Schizophrenia is associated with disconnectivity in the brain although it is still unclear whether changes within or between hemispheres are of greatest importance. In this paper, an analysis of 152 schizophrenia patients compared with 122 healthy controls was carried out. Comparisons were also made with 39 depression patients and 37 controls to examine whether brain-wide changes in inter- or intra-hemispheric functional connectivity are most associated with the disorder and can distinguish it from depression. The authors developed new techniques (first and second order symmetry) to investigate brain-wide changes in patients (45 regions per hemisphere) and their association with illness duration and symptom severity. Functional connectivity between the same regions in left- and right-hemispheres (first order symmetry) was significantly reduced as was that between the same pairs of regions in the left- and right-hemispheres (second order symmetry) or using all possible inter-hemispheric connections in schizophrenia patients. By contrast, no significant changes were found for brain-wide intra-hemispheric links. First order symmetry changes correlated significantly with positive and negative symptom severity for functional connections linked via the anterior commissure and negative symptoms for those linked via the corpus callosum. Support vector machine analysis revealed that inter-hemispheric symmetry changes had 73-81% accuracy in discriminating schizophrenia patients and either healthy controls or depressed patients. In conclusion, reduced brain-wide inter-hemispheric functional connectivity occurs in schizophrenia, is associated with symptom severity, and can discriminate schizophrenia patients from depressed ones or healthy controls. Brain-wide changes in inter-hemispheric connections may therefore provide a useful potential biomarker for schizophrenia.

A high-fidelity virtual environment for the study of paranoia

Psychotic disorders carry social and economic costs for sufferers and society. Recent evidence highlights the risk posed by urban upbringing and social deprivation in the genesis of paranoia and psychosis. Evidence based psychological interventions are often not offered because of a lack of therapists. Virtual reality (VR) environments have been used to treat mental health problems. VR may be a way of understanding the aetiological processes in psychosis and increasing psychotherapeutic resources for its treatment. We developed a high-fidelity virtual reality scenario of an urban street scene to test the hypothesis that virtual urban exposure is able to generate paranoia to a comparable or greater extent than scenarios using indoor scenes. Participants (n = 32) entered the VR scenario for four minutes, after which time their degree of paranoid ideation was assessed. We demonstrated that the virtual reality scenario was able to elicit paranoia in a nonclinical, healthy group and that an urban scene was more likely to lead to higher levels of paranoia than a virtual indoor environment. We suggest that this study offers evidence to support the role of exposure to factors in the urban environment in the genesis and maintenance of psychotic experiences and symptoms. The realistic high-fidelity street scene scenario may offer a useful tool for therapists.

Cognitive-behavioral therapy for schizophrenia: a critical evaluation of its theoretical framework from a clinical-phenomenological perspective

BACKGROUND

Cognitive-behavioral therapy (CBT) has played an increasingly important role in psychotherapy for schizophrenia since the 1990s, but it has also encountered many theoretical and practical limitations. For example, methodologically rigorous meta-analyses have recently found only modest overall effect sizes of CBT treatment, and therefore questions have emerged about forwhat and for whom it actually works.

METHOD

The focus of the present paper is to elucidate the theoretical assumptions underlying CBT for schizophrenia and to examine their consistency with abnormalities of experience and self-awareness frequently reported by schizophrenia patients and systematically studied in phenomenological psychopathology from the beginning of the 20th century.

RESULTS

We argue that a strong theoretical emphasis on cognitive appraisals with only subsidiary attention devoted to affective and behavioral processes - as is characteristic of many forms of CBT - cannot satisfactorily account for the complex subjective experiences of schizophrenia patients. We further argue that certain theoretical strategies widely employed in CBT to explore and explain mental disorders, which involve atomization and, at times, a reification of mental phenomena, can be problematic and may result in a loss of explanatory potential. Finally, we provide a detailed account of how negative symptoms and delusions are conceptualized in CBT and consider the question of how these concepts fit the actual phenomenology of schizophrenia.

CONCLUSION

We suggest that further advancement of CBT theory and practice can benefit from a dialogue with phenomenological psychiatry in the search for effective psychotherapeutic strategies for schizophrenia patients.

Prophylactic valproic acid treatment prevents schizophrenia-related behaviour in Disc1-L100P mutant mice

BACKGROUND

Schizophrenia is a neurodevelopmental disorder with onset early in adulthood. Disrupted-In-Schizophrenia-1 (DISC1) is a susceptibility gene for schizophrenia and other psychiatric disorders. Disc1-L100P mutant mice show behaviors relevant to schizophrenia at 12 weeks, but not at 8 weeks of age, and may be useful for investigating the onset of schizophrenia in early adulthood.

METHODS

We investigated whether early valproic acid treatment would prevent behavioral, cellular and gene expression abnormalities in Disc1-L100P mutants.

RESULTS

Valproic acid prevented hyperactivity and deficits in prepulse inhibition and latent inhibition in Disc1-L100P mice. Genome-wide transcription profiling identified Lcn2 (lipocalin2) transcripts as being elevated by the Disc1 mutation and corrected by valproate. Disc1-L100P mice also had increased glial cell numbers in the subventricular zone, which was normalized by valproate. Genetic deletion of Lcn2 normalized glial cell numbers and behavior in Disc1-L100P mutants.

CONCLUSIONS

Pharmacological treatments are a feasible way of preventing abnormal behaviour in a genetic model of schizophrenia. Lcn2 is a potential novel drug target for early intervention in schizophrenia.

Longitudinal follow-up of cavum septum pellucidum and adhesio interthalamica alterations in first-episode psychosis: a population-based MRI study

BACKGROUND

Neurodevelopmental alterations have been described inconsistently in psychosis probably because of lack of standardization among studies. The aim of this study was to conduct the first longitudinal and population-based magnetic resonance imaging (MRI) evaluation of the presence and size of the cavum septum pellucidum (CSP) and adhesio interthalamica (AI) in a large sample of patients with first-episode psychosis (FEP).

METHOD

FEP patients (n=122) were subdivided into schizophrenia (n=62), mood disorders (n=46) and other psychosis (n=14) groups and compared to 94 healthy next-door neighbour controls. After 13 months, 80 FEP patients and 52 controls underwent a second MRI examination.

RESULTS

We found significant reductions in the AI length in schizophrenia FEP in comparison with the mood disorders and control subgroups (longer length) at the baseline assessment, and no differences in any measure of the CSP. By contrast, there was a diagnosis×time interaction for the CSP length, with a more prominent increase for this measure in the psychosis group. There was an involution of the AI length over time for all groups but no diagnosis×time interaction.

CONCLUSIONS

Our findings suggest that the CSP per se may not be linked to the neurobiology of emerging psychotic disorders, although it might be related to the progression of the disease. However, the fact that the AI length was shown to be shorter at the onset of the disorder supports the neurodevelopmental model of schizophrenia and indicates that an alteration in this grey matter junction may be a risk factor for developing psychosis.

The role of safety-seeking behaviours in maintaining threat appraisals in psychosis

AIM

This study investigated the interaction between appraisals and safety behaviours in the maintenance of psychotic symptoms.

METHOD

The study recruited a population who had persistent psychotic experiences but who had no 'need-for-care' (Persistence group; n = 39) as well as a population who had a diagnosed psychotic disorder and were receiving current treatment (Impairment group; n = 28). The participants were assessed on semi-structured interviews of appraisals and safety behaviours and on anxiety and depression questionnaires.

RESULTS

The two groups did not differ in total or first rank psychotic experiences, but the Persistence group showed less anomaly-related distress, depression and anxiety than the Impairment group. As predicted, the Impairment group displayed more threat appraisals and safety behaviours than the Persistence group, with a greater frequency of safety behaviours being related to higher levels of threat appraisals and anomaly-related distress. Threat appraisals mediated the relationship between safety behaviours and anomaly-related distress, suggesting that threat appraisals may maintain distress, a defining feature of Impairment status.

CONCLUSIONS

These data provide support for the cognitive model of psychosis in suggesting that cognitive and behavioural factors are key in differentiating non-clinical anomalous experiences from clinical psychotic status. These data suggest that therapy should target threat appraisals and safety-seeking behaviours in order to decrease distress.

First-episode psychosis at the West Bologna Community Mental Health Centre: results of an 8-year prospective study

BACKGROUND

Research mostly conducted in the UK and northern Europe has established that there are high rates of first-episode psychosis (FEP) in large cities and immigrant populations; moreover, psychosis has been found to be associated with cannabis use and early trauma. The present study aimed to evaluate the incidence rate of FEP and the distribution of several risk factors (e.g. age, ethnicity, substance abuse) in Bologna, Italy.

METHOD

The Bologna FEP (BoFEP) study is an 8-year prospective study. All FEP patients, 18-64 years old, consecutively referred to the West Bologna Community Mental Health Centre (CMHC) from 2002 to 2009 were evaluated. Sociodemographic information, migration history and clinical data were collected through an ad-hoc schedule. Psychiatric diagnoses were recorded using the Schedule for Clinical Assessment of Neuropsychiatry (SCAN).

RESULTS

The overall incidence rate (IR) in the BoFEP study was 16.4 per 100 000 person-years [95% confidence interval (CI) 13.9-18.9]. The incidence was higher in young people, men and migrants (MI).

CONCLUSIONS

The IR of FEP found by the Bologna study is lower than that found by other European studies. However, as in other studies, the incidence was higher in certain groups. This heterogeneity has implications for policy and mental health service development, and for understanding the aetiology of psychosis.