Subclinical hallucinations in adolescent outpatients: an outcome study

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

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

Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults

Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

Predicting hallucination proneness based on mindfulness in university students: the mediating role of mental distress

As a risk factor of hallucination proneness, the level of mindfulness has not yet been investigated in non-clinical participants. Other potential mediators, such as mental distress (depression, anxiety, and stress) which contribute to hallucination proneness also need to be assessed. This study investigated the mediating effect of mental distress in predicting hallucination proneness based on mindfulness. A number of 168 Iranian university students completed three questionnaires: (1) the five-facet mindfulness questionnaire, (2) the depression, anxiety and stress scale; and (3) the revised hallucination scale. The results showed that there was a significant association between levels of mindfulness and hallucination proneness. Mental distress has a significant effect on four facets of mindfulness questionnaire and an insignificant effect on one facet (awareness) in predicting hallucination. These effects were both direct and indirect. The indirect effect was developed by the mediating role of mental distress.

Validation of the Launay-Slade Hallucination Scale among Indian Healthy Adults

Psychotic Like Experiences (PLEs) have been reported in several cultures. The 16 item Launay-Slade Hallucination Scale-Extended (LSHS-E) measures hallucination like experiences (HLEs) in the general population. This study investigated the psychometric properties and the factor structure of LSHS-E Hindi among healthy adults of Delhi. LSHS-E was translated from English to Hindi and then back to English. It was administered as a paper pencil questionnaire to 182 adults from the general population. Reliability of LSHS-E Hindi was measured using Cronbach's alpha and factor structure was established using confirmatory factor analysis (CFA). It was tested against the Community Assessment of Psychic Experiences (CAPE-42) for convergent and divergent validity. Latent Class Analysis (LCA) was performed to identify subgroups with different endorsement of HLEs. Among 182, 18 participants reporting mental and neurological disorders were excluded. LSHS-E Hindi had good reliability (0.85; 95% CI: 0.82 to 0.88). CFA of Hindi LSHS-E revealed the a priori four-factor solution to be best, namely: 'intrusive thoughts', 'vivid daydreams', 'multisensory HLEs', 'auditory and visual HLEs'. LSHS-E Hindi showed stronger correlation with positive domain of CAPE than with negative and depression domains. LCA revealed three classes: low, intermediate and high endorsement of HLEs. Participants with highest endorsement of HLEs were less educated and had highest endorsement on all CAPE dimensions. LSHS-E Hindi has good psychometric properties and can be used to study HLEs in Indians. The four-factor structure model depicts the multidimensionality of HLEs, with 'intrusive thoughts' being the most commonly reported HLE in the sample. LCA supports the continuum hypothesis of HLEs.

Characterization of children and adolescents with psychosis risk syndrome: The Children and Adolescents Psychosis Risk Syndrome (CAPRIS) study

AIM

Despite the interest in psychosis risk syndrome (PRS) in children and adolescents, information on the syndrome in this population is scarce.

METHODS

Prospective naturalistic multi-site study in which 10- to 17-year-old help-seeking subjects who met PRS criteria (positive or negative attenuated symptoms; brief limited intermittent psychotic symptoms; genetic risk or schizotypal personality disorder plus impairment in functioning) were included, along with 45 age and sex-matched healthy controls (HC). All subjects were clinically and functionally assessed.

RESULTS

Ninety-one PRS subjects (PRSS) with a mean age of 15.5 ± 1.4 met inclusion criteria (IC). Compared with HC, PRSS presented worse global and academic functioning in the previous year, had experienced more psychiatric and psychological problems, and presented gestational ages outside the normal range. More than 80% of PRSS met ≥2 IC, with 65.9% having one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision diagnosis, and 61.7% of those having ≥2 diagnoses. Some 49.5% of PRSS had a first- or second-degree family history (FH) of psychosis. Patients with first- and second-degree FH do not differ in their clinical expression.

CONCLUSIONS

Children and adolescents with PRS are a patient group with a pattern of neurodevelopmental impairment and clinical complexity similar to patients with schizophrenia spectrum disorders, highlighting the importance of assessing these variables in child and adolescent samples. PRSS with first- and second-degree relatives with FH do not present differences in their clinical presentation, suggesting that including these two groups of patients in the genetic risk criteria would enrich knowledge of these criteria.

Hallucination in Adolescence-Or, Nora in Nowhereland Between Neurosis and Psychosis

The authors present a case history in which they investigate the psychic mechanisms behind the production and function of adolescent hallucinations against the background of Freud's framework and Laplanche's concept of enigmatic messages. They conclude that these hallucinations, although to all appearance psychotic, are basically neurotic in nature, and that both their content and hallucinatory form serve to protect the defense mechanisms with which parents ward off their unconscious conflicts.

Very early hallucinatory experiences: a school-based study

BACKGROUND

The prevalence and clinical significance of hallucinatory experiences among children below 7 years of age remain unknown. We aimed to determine the independent influences of sensory deficits, the presence of an imaginary companion and metacognition on hallucinatory experiences. We assumed that hallucinatory experiences were associated with (a) sensory deficits, (b) the presence of an imaginary companion (IC) and (c) metacognition defaults (i.e. first- and second-order theory of mind default).

METHODS

All children in the third year of preschool from a region of Northern France underwent medical screening. We compared the prevalence rates of visual, auditory and audio-visual hallucinatory experiences based on (a) the presence of visual or auditory deficits, (b) the actual presence of an IC and (c) metacognition. The analyses were adjusted for age.

RESULTS

A total of 1,087 children aged between 5 and 7 years were included. The prevalence rates of auditory, visual and audio-visual hallucinatory experiences were 15.8%, 12.5% and 5.8%, respectively. The prevalences of different types of hallucinatory experiences were not significantly different according to sensory deficit. The prevalences of all types of hallucinatory experiences were significantly higher among children with an IC and among children with metacognition defaults.

CONCLUSIONS

The association between hallucinatory experiences and sensory deficits might concern only long-lasting deficits. The association with the presence of an IC confirms experimental findings of the likelihood of perceiving words among meaningless auditory stimuli. Relations between hallucinatory experiences and theory of mind need to be addressed in longitudinal studies.

On "Hearing" Voices and "Seeing" Things: Probing Hallucination Predisposition in a Portuguese Nonclinical Sample with the Launay-Slade Hallucination Scale-Revised

The experience of hallucinations is a hallmark of psychotic disorders, but they are also present in other psychiatric and medical conditions, and may be reported in nonclinical individuals. Despite the increased number of studies probing the incidence of nonclinical hallucinations, the underlying phenomenological characteristics are still poorly understood. This study aimed to examine the psychometrics proprieties of the Portuguese adaptation of the 16-item Launay-Slade Hallucinations Scale (LSHS), the phenomenological characteristics of nonclinical hallucinatory experiences in a Portuguese sample, and the relationship between clinical symptoms and hallucination predisposition. Three-hundred-and-fifty-four European Portuguese college students completed the LSHS. Of those, 16 participants with high LSHS scores and 14 with low LSHS scores were further screened for clinical symptoms. A three-factor solution for the LSHS Portuguese version proved to be the most adequate. Intrusive or vivid thoughts and sleep-related hallucinations were the most common. Although, fundamentally perceived as positive experiences, all types of hallucinations were described as uncontrollable and dominating. However, the more pleasant they were perceived, the more controllable they were assessed. In addition, hallucination predisposition was associated with increased clinical symptoms. These results corroborate the lower severity of hallucinations in the general population compared to psychotic individuals. Further, they support an association between clinical symptoms and increased vulnerability to hallucinations. Specifically, increased schizotypal tendencies and negative mood (anxiety and depression) may be related to increased psychotic risk.

North American Prodrome Longitudinal Study (NAPLS 2): The Prodromal Symptoms

In studies describing the long-term follow-up up of youth at clinical high risk (CHR) of psychosis, little attention has been given to details of specific prodromal symptoms. In this paper, we describe the prodromal symptoms of 764 CHR participants recruited in the multi-site North American Prodrome Longitudinal Study (NAPLS). Symptoms were rated on the Scale of Prodromal Symptoms (SOPS) at baseline and 6-, 12-, 18-, and 24-month follow-ups. Clinical outcome at the 2-year assessment was categorized as psychotic, prodromal progression, symptomatic or in remission. Most of the CHR sample (92%) met criteria for the attenuated positive symptoms syndrome (APSS). Significant improvements in SOPS symptoms were observed over time. Unusual thought content, disorganized communication, and overall ratings on disorganized symptoms differentiated those who transitioned to psychosis from the other clinical outcome groups. Suspiciousness and total positive symptoms differentiated those in remission from the other clinical outcome groups.

Carving versus Stitching: The Concept of Psychic Function and the Continuity/Discontinuity Debate

BACKGROUND

The current debate on the continuity or discontinuity of psychotic symptoms and common psychic experiences has mainly dealt with methodological, epidemiological and clinical issues, but it has neglected epistemological research on the main concepts of the field.

METHODS

The implicit epistemic structure of continuity models of psychotic symptoms and its effect on research are addressed.

RESULTS

We explain how the seemingly commonsense, unproblematic concept of psychic function may explain the contradictions and paradoxes of research.

CONCLUSIONS

A new model of symptom individuation and symptom eliciting is proposed - based on the concepts of 'schemas', 'embodied affordances' and 'thick/thin descriptions'.

Declining transition rates to psychosis: the role of diagnostic spectra and symptom overlaps in individuals with attenuated psychosis syndrome

Transition to psychosis in at-risk individuals has markedly declined in recent years. So far it has never been discussed in detail that with the growing awareness and increasing availability of early psychosis services, a much broader diagnostic spectrum is now being seen in these services. Subsequently, subjects present with symptoms that meet psychosis risk on a purely psychometric basis but may be the phenotypical expression of another underlying mental disorder. Here we critically review four groups of symptoms and clinical features that are frequently reported by individuals with suspected psychosis risk states, yet share strong commonalities with other mental disorders and conditions: isolated hallucinations; unusual bodily perceptions, hypochondriatic fears and cenesthetic psychotic symptoms; depersonalization; obsessive-compulsive, overvalued and delusional ideas. Of the 616 individuals so far assessed in the Bruderholz Early Psychosis Outpatient Service for Adolescents and Young Adults, 218 (30.5%) met ultra-high risk (UHR) criteria, 188 (86.2%) of whom suffered from one of the four above-mentioned symptom groups. The appraisal of the diagnostic spectra and their overlapping symptoms constitute a tremendous challenge in the clinical assessment of each referred individual. The final conclusion of a clinical assessment should not end with the mere assignment - or non-assignment - to a presumed psychosis risk group, but needs to take into account the 'Gestalt' of these particular symptoms and clinical features and thus be based on many more facets than solely a psychometric or nosological approach. Such an approach may break down the heterogeneous psychosis risk group and enable appropriate treatment regimes.

Predicting psychosis in a general adolescent psychiatric sample

INTRODUCTION

Current psychosis risk criteria have often been studied on a pre-selected population at specialized clinics. We investigated whether the Structured Interview for Prodromal Syndromes (SIPS) is a useful tool for psychosis risk screening among adolescents in general psychiatric care.

METHODS

161 adolescents aged 15-18 with first admission to adolescent psychiatric services in Helsinki were interviewed with the SIPS to ascertain Clinical High-Risk (CHR) state. The participants were followed via the national hospital discharge register, patient files, and follow-up interviews. DSM-IV Axis I diagnoses were made at baseline and 12 months. Register follow-up spanned 2.8-8.9 years, and hospital care for a primary psychotic disorder and any psychiatric disorder were used as outcomes.

RESULTS

CHR criteria were met by 54 (33.5%) of the adolescents. Three conversions of psychosis as defined by SIPS emerged during follow-up, two of whom belonged to the CHR group. The positive predictive value of the CHR status was weak (1.9%) but its negative predictive value was 98.0%. Using the DSM-IV definition of psychosis, there were five conversions, three of which were in the CHR group. In regression analyses, hospital admissions for primary psychotic disorder were predicted by positive symptom intensity in the baseline SIPS. In addition, CHR status and SIPS positive and general symptoms predicted hospitalization for psychiatric disorder.

DISCUSSION

Psychosis incidence was low in our unselected sample of adolescent psychiatric patients. CHR status failed to predict SIPS or DSM-IV psychoses significantly at 12 months. However, in a longer follow-up, CHR did predict psychiatric hospitalization.

Neurocognitive and clinical predictors of long-term outcome in adolescents at ultra-high risk for psychosis: a 6-year follow-up

Background

Most studies aiming to predict transition to psychosis for individuals at ultra-high risk (UHR) have focused on either neurocognitive or clinical variables and have made little effort to combine the two. Furthermore, most have focused on a dichotomous measure of transition to psychosis rather than a continuous measure of functional outcome. We aimed to investigate the relative value of neurocognitive and clinical variables for predicting both transition to psychosis and functional outcome.

Methods

Forty-three UHR individuals and 47 controls completed an extensive clinical and neurocognitive assessment at baseline and participated in long-term follow-up approximately six years later. UHR adolescents who had converted to psychosis (UHR-P; n = 10) were compared to individuals who had not (UHR-NP; n = 33) and controls on clinical and neurocognitive variables. Regression analyses were performed to determine which baseline measures best predicted transition to psychosis and long-term functional outcome for UHR individuals.

Results

Low IQ was the single neurocognitive parameter that discriminated UHR-P individuals from UHR-NP individuals and controls. The severity of attenuated positive symptoms was the only significant predictor of a transition to psychosis and disorganized symptoms were highly predictive of functional outcome.

Conclusions

Clinical measures are currently the most important vulnerability markers for long-term outcome in adolescents at imminent risk of psychosis.

The 'at-risk mental state' for psychosis in adolescents: clinical presentation, transition and remission

Despite increased efforts over the last decade to prospectively identify individuals at ultra-high risk of developing a psychotic illness, limited attention has been specifically directed towards adolescent populations (<18 years). In order to evaluate how those under 18 fulfilling the operationalised criteria for an At-Risk Mental State (ARMS) present and fare over time, we conducted an observational study. Participants (N = 30) generally reported a high degree of functional disability and frequent and distressing perceptual disturbance, mainly in the form of auditory hallucinations. Seventy percent (21/30) were found to fulfil the criteria for a co-morbid ICD-10 listed mental health disorder, with mood (affective; 13/30) disorders being most prevalent. Overall transition rates to psychosis were low at 24 months follow-up (2/28; 7.1 %) whilst many participants demonstrated a significant reduction in psychotic-like symptoms. The generalisation of these findings may be limited due to the small sample size and require replication in a larger sample.

Practitioner review: schizophrenia spectrum disorders and the at-risk mental state for psychosis in children and adolescents--evidence-based management approaches

BACKGROUND

Schizophrenia spectrum disorders are severe mental illnesses which often result in significant distress and disability. Attempts have been made to prospectively identify and treat young people viewed as at high risk of impending nonaffective psychosis. Once a schizophrenia spectrum disorder has developed, prompt identification and management is required.

METHODS

This article reviews the literature relating to the assessment and management of 'at-risk mental states' (ARMS) and the treatment of schizophrenia spectrum disorders in children and adolescents. A systematic search of the literature was undertaken using EMBASE, MEDLINE, PsycINFO databases for the period January 1970-December 2012.

RESULTS

Evidence suggests that young people fulfilling the ARMS criteria are at high risk of adverse mental health outcomes but that the majority do not develop nonaffective psychosis over the medium term. Although clinical trial findings have been inconsistent, psychosocial approaches, such as cognitive behaviour therapy, may reduce the risk of transition to psychosis and improve some symptoms, at least over the short term. The effectiveness of psychotropic medication for the ARMS is uncertain although there is accumulating evidence for potential adverse effects of antipsychotic medication, even at low dose, in this population. For the schizophrenias, clinical trial findings suggest that, as in adults, antipsychotics should be selected on the basis of side-effect profile although clozapine may be helpful in treatment refractory illness. There are almost no studies of psychosocial treatments for schizophrenia in young people under 18, and some caution must be exercised when extrapolating the findings of adult studies to younger individuals.

CONCLUSIONS

A stepped care approach to the ARMS in young people represents a plausible potential management approach for those at high risk of serious mental health problems. However, predictive models currently lack precision and should focus on accurately identifying those at high risk for a variety of poor outcomes who may benefit most from intervention. There is also an urgent need for age-specific research in the area of psychosocial treatments for children and adolescents with schizophrenia.

Moving beyond transition outcomes: meta-analysis of remission rates in individuals at high clinical risk for psychosis

Recent evidence suggests that transition risks from initial clinical high risk (CHR) status to psychosis are decreasing. The role played by remission in this context is mostly unknown. The present study addresses this issue by means of a meta-analysis including eight relevant studies published up to January 2012 that reported remission rates from an initial CHR status. The primary effect size measure was the longitudinal proportion of remissions compared to non-remission in subjects with a baseline CHR state. Random effect models were employed to address the high heterogeneity across studies included. To assess the robustness of the results, we performed sensitivity analyses by sequentially removing each study and rerunning the analysis. Of 773 subjects who met initial CHR criteria, 73% did not convert to psychosis along a 2-year follow. Of these, about 46% fully remitted from the baseline attenuated psychotic symptoms, as evaluated on the psychometric measures usually employed by prodromal services. The corresponding clinical remission was estimated as high as 35% of the baseline CHR sample. The CHR state is associated with a significant proportion of remitting subjects that can be accounted by the effective treatments received, a lead time bias, a dilution effect, a comorbid effect of other psychiatric diagnoses.

Diagnosis and evaluation of hallucinations and other psychotic symptoms in children and adolescents

Recognizing positive psychotic symptoms and their diagnostic context in youth is challenging. A large minority say they "hear things others do not hear," though they seldom present with complaints of hallucinations or delusions. Few have schizophrenia spectrum disorder, but many have other psychiatric disorders. Frequently, they have psychotic symptoms for an extended period before diagnosis. Clinicians should understand psychotic symptoms and their differential diagnoses. This article reviews the epidemiology, associated diagnoses, and prognosis of hallucinations and delusions in youth. Strategies for optimizing the clinical diagnostic interview, appropriate laboratory tests, indications for psychological testing, and rating scales are reviewed.

Examining the course of hallucinatory experiences in children and adolescents: a systematic review

BACKGROUND

Childhood and adolescence represent the periods during which hallucinatory experiences occur at the greatest prevalence, and also constitute a critical window of vulnerability for the pathogenesis of psychotic disorders. The longitudinal course of hallucinatory experiences during late childhood and adolescence, as well as their relationship to psychotic disorders, has never been the subject of review.

METHODS

We followed the PRISMA guidelines for conducting systematic reviews and combined the use of electronic and manual systematic search methods. Data were extracted upon pre-defined requested items and were analyzed using several epidemiological measures. The interpretation of the results was conducted in relation to the study design variables.

RESULTS

A total of 11 datasets (6 epidemiological and 5 clinical) were reviewed. The baseline prevalence of hallucinatory experiences ranged from 4.9% to 9%. Discontinuation occurred in between 58.7% and 94.5% of the cases, and person-year discontinuation rates ranged from 3% to 40.7% and appeared to be related to the duration of follow-up. Despite low person-year incidence rate, incident cases constituted between 27.7% and 83.3% of outcome samples. 2 of 3 studies showed evidence to predict transition to psychosis with likelihood ratios of 2.5 and 6.6.

CONCLUSIONS

Hallucinatory experiences are a common experience during childhood and adolescence. A review of the current literature suggests that there is a considerable turnover of incident-discontinuing cases and that most cases discontinue in the short term. A subset of the cases was at risk for persistence or transition to psychosis, probably related to indicators of severity of the hallucinatory experience.

Experience of child and adolescent mental health clinicians working within an at-risk mental state for psychosis service: a qualitative study

AIM

To qualitatively examine the common experiences of child and adolescent mental health clinicians working with adolescents suspected of having an 'at-risk mental state' (ARMS) for psychosis.

METHODS

A semistructured interview was conducted with six experienced child and adolescent mental health clinicians working in North East England.

RESULTS

A thematic analysis of clinicians' experiences indicated that the identification and management of an ARMS within this patient group is particularly complex. In terms of treatment options, approaches that promoted social inclusion were favoured, but the use of antipsychotic medication was perceived as a 'last resort', requiring serious consideration. Clear guidelines and an overall consensus were judged to be lacking in terms of coordinating care and multi-agency working practices.

CONCLUSIONS

Establishing a formalized care pathway that also incorporates regular training and supervision may be required by this and other clinical services working with adolescents suspected of having an ARMS. Improved identification, a firmer evidence base regarding treatment practices and clear guidelines are required for this age group. This need will become more urgent should a psychosis risk syndrome be included as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

Ultra high-risk state for psychosis and non-transition: a systematic review

BACKGROUND

Most effort in ultra high-risk (UHR) research has been directed at defining the clinical and neurobiological characteristics of those UHR subjects who go on to develop psychosis. The characteristics and outcome of the remaining UHR subjects have remained relatively unexplored.

METHOD

We performed a systematic review of clinical UHR studies to investigate whether information was available on the characteristics and outcome of UHR subjects who did not convert to psychosis.

RESULTS

Of 2462 potentially relevant papers, 31 met inclusion criteria, i.e. 20 naturalistic and 11 intervention studies. On average 76% (range 46-92.6%) of the UHR patients made no transition to psychosis during follow-up (range 6 to 40 months). Nearly half of the studies provided no characteristics of those UHR subjects who did not develop psychosis. Six studies reported remission rates from initial UHR status (range 15.4% to 54.3%). Linear regression showed that more recent studies reported significantly lower transition rates as compared to earlier publications. An older mean age at baseline was associated with significant lower transition rates in publications with follow-ups exceeding 1 year.

CONCLUSIONS

Our review illustrates that the long-term outcome of UHR subjects that do not develop psychosis is to date under-investigated. The studies reporting remission rates suggest that UHR criteria capture a non-negligible proportion of subjects that do not convert to psychosis.

Transition and remission in adolescents at ultra-high risk for psychosis

BACKGROUND

Future success of early intervention initiatives to prevent the onset of psychosis will rely on the validity of methods to predict clinical outcome. Proper identification is particularly essential for young adolescents, as psychotic-like symptoms are often transitory during this period and mislabeling can lead to early stigmatization and unnecessary treatment. This article presents results from a prospective, naturalistic 2-year follow-up study of a cohort of young adolescents putatively at ultra-high risk (UHR) for psychosis.

METHODS

Seventy-two adolescents between 12 and 18years were recruited, fulfilling either UHR criteria or the basic symptom-based criterion cognitive disturbances (COGDIS). Incidence of transition as well as the remission rate from UHR status was calculated. Individuals who made a transition (UHR-P) were compared to those who did not (UHR-NP) and to those who remitted (UHR-R) on socio-demographic and clinical characteristics.

RESULTS

Fifty-seven UHR individuals completed the 2-year follow-up assessment. The confirmed transition rate was 15.6% and 35.3% still met UHR criteria. The remaining 49.1% had remitted from an initial UHR status. The UHR subgroups did not differ on socio-demographic or clinical variables at baseline.

CONCLUSIONS

Half of young adolescents meeting UHR criteria continue to experience prodromal or psychotic symptoms after 2 years. However, they are at least three times more likely to have remitted from their UHR status than to have made a transition to psychosis. In addition, baseline characteristics are not indicative of clinical outcome at follow-up. Our results emphasize the need for further improvement and stratification of relative risk factors for psychosis.

Associations between psychotic-like symptoms and inattention/hyperactivity symptoms

OBJECTIVE

Our aim was to study the association between psychotic-like symptoms and inattention/hyperactivity symptoms in a general adolescent population.

SUBJECTS AND METHODS

The sample is based on a population-based prospective mother-child birth cohort, the Northern Finland Birth Cohort 1986. In the 15-16-year follow-up survey, the adolescents completed the Youth Self-Report questionnaire as well as the PROD-Screen questionnaire that addressed prodromal symptoms of psychosis. Meanwhile, their parents assessed inattention and hyperactive symptoms of their offspring by completing the Strengths and Weaknesses of ADHD Symptoms and Normal Behaviors questionnaire (N = 5,318). The cross-sectional associations between psychotic-like symptoms and inattention/hyperactivity symptoms were studied with logistic regression models.

RESULTS

The association between negative psychotic-like symptoms and inattention symptoms, especially the dreamy type of inattention symptoms (e.g., difficulties in organizing tasks, losing things, being forgetful), was statistically significant for both genders. Psychotic-like symptoms, however, were not associated with hyperactivity symptoms.

CONCLUSIONS

The present findings demonstrate that an association between psychotic-like symptoms and attentional dysfunction, which has been found in clinical samples, is also present in a general adolescent population.

Why we need more debate on whether psychotic symptoms lie on a continuum with normality

The notion that psychotic symptoms lie on a continuum with normality has become an accepted dogma. It is supported by several lines of empirical evidence, fits in with the orientation of modern services and has a 'moral' appeal. However, there is confusion as to the nature of the continuum or continua under discussion. According to the author, commentators on this topic do not often distinguish between the variability and severity of the phenomena themselves, within or between individuals, versus the distribution of symptoms or risk factors in a population. The implications of these two types of continua differ. Furthermore, the evidence for continua of delusional beliefs and hallucinations can be challenged on a number of grounds, both methodological and conceptual. To some extent, whether phenomena are viewed as continua or categories depends on the intentions of the observer. Finding the distinctive characteristics of psychotic phenomena in people with clinical disorders, in addition to their origins in 'normal' cognitive processes, is a worthwhile goal.

The relationship between psychotic-like symptoms and neurocognitive performance in a general adolescent psychiatric sample

INTRODUCTION

The current criteria for detecting a Clinical High-Risk (CHR) state for psychosis do not address cognitive impairment. A first step for identifying cognitive markers of psychosis risk would be to determine which aspects of neurocognitive performance are related with more severe psychotic-like symptoms. This study assessed cognitive impairment associated with prodromal symptoms in adolescents receiving public psychiatric treatment.

METHODS

189 adolescents were recruited from consecutive new patients aged 15-18 attending mainly outpatient adolescent psychiatric units in Helsinki. They had been screened for prodromal symptoms using the Prodromal Questionnaire, and all screen-positives as well as a random sample of screen-negatives were interviewed using the Structured Interview for Prodromal Symptoms (SIPS) and underwent testing using a large, standardized neurocognitive test battery. The sample included 62 adolescents who met the CHR criteria (CHR) and 112 who did not (non-CHR). A healthy control sample (n=72) was also included to provide age- and gender-matched norms.

RESULTS

The CHR group performed worse on visuospatial tasks than the non-CHR group. Among CHR adolescents, negative symptoms were associated with slower processing speed and poorer performance on verbal tasks. Among non-CHR adolescents, positive symptoms were associated with poorer performance on visuospatial tasks, and negative symptoms with poorer performance on verbal tasks.

CONCLUSION

Clinical high-risk status is associated with impaired visuospatial task performance. However, both positive, psychotic-like symptoms and negative symptoms are associated with lower levels of neurocognitive functioning among adolescents in psychiatric treatment regardless of whether CHR criteria are met. Thus, even mild positive and negative symptoms may have clinical relevance in adolescents in psychiatric care. Adolescents with both psychotic-like symptoms and neurocognitive deficits constitute a group requiring special attention.

Transient auditory hallucinations in an adolescent

In adolescents, hallucinations can be a transient illness or can be associated with non-psychotic psychopathology, psychosocial adversity, or a physical illness. We present the case of a 15-year-old secondary-school student who presented with a 1-month history of first onset auditory hallucinations, which had been increasing in frequency and severity, and mild paranoid ideation. Over a 10-week period, there was a gradual diminution, followed by a complete resolution, of symptoms. We discuss issues regarding the diagnosis and prognosis of auditory hallucinations in adolescents.

High remission rates from an initial ultra-high risk state for psychosis

OBJECTIVE

To investigate the proportion of patients among subjects initially identified as fulfilling the ultra-high risk (UHR) criteria for psychosis using the Scale of Prodromal Symptoms (SOPS) who fully remitted after one year.

METHOD

Seventy-two patients between 14 and 40 years who were referred to the Bruderholz Early Psychosis Outpatient Service in Switzerland and who met UHR criteria were included in the present study. At 1-year follow-up, data for 52 patients were available. Patients with transition to psychosis and patients with sustained UHR criteria were defined as 'cases', and patients with remission from UHR criteria as 'non-cases'. We compared clinical and socio-demographic characteristics between these two patient groups at baseline.

RESULTS

13.5% of the patients converted to full-blown psychosis within one year, one quarter displayed sustained UHR criteria, and 59.2% of the patients fully remitted from the initial UHR status. Outcome was independent of medication or treatment status. 'Cases' and 'non-cases' did not differ significantly on socio-demographic and clinical variables at baseline.

CONCLUSIONS

The chance of remission to a non-risk state was over fourfold higher than the chance of conversion to psychosis within a year of establishing UHR status. Our data underline that the commonly used symptoms to identify UHR patients are often transitory and may not capture the stable core of developing psychosis. This highlights the danger of provoking anxiety and stigmatization in mislabeled individuals and missing true at-risk patients who present features of the psychosis core, but who do not yet-or maybe never will-manifest positive symptoms.