Logic and justification for dimensional assessment of symptoms and related clinical phenomena in psychosis: relevance to DSM-5

Clinical, cognitive, and functional characteristics of recent-onset psychosis with autistic features: A 2-year longitudinal study

Though categorized as separate illnesses, schizophrenia and autism are known to exhibit shared characteristics. This study explored the distinctions in clinical, cognitive, and functional characteristics among individuals with recent-onset psychosis, considering the severity of their autistic symptoms, involving longitudinal examinations. We analyzed 671 patients with recent-onset psychosis from Korean Early Psychosis Cohort Study (KEPS), and used the PANSS Autism Severity Score (PAUSS) to categorize patient into 'autistic', 'moderate', and 'non-autistic' groups. The autistic group had the highest rate of schizophrenia diagnosis, and the lowest incidence of comorbid psychiatric disorders. Schizophrenia diagnosis predicted membership of the autistic group. More severe autistic symptoms correlated with worse overall symptoms and functional outcomes, which significantly predicted membership of the autistic group. Cognitive impairments and emotional recognition difficulties increased with the severity of autistic symptoms. 2-year longitudinal assessments demonstrated that group differences in autistic features and overall symptoms, and functional outcomes remained consistent, and membership of the autistic group significantly predicted symptomatic remission and functional recovery. In conclusion, the presence of autistic symptoms has a significant impact on the overall symptomatology and functional capabilities. They are enduring attributes rather than temporary state variables, and serve as a significant predictor for both symptomatic and functional recovery.

Psychosis superspectrum II: neurobiology, treatment, and implications

Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.

The mediating role of psychological flexibility in the relationship between psychotic symptom severity and depression in individuals diagnosed with schizophrenia

WHAT IS KNOWN ABOUT THE SUBJECT?: Psychotic symptoms and depression are common problems in people diagnosed with schizophrenia. Psychological flexibility is a skill that facilitates coping with difficulties. There is limited research on the role of psychological flexibility in the relationship between psychotic symptoms and depression in people diagnosed with schizophrenia. WHAT DOES THE ARTICLE ADD TO EXISTING KNOWLEDGE?: This article investigates the role of psychological flexibility in the link between psychotic symptom severity and depression in people diagnosed with schizophrenia. The article shows that psychological flexibility partially mediates the relationship between psychotic symptom severity and depression. The article suggests that interventions aimed at improving psychological flexibility may be beneficial in reducing depressive symptoms in people diagnosed with schizophrenia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should consider psychotic symptom severity and psychological flexibility when assessing and intervening for depressive symptoms in people diagnosed with schizophrenia. Mental health nurses should receive training to improve psychological flexibility and pass this skill on to their patients. Mental health nurses should continue to research the effectiveness and outcomes of interventions aimed at improving psychological flexibility.

ABSTRACT

INTRODUCTION: Psychological flexibility may help people diagnosed with schizophrenia (PWS) cope with their psychotic symptoms and reduce their depressive symptoms, but the mechanism of this effect is unclear.

AIM

To investigate whether psychological flexibility mediates the relationship between psychotic symptom severity and depression in PWS.

METHOD

A cross-sectional study was conducted, in which a total of 111 PWS were assessed with DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity, Calgary Depression Scale for Schizophrenia and Acceptance and Action Questionnaire. Data analysis was performed using SPSS 25 and PROCESS macro.

RESULTS

Significant correlations were found between psychotic symptoms, depression and psychological flexibility. Psychological flexibility partially mediated the relationship between psychotic symptom severity and depression.

DISCUSSION

Psychological flexibility could weaken the impact of psychotic symptom severity on depression in PWS. Higher psychotic symptoms were associated with lower psychological flexibility and higher depression.

IMPLICATIONS FOR PRACTICE

Interventions to improve psychological flexibility may prevent depressive symptoms in PWS. Psychiatric nurses can use psychological flexibility as a goal for evaluation and intervention.

Duration of the psychosis prodrome and its relationship to duration of untreated psychosis across all 12 DSM-IV psychotic diagnoses: Evidence for a trans-diagnostic process associated with resilience

While duration of the psychosis prodrome (DPP) attracts attention in relation to the developmental trajectory of psychotic illness and service models, fundamental issues endure in the context of dimensional-spectrum models of psychosis. Among 205 epidemiologically representative subjects in the Cavan-Monaghan First Episode Psychosis Study, DPP was systematically quantified and compared, for the first time, across all 12 DSM-IV psychotic diagnoses. DPP was also compared with duration of untreated psychosis (DUP) and each was then analysed in relation to premorbid features across three age ranges: <12, 12-15 and 16-18 years. For each diagnosis, medians for both DPP and DUP were shorter than means, indicating common right-skewed distributions. Rank orders for both DPP and DUP were longest for schizophrenia, intermediate for other schizophrenia-spectrum psychoses, psychotic depression and psychotic disorder not otherwise specified, and shortest for brief psychotic disorder, bipolar disorder and substance-induced psychotic disorder, though with overlapping right-skewed distributions. DPP was longer than DUP for all diagnoses except substance-induced psychotic disorder. Across functional psychotic diagnoses, longer DPP was predicted by higher premorbid intelligence and better premorbid adjustment during age 16-18 years. These findings indicate that, trans-diagnostically, DPP and DUP share right-skewed continuities, in accordance with a dimensional-spectrum model of psychotic illness, and may reflect a unitary process that has been dichotomized at a subjective threshold along its trajectory. Better premorbid functioning during age 16-18 years appears to confer resilience by delaying progression to overt psychotic symptoms and may constitute a particular target period for psychosocial interventions.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

From operational diagnostic to dimensional-continuum concepts of psychotic and non-psychotic illness: Embracing catatonia across psychopathology and intrinsic movement disorder in neural network dysfunction

Psychiatry is currently negotiating several challenges that are typified by (but are not unique to) schizophrenia: do periodic refinements in operational diagnostic algorithms (a) resolve intricacies and subtleties within and between psychotic and non-psychotic disorders that are authentic and impactful, or (b) constitute arbitrary and porous boundaries that should be complemented, or even replaced, by dimensional-continuum concepts of abnormality and dysfunction. Critically, these issues relate not only to apparent boundaries between diagnoses but also to those between 'health' and 'illness'. This article considers catatonia within evolving dimensional-continuum approaches to the description of impairment and dysfunction among psychotic and non-psychotic disorders. It begins by considering the definition and assessment of catatonia vis-à-vis other disorders, followed by its long-standing conjunction with schizophrenia, relationship with antipsychotic drug treatment, transdiagnostic perspectives and relationships, and pathobiological processes. These appear to involve dysfunction across elements in overlapping neural networks that result in a confluence of psychopathology and intrinsic hypo- and hyperkinetic motor dysfunction. It has been argued that while current diagnostic approaches can have utility in defining groups of cases that are closely related, contemporary evidence indicates categorical diagnoses to be arbitrary divisions of what is essentially a continuous landscape. Psychotic and non-psychotic diagnoses, including catatonia, may reflect arbitrary areas around points of intersection between orthogonal dimensions of psychopathology and intrinsic movement disorder in a poly-dimensional space that characterises this continuous landscape of mental health and dysfunction.

Applying the Project ECHO Model to Support Implementation and Sustainment of Cognitive Behavioral Therapy for Psychosis

INTRODUCTION

Project Extension for Community Healthcare Outcomes (ECHO) is a teleconsultation model that leverages technology to sustain specialized interventions in underresourced settings. We present the application of the ECHO model to longitudinal training and consultation for community behavioral health providers learning to deliver cognitive behavioral therapy for psychosis, an evidence-based psychotherapy for individuals with psychotic disorders that has poorly penetrated the US mental health system.

METHODS

We analyzed within-group change over practitioners' 6-month ECHO participation cycle using the Expanded Outcomes Framework. We evaluated outcomes associated with participation, satisfaction, knowledge acquisition, performance, patient symptom severity, and functional impairment.

RESULTS

In the first 3 years, the cognitive behavioral therapy for psychosis ECHO Clinics supported 150 providers from 12 community agencies. Forty percent did not complete the 6-month ECHO calendar, most commonly due to separation from their agency. Participants reported high degrees of satisfaction. Declarative and procedural knowledge increased over the 6-month period. Of the 24 providers who received a fidelity review, 87.5% met or exceeded the competency benchmark within the 6-month period. Clinical outcomes reflected reductions in hallucinations, negative symptoms, depression, mania, and functional impairment, but no reductions were detected in delusions, disorganized speech, or abnormal psychomotor behavior.

DISCUSSION

ECHO Clinics offer a mode of providing continuous access to expert instruction, peer-to-peer consultation, and case-based learning that other workforce training models lack. Our evaluation suggests that the ECHO model supports continuous professional development for practitioners, most of whom had indicated inadequate preparation for their role. We observed improved learner and select patient outcomes.

Cognitive impairment in schizophrenia: aetiology, pathophysiology, and treatment

Cognitive deficits are a core feature of schizophrenia, account for much of the impaired functioning associated with the disorder and are not responsive to existing treatments. In this review, we first describe the clinical presentation and natural history of these deficits. We then consider aetiological factors, highlighting how a range of similar genetic and environmental factors are associated with both cognitive function and schizophrenia. We then review the pathophysiological mechanisms thought to underlie cognitive symptoms, including the role of dopamine, cholinergic signalling and the balance between GABAergic interneurons and glutamatergic pyramidal cells. Finally, we review the clinical management of cognitive impairments and candidate novel treatments.

Dysregulation of Long Intergenic Non-Coding RNA Expression in the Schizophrenia Brain

BACKGROUND

Transcriptomic studies of the brains of schizophrenia (SZ) patients have produced abundant but largely inconsistent findings about the disorders pathophysiology. These inconsistencies might stem not only from the heterogeneous nature of the disorder, but also from the unbalanced focus on particular cortical regions and protein-coding genes. Compared to protein-coding transcripts, long intergenic non-coding RNA (lincRNA) display substantially greater brain region and disease response specificity, positioning them as prospective indicators of SZ-associated alterations. Further, a growing understanding of the systemic character of the disorder calls for a more systematic screening involving multiple diverse brain regions.

AIM

We aimed to identify and interpret alterations of the lincRNA expression profiles in SZ by examining the transcriptomes of 35 brain regions.

METHODS

We measured the transcriptome of 35 brain regions dissected from eight adult brain specimens, four SZ patients, and four healthy controls, using high-throughput RNA sequencing. Analysis of these data yielded 861 annotated human lincRNAs passing the detection threshold.

RESULTS

Of the 861 detected lincRNA, 135 showed significant region-dependent expression alterations in SZ (two-way ANOVA, BH-adjusted p 0.05) and 37 additionally showed significant differential expression between HC and SZ individuals in at least one region (post hoc Tukey test, p 0.05). For these 37 differentially expressed lincRNAs (DELs), 88% of the differences occurred in a cluster of brain regions containing axon-rich brain regions and cerebellum. Functional annotation of the DEL targets further revealed stark enrichment in neurons and synaptic transmission terms and pathways.

CONCLUSION

Our study highlights the utility of a systematic brain transcriptome analysis relying on the expression profiles measured across multiple brain regions and singles out white matter regions as a prospective target for further SZ research.

Cerebral blood flow in schizophrenia: A systematic review and meta-analysis of MRI-based studies

INTRODUCTION

Schizophrenia-spectrum disorders (SSD) represent one of the leading causes of disability worldwide and are usually underpinned by neurodevelopmental brain abnormalities observed on a structural and functional level. Nuclear medicine imaging studies of cerebral blood flow (CBF) have already provided insights into the pathophysiology of these disorders. Recent developments in non-invasive MRI techniques such as arterial spin labeling (ASL) have allowed broader examination of CBF across SSD prompting us to conduct an updated literature review of MRI-based perfusion studies. In addition, we conducted a focused meta-analysis of whole brain studies to provide a complete picture of the literature on the topic.

METHODS

A systematic OVID search was performed in Embase, MEDLINEOvid, and PsycINFO. Studies eligible for inclusion in the review involved: 1) individuals with SSD, first-episode psychosis or clinical-high risk for psychosis, or; 2) had healthy controls for comparison; 3) involved MRI-based perfusion imaging methods; and 4) reported CBF findings. No time span was specified for the database queries (last search: 08/2022). Information related to participants, MRI techniques, CBF analyses, and results were systematically extracted. Whole-brain studies were then selected for the meta-analysis procedure. The methodological quality of each included studies was assessed.

RESULTS

For the systematic review, the initial Ovid search yielded 648 publications of which 42 articles were included, representing 3480 SSD patients and controls. The most consistent finding was that negative symptoms were linked to cortical fronto-limbic hypoperfusion while positive symptoms seemed to be associated with hyperperfusion, notably in subcortical structures. The meta-analysis integrated results from 13 whole-brain studies, across 426 patients and 401 controls, and confirmed the robustness of the hypoperfusion in the left superior and middle frontal gyri and right middle occipital gyrus while hyperperfusion was found in the left putamen.

CONCLUSION

This updated review of the literature supports the implication of hemodynamic correlates in the pathophysiology of psychosis symptoms and disorders. A more systematic exploration of brain perfusion could complete the search of a multimodal biomarker of SSD.

Autobiographical memory and the self on the psychosis continuum: investigating their relationship with positive- and negative-like symptoms

Autobiographical memory is severely impaired in schizophrenia, but previous work has largely treated both as unitary concepts. Here, we examined how various dimensions of autobiographical memory relate to different aspects of psychosis. Participants were recruited from the general population (Study 1, N = 264) and a university subject pool (Study 2, N = 305). We examined different measures of autobiographical memory and self (i.e., involuntary memory, autobiographical recollection, self-knowledge and self-awareness), at the trait level in Study 1 and both trait and state levels in Study 2, as a function of positive-and negative-like symptoms of psychosis. Across both studies, positive and negative dimensions of psychosis were found to be related to an increase in involuntary memories (i.e., the spontaneous recall of personal memories), and to lower self-concept clarity and insight. Positive and negative dimensions of psychosis correlated differently with autobiographical recollection characteristics, measured at both trait (Studies 1 and 2) and state levels (Study 2). Positive-like symptoms (in particular hallucination-proneness) showed a stronger and more consistent pattern of correlations than negative-like symptoms. These findings call for a dimensional approach to the relationship between autobiographical memory and psychosis symptoms in clinical and non-clinical individuals, to better understand the breakdown of autobiographical memory in the psychopathology of psychosis.

Psychopathological networks in psychosis: Changes over time and clinical relevance. A long-term cohort study of first-episode psychosis

BACKGROUND

First-episode psychosis is a critical period for early interventions to reduce the risk of poor outcomes and relapse as much as possible. However, uncertainties about the long-term outcomes of symptomatology remain to be ascertained.

METHODS

The aim of the present study was to use network analysis to investigate first-episode and long-term stages of psychosis at three levels of analysis: micro, meso and macro. The sample was a cohort of 510 patients with first-episode psychoses from the SEGPEP study, who were reassessed at the long-term follow-up (n = 243). We used the Comprehensive Assessment of Symptoms and History for their assessments and lifetime outcome variables of clinical relevance.

RESULTS

Our results showed a similar pattern of clustering between first episodes and long-term follow-up in seven psychopathological dimensions at the micro level, 3 and 4 dimensions at the meso level, and one at the macro level. They also revealed significant differences between first-episode and long-term network structure and centrality measures at the three levels, showing that disorganization symptoms have more influence in long-term stabilized patients.

CONCLUSIONS

Our findings suggest a relative clustering invariance at all levels, with the presence of two domains of disorganization as the most notorious difference over time at micro level. The severity of disorganization at the follow-up was associated with a more severe course of the psychosis. Moreover, a relative stability in global strength of the interconnections was found, even though the network structure varied significantly in the long-term follow-up. The macro level was helpful in the integration of all dimensions into a common psychopathology factor, and in unveiling the strong relationships of psychopathological dimensions with lifetime outcomes, such as negative with poor functioning, disorganization with high antipsychotic dose-years, and delusions with poor adherence to treatment. These results add evidence to the hierarchical, dimensional and longitudinal structure of psychopathological symptoms and their clinical relevance in first-episode psychoses.

Towards mapping neuro-behavioral heterogeneity of psychedelic neurobiology in humans

Precision psychiatry aims to identify markers of inter-individual variability that allow predicting the right treatment for each patient. However, bridging the gap between molecular-level manipulations and neural systems-level functional alterations remains an unsolved problem in psychiatry. After decades of low success rates in pharmaceutical R&D for psychiatric drugs, multiple studies now point to the potential of psychedelics as a promising fast-acting and long-lasting treatment for some psychiatric symptoms. Yet, given the highly psychoactive nature of these substances, a precision medicine approach is essential to map the neural signals related to clinical efficacy in order to identify patients who can maximally benefit from this treatment. Recent studies have shown that bridging the gap between pharmacology, systems-level neural response in humans and individual experience is possible for psychedelic substances, therefore paving the way for a precision neuropsychiatric therapeutic development. Specifically, it has been shown that the integration of brain-wide PET or transcriptomic data, i.e. receptor distribution for the serotonin 2A receptor, with computational neuroimaging methods can simulate the effect of psychedelics on the human brain. These novel 'computational psychiatry' approaches allow for modeling inter-individual differences in neural as well as subjective effects of psychedelic substances. Collectively, this review provides a deep dive into psychedelic pharmaco-neuroimaging studies with a core focus on how recent computational psychiatry advances in biophysically based circuit modeling can be leveraged to predict individual responses. Finally, we emphasize the importance of human pharmacological neuroimaging for the continued precision therapeutic development of psychedelics.

Affective symptom dimensions in early-onset psychosis over time: a principal component factor analysis of the Young Mania Rating Scale and the Hamilton Depression Rating Scale

Early-onset psychosis (EOP) is a complex disorder characterized by a wide range of symptoms, including affective symptoms. Our aim was to (1) examine the dimensional structure of affective symptoms in EOP, (2) evaluate the predominance of the clinical dimensions and (3) assess the progression of the clinical dimensions over a 2-year period. STROBE-compliant prospective principal component factor analysis of Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale-21 (HDRS-21) at baseline, 6-months, 1-year and 2-year follow-up. We included 108 EOP individuals (mean age = 15.5 ± 1.8 years, 68.5% male). The factor analysis produced a four-factor model including the following dimensions: mania, depression/anxiety, sleep and psychosis. It explained 47.4% of the total variance at baseline, 60.6% of the total variance at 6-months follow-up, 54.5% of the total variance at 1-year follow-up and 49.5% of the total variance at 2-year follow-up. According to the variance explained, the mania factor was predominant at baseline (17.4%), 6-month follow-up (23.5%) and 2-year follow-up (26.1%), while the depression/anxiety factor was predominant at 1-year follow-up (23.1%). The mania factor was the most stable; 58.3% items that appeared in this factor (with a load > 0.4) at any time point appeared in the same factor at ≥ 3/4 time points. Affective symptoms are frequent and persistent in EOP. Mania seems to be the most predominant and stable affective dimension. However, depression and anxiety may gain predominance with time. A comprehensive evaluation of the dimensional structure and the progression of affective symptoms may offer clinical and therapeutic advantages.

Diagnostic Dilemma and Management Difficulties in a Young Patient With Psychosis and Benign Chorea: A Case Report and Review of the Literature

Psychosis presents with hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. It most commonly appears in the setting of schizophrenia, although it could also appear in bipolar disorder, major depression, post-traumatic stress disorder (PTSD) and even in medical conditions and substance use. In young people, the diagnosis of psychosis can present as a challenge due to the overlap of psychotic conditions and other emotional, behavioral, and developmental disorders. In this case report, we present the case of a 19-year-old female with a history of bipolar disorder, oppositional defiant disorder (ODD), depression, anxiety, PTSD, and schizophrenia-spectrum disorder who was admitted to an inpatient psychiatric facility after presenting with acute onset of confusion. 

The factor structure and clinical utility of clinician-rated dimensions of psychosis symptom severity in patients with recent-onset psychosis: Results of a 1-year longitudinal follow-up prospective cohort study

The classic subtype classification of schizophrenia has been removed, and DSM-5 now includes the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS). In the present study, a factor analysis of the CRDPSS was performed, and we assessed whether patient classification using the derived factor structure helps predict the clinical course. The participants were 390 patients with recent-onset psychosis enrolled in the Korean Early Psychosis Cohort Study (KEPS). Two factors were identified: psychotic (including delusions, hallucinations, disorganization, and abnormal psychomotor behavior) and negative-cognitive (including negative symptoms and impaired cognition). Patients were grouped based on the factor structure and changes in clinical course were monitored over 1 year. The negative-cognitive group demonstrated longer duration of untreated psychosis, earlier onset, and a higher rate of psychiatric comorbidities. Baseline Positive and Negative Syndrome Scale (PANSS) total and Clinical Global Impression-Severity (CGI-S) scores were higher in psychotic group, but group differences were not observed after 2 months. Conversely, the PANSS negative scale score was significantly higher in negative-cognitive group throughout follow-up, and CGI-S score was reversed at 12 months. The findings indicate that the factor structure derived herein for the CRDPSS could be helpful for predicting the clinical course of recent-onset psychosis patients.

Different patterns of white matter microstructural alterations between psychotic and non-psychotic bipolar disorder

This study aimed to investigate alterations in white matter (WM) microstructure in patients with psychotic and non-psychotic bipolar disorder (PBD and NPBD, respectively). We used 3T-magnetic resonance imaging to examine 29 PBD, 23 NPBD, and 65 healthy control (HC) subjects. Using tract-based spatial statistics for diffusion tensor imaging data, we compared fractional anisotropy (FA) and mean diffusion (MD) pairwise among the PBD, NPBD, and HC groups. We found several WM areas of decreased FA or increased MD in the PBD and NPBD groups compared to HC. PBD showed widespread FA decreases in the corpus callosum as well as the bilateral internal capsule and fornix. However, NPBD showed local FA decreases in a part of the corpus callosum body as well as in limited regions within the left cerebral hemisphere, including the anterior and posterior corona radiata and the cingulum. In addition, both PBD and NPBD shared widespread MD increases across the posterior corona radiata, cingulum, and sagittal stratum. These findings suggest that widespread WM microstructural alterations might be a common neuroanatomical characteristic of bipolar disorder, regardless of being psychotic or non-psychotic. Particularly, PBD might involve extensive inter-and intra-hemispheric WM connectivity disruptions.

Subjective Cognitive Complaints in Unaffected First-Degree Relatives of Schizophrenia Patients: Relation to Cognitive Performance, Psychotic Experiences, and Social Functioning

BACKGROUND

Neurocognitive deficits are well-documented in patients of schizophrenia and their first-degree relatives (FDRs). Metacognitive awareness of these deficits, called neurocognitive insight (NI), has been found to be poor in schizophrenia patients but has not been assessed in their FDRs. This study evaluated NI and its relationship with objective cognitive performance, a history of psychotic experiences (PEs), and social functioning in unaffected FDRs.

METHODS

This cross-sectional study was conducted at the outpatient department of a tertiary care teaching hospital. A total of 100 FDRs were assessed for PEs and evaluated for subjective cognitive complaints (SCC), objective cognitive performance, and social functioning using the Subjective Scale to Investigate Cognition in Schizophrenia, neurocognitive tests from the National Institute of Mental Health and Neurosciences battery, and SCARF Social Functioning Index, respectively.

RESULTS

Compared to normative data, episodic memory was the most commonly impaired domain (up to 72% of participants), followed by working memory, attention, and executive function. There was no correlation between SCC and neuropsychological test scores in the corresponding cognitive domains, implying poor NI. 15% of participants had a lifetime history of PEs. This group had significantly higher SCC as compared to those without PEs (U = 0.366, P = 0.009, r = 0.26). A regression analysis showed that the FDRs' social functioning reduced by 0.178 units for each unit increase in SCC [F (1,98) = 5.198, P = 0.025].

CONCLUSION

Similar to schizophrenia patients, FDRs also have poor NI. The severity and progression of SCC could be explored as a possible marker for screening and monitoring FDRs at an ultrahigh risk for psychosis. Importantly, even in unaffected FDRs, SCC could affect socio-occupational functioning and need further research.

The Impact of Long-acting Paliperidone in Reducing Hospitalizations and Clinical Severity in Recent Onset Schizophrenia: A Mirror-image Study in Real-world Clinical Setting

Objective

Schizophrenia is a debilitating disease that disrupts the lives of many affected individuals and exerts a toll on the health system. Only few studies assessed once-monthly injectable formulation of paliperidone palmitate (PP-1M) and other long-acting antipsychotics in recent onset schizophrenia (ROS). To evaluate whether PP-1M is efficacious in reducing frequency and length of hospitalizations and psychosis symptom severity in patients with ROS.

Methods

This mirror-image study included 112 patients, suffering from ROS admitted in a psychiatric ward and successively treated with PP-1M for 1-year. Other psychotic disorders were excluded. We collected socio-demographic data of all subjects included, number and days of hospitalization, as well as Clinical Global Impression-Severity scale (CGI-S) and Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) scores at the initiation and after 1-year of PP treatment.

Results

After 1-year PP-1M treatment, mean scores of both CGI and CRDPSS significantly decreased (p < 0.001), as well as the mean number of hospitalizations (p = 0.002) and total hospitalization days (p < 0.001) in comparison with those of the previous year.

Conclusion

Our results suggest that PP-1M can be considered as an important therapeutic option in patients with ROS. Its use led to a meaningful reduction in the patient’s use of hospital services, as well as a significant clinical improvement of psychotic symptoms in our sample.

Alternative Diagnostic Models of the Psychotic Disorders: Evidence-Based Choices

Standard diagnostic systems, the predominantly categorical DSM-5 and ICD-11, have limitations in validity, utility, and predictive and descriptive power. For psychotic disorders, these issues were partly addressed in current versions, but additional modifications are thought to be needed. Changes should be evidence based. We reviewed categorical, modified-categorical, and continuum-based models versus factor-based models of psychosis. Factors are clusters of symptoms or single prominent aspects of illness. Consistent evidence from studies of the genetics, pathobiology, and clinical presentation of psychotic disorders all support an underlying structure of factors, not categories, as best characterizing psychoses. Factors are not only the best fit but also comprehensive, as they can encompass any key feature of illness, including symptoms and course, as well as determinants of risk or response. Factors are inherently dimensional, even multidimensional, as are the psychoses themselves, and they provide the detail needed for either grouping or distinguishing patients for treatment decisions. The tools for making factor-based diagnoses are available, reliable, and concordant with actual practices used for clinical assessments. If needed, factors can be employed to create categories similar to those in current use. In addition, they can be used to define unique groupings of patients relevant to specific treatments or studies of the psychoses. Lastly, factor-based classifications are concordant with other comprehensive approaches to psychiatric nosology, including personalized (precision treatment) models and hierarchical models, both of which are currently being explored. Factors might be considered as the right primary structural choice for future versions of standard diagnostic systems, both DSM and ICD.

Association between the examination rate of treatment-resistant schizophrenia and the clozapine prescription rate in a nationwide dissemination and implementation study

BACKGROUND

The decision to initiate clozapine treatment should be made on an individual basis and may be closely related to the early detection of treatment-resistant schizophrenia (TRS), although there is evidence that the early use of clozapine results in a better response to treatment. Therefore, we investigated the relationship between the examination rate of TRS and the prescription rate of clozapine.

METHODS

After attending a 1-day educational program on schizophrenia based on the "Guidelines for the Pharmacological Treatment of Schizophrenia," we asked the participating facilities to submit records of whether or not TRS was evaluated for each patient. We calculated the clozapine prescription rate from the schizophrenic patients prescribed clozapine and all of the schizophrenic patients. Forty-nine facilities in 2017 were included in the study.

RESULTS

There were dichotomous distributions in the examination rate of TRS and a non-normal distribution in the prescription rate of clozapine. There was a significant correlation between the prescription rate of clozapine and the examination rate of TRS (r_s  = 0.531, P = 1.032 × 10^-4 ). A significant difference was found in the prescription rate of clozapine between the three groups of facilities according to the examination rate of TRS.

CONCLUSION

As a preliminary problem for the use of clozapine, in Japan, the examination rate of TRS varies, and there are many facilities that typically do not consider the possibility of TRS; this trend leads to a low rate of clozapine use. Clearly, further clinician training is needed for the early detection and appropriate management of TRS that includes an explanation of TRS and how to introduce clozapine therapy to patients and their families.

Converting scores between the PANSS and SAPS/SANS beyond the positive/negative dichotomy

Previous work provided conversion equations for overall indices of positive and negative symptomatology between the Positive and Negative Syndrome Scale (PANSS) and the Scales for the Assessment of Positive/Negative Symptoms (SAPS/SANS). Our objective was to provide such conversion equations for subdomains of positive and negative symptomatology in order to better account for the diversity of symptom profiles in schizophrenia. Symptoms severity was assessed using both the PANSS and SAPS/SANS in 205 patients with schizophrenia. Two exploratory factor analyses combining items from both scales were first performed separately in the positive and negative symptom domains. Positive factors were termed 'Hallucinations', 'Delusions' and 'Disorganization', while negative factors were associated with 'Expressivity', 'Amotivation' and 'Cognition', consistent with current descriptions of symptom dimensions in schizophrenia. For each factor, linear regression analyses were conducted on 80% of the data to obtain conversion equations from the PANSS to the SAPS/SANS and vice versa. Reliability was then evaluated on the 20% remaining data, with good to excellent intra-class correlation coefficients between the original and predicted scores for all but the cognition factor. These findings show that symptom severity scores can be converted with good accuracy between clinical scales beyond the positive/negative symptom dichotomy.

A retrospective naturalistic study on the psychopharmacological treatment of schizoaffective disorder

Evidence on the effectiveness of psychopharmacological treatment of schizoaffective disorder is scarce and mostly comes from indirect, nonspecific sources. We carried out a large retrospective study (n = 770) of every other consecutively numbered clinical record with a recorded ICD-10 diagnosis of schizoaffective disorder in the Andalusian Health Service record system. We gathered sociodemographic, drug treatment and clinical outcomes such as improvement, relapses and change over time on DSM-5 psychotic dimensions. We analyzed data to explore associations between drug use and clinical improvement. Antipsychotics were the most commonly used drugs (77%). 22.4% of patients experienced at least a mild improvement. Clozapine (odds ratio [OR] = 2.4) and aripiprazole (OR = 2.3) for global improvement, and quetiapine (OR = 3.5) for depression were the most effective drugs. Antidepressants, mood stabilizers and benzodiazepines were also associated with a better outcome in some DSM-5 dimensions such as delusions, hallucinations and language, respectively. Antipsychotic monotherapy was not associated with a better outcome. Our findings corroborate the role of antipsychotics as the essential psychopharmacological treatment for different symptoms of schizoaffective disorder. However, the role of mood stabilizers, antidepressants or BZD is controversial and should be individually considered.

Predicting Long-Term Outcomes in First-Admission Psychosis: Does the Hierarchical Taxonomy of Psychopathology Aid DSM in Prognostication?

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical, dimensional model of psychological symptoms and functioning. Its goals are to augment the use and address the limitations of traditional diagnoses, such as arbitrary thresholds of severity, within-disorder heterogeneity, and low reliability. HiTOP has made inroads to addressing these problems, but its prognostic validity is uncertain. The present study sought to test the prediction of long-term outcomes in psychotic disorders was improved when the HiTOP dimensional approach was considered along with traditional (ie, DSM) diagnoses. We analyzed data from the Suffolk County Mental Health Project (N = 316), an epidemiologic study of a first-admission psychosis cohort followed for 20 years. We compared 5 diagnostic groups (schizophrenia/schizoaffective, bipolar disorder with psychosis, major depressive disorder with psychosis, substance-induced psychosis, and other psychoses) and 5 dimensions derived from the HiTOP thought disorder spectrum (reality distortion, disorganization, inexpressivity, avolition, and functional impairment). Both nosologies predicted a significant amount of variance in most outcomes. However, except for cognitive functioning, HiTOP showed consistently greater predictive power across outcomes-it explained 1.7-fold more variance than diagnoses in psychiatric and physical health outcomes, 2.1-fold more variance in community functioning, and 3.4-fold more variance in neural responses. Even when controlling for diagnosis, HiTOP dimensions incrementally predicted almost all outcomes. These findings support a shift away from the exclusive use of categorical diagnoses and toward the incorporation of HiTOP dimensions for better prognostication and linkage with neurobiology.

Hallucinations and Delusions as Low-Quality Attributions: Influencing Factors and Proposal for Their Analysis

Hallucinations and delusions, in keeping with the distress accompanying them, are major features in the diagnosis of psychosis in international classifications. In spite of their human and clinical importance, the concepts are unclear. The distinction between hallucinations and delusions in terms of perception-thought is not precise enough, causing problems in analyzing the patient's words. Nor are the differentiations or variations within each precise enough. Continuing the long clinical tradition discussing the distinction between hallucinations and delusions while assuming their similarities, this study poses a concept integrating the two phenomena as attributions people make about themselves and their settings. Then the elements of any attribution can be used as guides for structuring significant literature on both, and reduce analytical ambiguity. Such attributions make more sense within the structure of two-way relationships with factors in a person's own framework and setting. This structure is described with its variables and relationships as a guide to assessment, follow-up, and intervention. Two checklists are provided for orientation.

Mapping brain-behavior space relationships along the psychosis spectrum

Difficulties in advancing effective patient-specific therapies for psychiatric disorders highlight a need to develop a stable neurobiologically grounded mapping between neural and symptom variation. This gap is particularly acute for psychosis-spectrum disorders (PSD). Here, in a sample of 436 PSD patients spanning several diagnoses, we derived and replicated a dimensionality-reduced symptom space across hallmark psychopathology symptoms and cognitive deficits. In turn, these symptom axes mapped onto distinct, reproducible brain maps. Critically, we found that multivariate brain-behavior mapping techniques (e.g. canonical correlation analysis) do not produce stable results with current sample sizes. However, we show that a univariate brain-behavioral space (BBS) can resolve stable individualized prediction. Finally, we show a proof-of-principle framework for relating personalized BBS metrics with molecular targets via serotonin and glutamate receptor manipulations and neural gene expression maps derived from the Allen Human Brain Atlas. Collectively, these results highlight a stable and data-driven BBS mapping across PSD, which offers an actionable path that can be iteratively optimized for personalized clinical biomarker endpoints.

A multimodal approach to studying the relationship between peripheral glutathione, brain glutamate, and cognition in health and in schizophrenia

Involvement of oxidative stress in the pathophysiology of schizophrenia (SZ) is suggested by studies of peripheral tissue. Nonetheless, it is unclear how such biological changes are linked to relevant, pathological neurochemistry, and brain function. We designed a multi-faceted study by combining biochemistry, neuroimaging, and neuropsychology to test how peripheral changes in a key marker for oxidative stress, glutathione (GSH), may associate with central neurochemicals or neuropsychological performance in health and in SZ. GSH in dorsal anterior cingulate cortex (dACC) was acquired as a secondary 3T ¹H-MRS outcome using a MEGA-PRESS sequence. Fifty healthy controls and 46 patients with SZ were studied cross-sectionally, and analyses were adjusted for effects of confounding variables. We observed lower peripheral total GSH in SZ compared to controls in extracellular (plasma) and intracellular (lymphoblast) pools. Total GSH levels in plasma positively correlated with composite neuropsychological performance across the total population and within patients. Total plasma GSH levels were also positively correlated with the levels of Glx in the dACC across the total population, as well as within each individual group (controls, patients). Furthermore, the levels of dACC Glx and dACC GSH positively correlated with composite neuropsychological performance in the patient group. Exploring the relationship between systemic oxidative stress (in particular GSH), central glutamate, and cognition in SZ will benefit further from assessment of patients with more varied neuropsychological performance.

Sequential Multiple-Assignment Randomized Trials to Compare Antipsychotic Treatments (SMART-CAT) in first-episode schizophrenia patients: Rationale and trial design

Accumulated studies have investigated pharmacological interventions for first-episode schizophrenia (FES) patients. However, studies on subsequent treatment steps, which are essential to guide clinicians, are largely missing. This Sequential Multiple-Assignment Randomized Trials comparing Antipsychotic Treatments (SMART-CAT) program intends to evaluate the effectiveness of commonly used antipsychotic drugs in FES patients. The major goals of this study are to examine: 1) what would be the optimal subsequent sequential treatment if the first antipsychotic drug failed; 2) whether clozapine could be used in those first-trial failed and have superior efficacy compared to other atypical antipsychotics. In this article we will report the detail protocol of SMART-CAT. The SMART-CAT is a randomized controlled clinical multicenter trial in which 9 institutions in China will participate. A total of 720 FES patients will be enrolled and followed up for 12 months in this study. The trial includes three treatment phases (each phase lasting for 8 weeks) and a naturalistic follow-up phase; participants who do well on an assigned treatment will remain on that treatment for the duration of the 12-month treatment period, while non-responders will move to the next phase of the study to receive a new treatment. Phase 1 is a randomized controlled trial; patients will be randomly assigned to one of the treatments with oral olanzapine, risperidone, amisulpride, aripiprazole or perphenazine. Subjects who fail to respond after 8 weeks will enter the phase 2 randomization. Phase 2 is an equipoise-stratified randomization trial, and patients will be randomly assigned to oral olanzapine, amisulpride or clozapine for 8 weeks. Subjects who fail to respond after phase 2 will enter an open label trial (phase 3); patients who receive clozapine in phase 2 and fail to respond will be assigned to an extended clozapine treatment or modified electroconvulsive therapy add-on therapy (Phase 3A). Patients who were not assigned to clozapine in phase 2 will be assigned to treatment with clozapine or another SGAs not previously used in phase 1 and 2 (Phase 3B). The primary outcome for the treatment phase is the treatment efficacy rate, which is defined as at least 40% reduction in Positive and Negative Syndrome Scale (PANSS) total score. We hypothesize that clozapine is more therapeutically effective than any other SGAs to patients who failed to meet efficacy criteria in Phase 1, and earlier treatment with clozapine can improve the functional outcomes of schizophrenia patients. As for the naturalistic follow-up phase, time to all-cause treatment failure, marked by its discontinuation is selected as the primary outcome, since it reflects both efficacy and side effects. The all-cause discontinuation is defined as discontinuing for any reasons, including poor efficacy, intolerance of adverse reactions, poor compliance and other reasons. The results of the SMART-CAT trial will provide evidence for the selection of antipsychotics in FES patients who fail to respond to the first trial of an antipsychotic drug. It will also provide evidence for the efficacy and safety of using clozapine in the early phase of schizophrenia treatment by comparing with other SGAs. The study is based on the combination of sequential therapy and dynamic therapy, which can be more suitable to assess the effectiveness of treatment options in the real-world clinical setting. As a result, we hope that this study can provide guidance for an optimal treatment algorithm in first-episode schizophrenia patients. Trial registration: ID NCT03510325 in ClinicalTrials.gov.

Effects of aripiprazole long-acting injectable antipsychotic on hospitalization in recent-onset schizophrenia

OBJECTIVE

Recent-onset schizophrenia (ROS) represents a critical period that can greatly influence the clinical course of schizophrenia. The use of long-acting injectable antipsychotics (LAIs) in this period is increasingly being considered as a first-line treatment option. Aripiprazole LAI (ALAI) is the newest of all LAI's available on the market, with limited data on its effects on hospitalization rates after first episode of schizophrenia. It was our goal to evaluate whether ALAI has an effect on hospitalization rates, number of bed days and clinical improvement in patients with ROS.

METHODS

This mirror-image study included 138 inpatients suffering from schizophrenia. We collected sociodemographic data on all individuals, number of hospitalization days, hospitalization rates as well as Clinical Global Impression Scale-severity of illness (CGI-S) and Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) scores at the initiation of ALAI and at the end of a 1 year follow up.

RESULTS

Mean number of hospitalizations and hospitalization days in the year after starting ALAI significantly decreased compared to the year before (p = 0.005 and p < 0.001). Mean scores on both CGI and CRDPSS also significantly decreased after initiating ALAI (p < 0.001).

CONCLUSION

Results suggest that ALAI is an important therapeutic option in patients with ROS. It leads to reduced usage of hospital services, potentially reducing the socio-economic healthcare burden.

Systematic epidemiological and clinical comparisons across all 12 DSM-IV psychotic diagnoses in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS)

BACKGROUND

Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.

METHODS

The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.

RESULTS

Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.

CONCLUSIONS

There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.

Grey and white matter associations of psychotic-like experiences in a general population sample (UK Biobank)

There has been a substantial amount of research reporting the neuroanatomical associations of psychotic symptoms in people with schizophrenia. Comparatively little attention has been paid to the neuroimaging correlates of subclinical psychotic symptoms, so-called "psychotic-like experiences" (PLEs), within large healthy populations. PLEs are relatively common in the general population (7-13%), can be distressing and negatively affect health. This study therefore examined gray and white matter associations of four different PLEs (auditory or visual PLEs, and delusional ideas about conspiracies or communications) in subjects of the UK Biobank study with neuroimaging data (N = 21,390, mean age = 63 years). We tested for associations between any PLE (N = 768) and individual PLEs with gray and white matter brain structures, controlling for sex, age, intracranial volume, scanning site, and position in the scanner. Individuals that reported having experienced auditory hallucinations (N = 272) were found to have smaller volumes of the caudate, putamen, and accumbens (β = -0.115-0.134, pcorrected = 0.048-0.036), and reduced temporal lobe volume (β = -0.017, pcorrected = 0.047) compared to those that did not. People who indicated that they had ever believed in unreal conspiracies (N = 111) had a larger volume of the left amygdala (β = 0.023, pcorrected = 0.038). Individuals that reported a history of visual PLEs (N = 435) were found to have reduced white matter microstructure of the forceps major (β = -0.029, pcorrected = 0.009), an effect that was more marked in participants who reported PLEs as distressing. These associations were not accounted for by diagnoses of psychotic or depressive illness, nor the known risk factors for psychotic symptoms of childhood adversity or cannabis use. These findings suggest altered regional gray matter volumes and white matter microstructure in association with PLEs in the general population. They further suggest that these alterations may appear more frequently with the presentation of different psychotic symptoms in the absence of clinically diagnosed psychotic disorders.

Clinical Features of Psychotic Disorders: Comparing Categorical and Dimensional Models

Objective

Despite research demonstrating the value of dimensional approaches, standard systems for classifying psychotic disorders rely primarily on categorization of patients into distinct diagnoses. We present the first study comparing analyses of dimensional features, categories, and standard diagnoses, all derived from the same sample.

Methods

Using symptom ratings from 934 patients hospitalized for psychosis, we examined dimensional models, fit using factor analysis, categorical models, fit to factor‐based scores from the dimensional model, and their correspondence with DSM‐defined diagnoses. We compared the ability of each model to discriminate patients' assignment to medication regimen as a clinical validator.

Results

Dimensional modeling identified four factors (manic, depressive, negative symptoms, and positive symptoms), which corresponded to factors in prior studies and appeared robust to statistical approach. Scores based on these factors overlapped substantially among DSM diagnoses. Patients assigned to clusters had less overlap in factor‐based scores. However, categorical models were sensitive to statistical approach. The addition of DSM diagnoses, but not cluster assignments, improved the fits of models with dimensional scores alone as the clinical predictors for some medication classes.

Conclusions

The results highlight the variability of symptom presentation within DSM‐defined diagnostic categories, the utility of symptom dimensions or factors, and a potential lack of robustness of data‐driven categorical approaches. Findings support initiatives to develop updated diagnostic systems that complement categorical classification of psychotic illness with factors representing dimensional ratings of symptoms.

This study compared results from dimensional and categorical models fit to symptom ratings from a large sample of patients hospitalized for psychosis.

Dimensional information, which was not fully captured by data‐derived or DSM‐defined categorical assignments, best predicted medication classes at discharge overall.

These findings support the incorporation of dimensional ratings into categorical classification systems for psychotic illness.

Latent Clinical-Anatomical Dimensions of Schizophrenia

Widespread structural brain abnormalities have been consistently reported in schizophrenia, but their relation to the heterogeneous clinical manifestations remains unknown. In particular, it is unclear whether anatomical abnormalities in discrete regions give rise to discrete symptoms or whether distributed abnormalities give rise to the broad clinical profile associated with schizophrenia. Here, we apply a multivariate data-driven approach to investigate covariance patterns between multiple-symptom domains and distributed brain abnormalities in schizophrenia. Structural magnetic resonance imaging and clinical data were derived from one discovery sample (133 patients and 113 controls) and one independent validation sample (108 patients and 69 controls). Disease-related voxel-wise brain abnormalities were estimated using deformation-based morphometry. Partial least-squares analysis was used to comprehensively map clinical, neuropsychological, and demographic data onto distributed deformation in a single multivariate model. The analysis identified 3 latent clinical-anatomical dimensions that collectively accounted for 55% of the covariance between clinical data and brain deformation. The first latent clinical-anatomical dimension was replicated in an independent sample, encompassing cognitive impairments, negative symptom severity, and brain abnormalities within the default mode and visual networks. This cognitive-negative dimension was associated with low socioeconomic status and was represented across multiple races. Altogether, we identified a continuous cognitive-negative dimension of schizophrenia, centered on 2 intrinsic networks. By simultaneously taking into account both clinical manifestations and neuroanatomical abnormalities, the present results open new avenues for multi-omic stratification and biotyping of individuals with schizophrenia.

Cognitive markers related to long-term remission status in Schizophrenia Spectrum Disorders

Cognitive impairment is an established feature of schizophrenia. From a cross-sectional perspective, studies have revealed associations between cognition and remission. Few studies have examined this relationship longitudinally. Here we examine which cognitive domains might be related to long-term remission and symptomatic severity. The present study followed 173 outpatients with schizophrenia for five years, divided into groups based on long-term remission status and symptomatic severity, assessed with the Positive and Negative Syndrome Scale. Cognitive functioning was assessed at baseline, with tests of vigilance, executive functions, processing speed, memory and learning, working memory, and premorbid functioning. Cognitive domains related to long-term remission status were executive functions, working memory, and premorbid functioning. The most prominent cognitive differences were found between the group in stable remission with minimal symptoms, and the non-remission group, the first group demonstrating better cognitive functioning. The study highlights the role of premorbid functioning as a cognitive feature in the prediction of long-term remission. It also indicates the possibility of viewing specific cognitive domains as markers for clinical outcome, highlighting the value of early assessment of cognition. In summary, a certain cognitive profile, in coexistence with long-term non-remission, suggests poorer outcome. Hence, this group is in need of increased support.

The role of nicotinic cholinergic neurotransmission in delusional thinking

Delusions are a difficult-to-treat and intellectually fascinating aspect of many psychiatric illnesses. Although scientific progress on this complex topic has been challenging, some recent advances focus on dysfunction in neural circuits, specifically in those involving dopaminergic and glutamatergic neurotransmission. Here we review the role of cholinergic neurotransmission in delusions, with a focus on nicotinic receptors, which are known to play a part in some illnesses where these symptoms appear, including delirium, schizophrenia spectrum disorders, bipolar disorder, Parkinson, Huntington, and Alzheimer diseases. Beginning with what we know about the emergence of delusions in these illnesses, we advance a hypothesis of cholinergic disturbance in the dorsal striatum where nicotinic receptors are operative. Striosomes are proposed to play a central role in the formation of delusions. This hypothesis is consistent with our current knowledge about the mechanism of action of cholinergic drugs and with our abstract models of basic cognitive mechanisms at the molecular and circuit levels. We conclude by pointing out the need for further research both at the clinical and translational levels.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

Schizophrenia in ICD-11: Comparison of ICD-10 and DSM-5

The conceptualization of schizophrenia has changed from its initial conception in the 19th century to the recent publication of the ICD-11. The changes incorporated in this latest version were made based on the evaluation of the current ICD, the available scientific evidence, and the consensus reached by its developers. In this paper we describe the conceptualization changes (diagnostic criteria and specifiers) of ICD-11 schizophrenia with respect to those of ICD-10 and DSM-5. The changes found are discussed based on the scientific literature published in Medline, Scopus and Scielo until July 2019 and the information on the Wordl Health Organization and American Psychiatric Association websites. Given that the diagnosis of schizophrenia is based on the diagnostic criteria of the diagnostic classification systems, it is important to know the changes made in its conceptualization and the evidence supporting such modifications.

Preliminary Evaluation of Washington State's Early Intervention Program for First-Episode Psychosis

OBJECTIVE

Early intervention programs are designed to address the needs of youths experiencing first-episode psychosis (FEP). Washington State developed New Journeys, a network of coordinated specialty care programs for FEP. In this study, the authors have outlined components of the New Journeys model and preliminary findings since its initial implementation.

METHODS

Youths and young adults diagnosed as having psychosis (N=112) completed measures at and after intake on a range of mental health assessments and functional outcomes for the first 12 months of treatment. Administrative data including state-funded emergency department and psychiatric hospitalizations were assessed 24 months before and after intake. Generalized estimating equations were used to assess change over time on multiple measures of mental health status.

RESULTS

Compared with their condition at intake, clients had significant decreases in symptoms of anxiety (β=-2.48, p<0.001), psychotic experiences (β=-3.37, p<0.05), and clinician-rated psychotic symptoms (β=-1.47, p<0.05) during treatment. Additionally, quality of life (β=-5.95, p<0.001) and school attendance (odds ratio=1.42, p<0.05) significantly improved during treatment. Administrative data indicated that postintake, clients were less likely to visit the emergency department for psychiatric reasons (β=0.22, p<0.05), utilize community psychiatric inpatient services (β=0.31, p<0.001), and utilize public assistance (β=0.71, p<0.05) compared with 24 months before intake.

CONCLUSIONS

New Journeys clients experienced improved clinical and functional outcomes during their first year of treatment, and rates of state-funded service utilization decreased during their treatment.

Measurement based care in schizophrenia-Feasibility in routine clinical practice

Measurement based care (MBC) implies the utilization of structured objective scales/batteries in the assessment and monitoring of an illness. Patients with schizophrenia with heterogeneous presentation would potentially benefit better through MBC. Time constraints and additional work burden are frequently cited as barriers in implementing objective assessments. In this selective review, the authors discuss the available standard scales for assessment in schizophrenia, the advantages and disadvantages in implementing MBC and a feasible approach to overcome the barriers by adapting shorter versions of structured scales.

Peripheral Blood Leukocyte RNA-Seq Identifies a Set of Genes Related to Abnormal Psychomotor Behavior Characteristics in Patients with Schizophrenia

BACKGROUND Schizophrenia is a multigene disease with a complex etiology and different clinical manifestations. It is of great significance to understand the etiology and pathogenesis of schizophrenia patients from different clinical dimensions and to interpret the potential molecular changes of schizophrenia patients from different clinical dimensions. MATERIAL AND METHODS RNA-Seq was performed on peripheral blood leukocytes of 50 patients with schizophrenia and 50 healthy controls. Phenotypic information of patients with schizophrenia was collected during blood sampling. Differentially expressed genes (DEGs) were screened by the edgeR package of R software. To better analyze the correlation between DEG expression values, explore the potential association between differential genes and clinical dimensions of schizophrenia, and identify hub genes, we constructed a DEG co-expression network using weighted gene co-expression network analysis (WGCNA). RESULTS We provide the transcription profiles of peripheral blood leukocytes in patients with schizophrenia and found a gene module (including 89 genes) closely related to the clinical dimension of abnormal psychomotor behavior in schizophrenia. CONCLUSIONS The findings enhance our understanding of the biological processes of schizophrenia, enabling us to identify specific clinical dimensions of genes for diagnosis and prognostic markers and possibly for targeted therapy.

Psychometric properties of the DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity

OBJECTIVE

The Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) was presented in the DSM-5 as a new scale to assess the dimensional aspects of psychosis in daily clinical practice. However, agreement in CRDPSS-ratings among raters in clinical practice remains unknown. We examined the inter-rater reliability (IRR) and convergent validity of the CRDPSS.

METHOD

Consecutively recruited outpatients with recent onset schizophrenia spectrum disorders were included between January 2015 and July 2018. We collected multiple CRDPSS measurements of 335 participants, of whom 179 PANSS measurements were available. IRR was determined by comparing the CRDPSS-ratings of psychiatrists with a vis-à-vis contact and CRDPSS observations based on a detailed clinical presentation. IRR was expressed in Krippendorff's alpha and we estimated convergent validity by studying associations with PANSS factors by Spearman's rank correlation coefficient.

RESULTS

Inter-rater reliability scores measured in Krippendorff's alpha were low (0.35-0.64) for all items of the CRDPSS, except the item delusions (0.74). A three-factor model was found: 'deficit/motor symptoms', 'positive symptoms' and 'mood symptoms'. Positive associations between CRDPSS factors with PANSS factors were found.

CONCLUSION

This study demonstrated that the IRR of the CRDPSS between raters in clinical practice was insufficient. We did find some supporting evidence for convergent validity of the CRDPSS, but these results should be interpreted carefully due to low IRR. Consequently, general implementation in clinical practice should be done with caution and we recommend assessors to be trained.