Persistent negative symptoms after first episode schizophrenia: A 2-year follow-up study

Plasma complement and coagulation proteins as prognostic factors of negative symptoms: An analysis of the NAPLS 2 and 3 studies

INTRODUCTION

Negative symptoms impact the quality of life of individuals with psychosis and current treatment options for negative symptoms have limited effectiveness. Previous studies have demonstrated that complement and coagulation pathway protein levels are related to later psychotic experiences, psychotic disorder, and functioning. However, the prognostic relationship between complement and coagulation proteins and negative symptoms is poorly characterised.

METHODS

In the North American Prodrome Longitudinal Studies 2 and 3, negative symptoms in 431 individuals at clinical high-risk for psychosis (mean age: 18.2, SD 3.6; 42.5 % female) were measured at multiple visits over 2 years using the Scale of Psychosis-Risk Symptoms. Plasma proteins were quantified at baseline using mass spectrometry. Four factors were derived to represent levels of proteins involved in the activation or regulation of the complement or coagulation systems. The relationships between standardised protein group factors and serial measurements of negative symptoms over time were modelled using generalised least squares regression. Analyses were adjusted for baseline candidate prognostic factors: negative symptoms, positive symptoms, functioning, depressive symptoms, suicidal ideation, cannabis use, tobacco use, antipsychotic use, antidepressant use, age, and sex.

RESULTS

Clinical and demographic prognostic factors of follow-up negative symptoms included negative, positive, and depressive symptoms, functioning, and age. Adjusting for all candidate prognostic factors, the complement regulators group and the coagulation regulators group were identified as prognostic factors of follow-up negative symptoms (β: 0.501, 95 % CI: 0.160, 0.842; β: 0.430, 95 % CI: 0.080, 0.780 respectively. The relationship between complement regulator levels and negative symptoms was also observed in NAPLS2 alone (β: 0.501, 95 % CI: -0.037, 1.039) and NAPLS3 alone, additionally adjusting for BMI (β: 0.442, 95 % CI: 0.127, 0.757).

CONCLUSION

The results indicate that plasma complement and coagulation regulator levels are prognostic factors of negative symptoms, independent of clinical and demographic prognostic factors. These results suggest complement and coagulation regulator levels could have potential utility in informing treatment decisions for negative symptoms in individuals at risk.

Interaction between catechol-O-methyltransferase Val/Met polymorphism and cognitive reserve for negative symptoms in schizophrenia

BACKGROUND

Cognitive reserve (CR) and the catechol-O-methyltransferase (COMT) Val/Met polymorphism are reportedly linked to negative symptoms in schizophrenia. However, the regulatory effect of the COMT genotype on the relationship between CR and negative symptoms is still unexamined.

AIM

To investigate whether the relationship between CR and negative symptoms could be regulated by the COMT Val/Met polymorphism.

METHODS

In a cross-sectional study, 54 clinically stable patients with schizophrenia underwent assessments for the COMT genotype, CR, and negative symptoms. CR was estimated using scores in the information and similarities subtests of a short form of the Chinese version of the Wechsler Adult Intelligence Scale.

RESULTS

COMT Met-carriers exhibited fewer negative symptoms than Val homozygotes. In the total sample, significant negative correlations were found between negative symptoms and information, similarities. Associations between information, similarities and negative symptoms were observed in Val homozygotes only, with information and similarities showing interaction effects with the COMT genotype in relation to negative symptoms (information, β = -0.282, 95%CI: -0.552 to -0.011, P = 0.042; similarities, β = -0.250, 95%CI: -0.495 to -0.004, P = 0.046).

CONCLUSION

This study provides initial evidence that the association between negative symptoms and CR is under the regulation of the COMT genotype in schizophrenia.

Effects of yoga on clinical symptoms, quality of life and social functioning in patients with schizophrenia: A systematic review and meta-analysis

BACKGROUND

Yoga is gradually being explored as a potential complementary intervention in addition to psychiatric drugs for schizophrenia. However, there are conflicts on the efficacy of yoga for schizophrenia. This meta-analysis was aimed to evaluate the association of yoga intervention with reductions on clinical symptoms and improvements in quality of life (QoL) as well as social functioning among schizophrenia.

METHOD

Systematic literature search was undertaken to identify all RCTs that compared yoga with active or passive controls for patients with schizophrenia from inception to July 2023. The outcomes were measurements of positive symptoms, negative symptoms, QoL and social functioning. Random-effects models were performed to calculate the effect sizes in the standardized mean differences reporting as Hedges' s g statistic.

RESULTS

19 studies enrolling 1274 participants with schizophrenia were included. Yoga had a medium effect on positive symptoms in the short term (Hedges's g = 0.31) and small effect in the long term (Hedges's g = 0.18). Medium significant effects were also found on negative symptoms in both the short term (Hedges's g = 0.44) and the long term (Hedges's g = 0.35). Yoga had a significant impact on improving both total QoL (Hedges's g = 0.34) and social functioning (Hedges's g = 0.45) with medium effect sizes.

CONCLUSIONS

Yoga was associated with significant reductions on negative and positive symptoms, and significant improvements in QoL as well as social functioning in patients with schizophrenia. Future research should explore the long-term efficacy of yoga for schizophrenia, encompassing more diverse populations.

Cognitive Inflexibility Predicts Negative Symptoms Severity in Patients with First-Episode Psychosis: A 1-Year Follow-Up Study

Negative symptoms and cognitive deficits play a major role in psychosis and significantly influence the functional outcomes of patients, particularly those with a first episode of psychosis (FEP). However, limited research has explored the predictive capacity of cognitive deficits during FEP for subsequent negative symptomatology. Drawing from the Athens FEP research study, we conducted a retrospective longitudinal study in 80 individuals with FEP. All patients were drug naive at admission. Cognitive tests were administered at 1-month and 1-year post-admission, while negative symptomatology was assessed at the same time points using PANSS by trained raters. We considered confounding factors such as age, gender, duration of untreated psychosis (DUP), treatment received, premorbid social adjustment, and premorbid IQ. Univariate regression analysis identified cognitive domains that correlated with negative symptomatology. These, along with the confounders, were incorporated into a multiple regression, with the 1-year PANSS negative scale serving as the dependent variable. Employing the backward elimination technique, we found a statistically significant inverse relationship between the categories completed in the Wisconsin card sorting test (WCST) and the 1-year PANNS negative scale (p = 0.01), beyond the associations with DUP and the 1-month PANSS negative scale. Our results suggest that cognitive flexibility, a key component of executive functions, predicts negative symptom severity one year after FEP.

Dimensional characteristics of persistent negative symptoms in schizophrenia and their relationships with schizotypy in first-degree relatives

PURPOSE OF THE ARTICLE

Schizophrenia with persistent negative symptoms (PNS) may have different characteristics regarding negative symptom dimensions and heritability patterns. This study aimed to investigate the dimensional characteristics of PNS and their relationships with schizotypal features in first-degree relatives (FDRs).

MATERIALS AND METHODS

The study included 142 patients, 142 FDRs, and 71 healthy controls (HC). Patients were evaluated with the Positive and Negative Symptom Scale (PANSS), Brief Negative Symptom Scale (BNSS), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Scale (SAS). Schizotypy Personality Questionnaire was applied to FDR and HC groups. Clinical symptoms were compared between primary-PNS, secondary-PNS, and non-PNS groups. In addition, schizotypy scores were compared between FDRs and HCs. Then, the relationship between the symptoms of the patients in the PNS group and the schizotypy scores of their relatives was evaluated by multiple regression analysis.

RESULTS

All negative symptom dimension scores were similar in primary-PNS and secondary-PNS and lowest in non-PNS. PNS-FDR had higher in all schizotypy scores than non-PNS-FDR and HC, except for lack of close friends and social anxiety. In the PNS group, positive symptom severity and PANSS experiential deficit scores significantly predicted positive and negative schizotypy scores in relatives. Negative schizotypy was associated with asociality.

CONCLUSIONS

The PNS is likely a subtype in which the genetic basis of negative symptoms is stronger and is associated with genetic abnormalities shared by positive and negative schizotypy dimensions in relatives. Family-based genetic studies will be beneficial in enlightening the genetic etiology of PNS.

Negative symptoms and sex differences in first episode schizophrenia: What's their role in the functional outcome? A longitudinal study

INTRODUCTION

Negative symptoms (NS) include asociality, avolition, anhedonia, alogia, and blunted affect and are linked to poor prognosis. It has been suggested that they reflect two different factors: diminished expression (EXP) (blunted affect and alogia) and amotivation/pleasure (MAP) (anhedonia, avolition, asociality). The aim of this article was to examine potential sex differences among first-episode schizophrenia (FES) patients and analyze sex-related predictors of two NS symptoms factors (EXP and MAP) and functional outcome.

MATERIAL AND METHODS

Two hundred and twenty-three FES (71 females and 152 males) were included and evaluated at baseline, six-months and one-year. Repeated measures ANOVA was used to examine the effects of time and sex on NS and a multiple linear regression backward elimination was performed to predict NS factors (MAP-EXP) and functioning.

RESULTS

Females showed fewer NS (p=0.031; Cohen's d=-0.312), especially those related to EXP (p=0.024; Cohen's d=-0.326) rather than MAP (p=0.086), than males. In both male and female group, worse premorbid adjustment and higher depressive symptoms made a significant contribution to the presence of higher deficits in EXP at one-year follow-up, while positive and depressive symptoms predicted alterations in MAP. Finally, in females, lower deficits in MAP and better premorbid adjustment predicted better functioning at one-year follow-up (R2=0.494; p<0.001), while only higher deficits in MAP predicted worse functioning in males (R2=0.088; p=0.012).

CONCLUSIONS

Slightly sex differences have been found in this study. Our results lead us to consider that early interventions of NS, especially those focusing on motivation and pleasure symptoms, could improve functional outcomes.

Autistic features and executive functions in first episode psychosis: Associations with functionality and quality of life

AIM

The present study aimed at investigating the relationships between autistic features and cognitive deficits, functionality and quality of life in first episode psychosis (FEP) patients.

METHODS

Sixty FEP patients [mean age (SD) = 32.53 (10.74), n = 23 female, n = 37 male] were enrolled in this cross-sectional study. Data was collected using a sociodemographic and clinical data form, the Positive and Negative Syndrome Scale (PANSS), the PANSS Autism Severity Score (PAUSS), the Personal and Social Performance Scale (PSP), the Frontal Assessment Battery (FAB), and the World Health Organization Quality of Life Scale Short Form in Turkish Version (WHOQOL-BREF TR).

RESULTS

Autistic symptom severity was found to be higher in males than females, and higher in patients with a family history of psychotic disorder. An inverse relationship was found between the duration of education and the severity of autistic symptoms. While there was an inverse relationship between autistic symptom severity and executive functions and functionality, no significant correlation was found with quality of life. Negative symptom severity was a predictor of executive functions and functionality. No significant difference was observed between autistic and psychotic domains which were related to executive functions.

CONCLUSIONS

Our study is the first to examine the relationship between autistic/psychotic symptoms and executive functions and functionality in patients with FEP. The results show that autistic symptoms are associated with worse social and personal functioning and worse executive functions in patients with FEP. Longitudinal follow-up studies with larger samples are required to determine the direction of the relations.

Negative symptoms in drug-naive patients with a first-episode psychosis (FEP)

INTRODUCTION

Negative symptoms are nuclear features of schizophrenia that may be present from the onset of the disease. In recent years, it has been described 2 subdomains of negative symptoms: experiential and expressive deficits. The aim of the study is to examine the relationship between negative symptoms and demographic and clinical variables in patients with first-episode psychosis. Also, to explore whether there are differences in the association among these variables and negative symptoms when divided into both subdomains.

MATERIAL AND METHODS

A cross-sectional study was performed in 160 patients (52 females and 108 males) with a diagnosis of a first episode psychosis. A questionnaire was administered to collect demographic and clinical variables.

RESULTS

A backward stepwise linear regressions analysis was performed in order to observe potential associations between demographic and clinical variables and the presence of negative symptoms. All three models are predicted by worse PSP score, a higher CDSS, a higher disorganized factor score and a lower excited factor score. A longer duration of untreated psychosis (DUP) is associated to a higher score in the experiential deficit subdomain only.

CONCLUSIONS

Our work highlights some clinical and phenomenological differences between experiential and expressive deficits. We think that taking into account both subdomains in future studies may lead to more accurate clinical assessment and interventions.

Longitudinal persistence of negative symptoms in young individuals with first episode schizophrenia: a 24-month multi-modal program follow-up

PURPOSE

Persistent Negative Symptoms (PNS) affect real-world functioning already at the onset of schizophrenia. Longitudinal studies on beneficial effects of psychosocial treatments for PNS in First Episode Schizophrenia (FES) are still relatively scarce. The aim of the current study was to evaluate the longitudinal persistence of PNS in young FES individuals treated according to the multimodal "Early Intervention in Psychosis" (EIP) program over a 2-year follow-up period.

MATERIALS AND METHODS

133 FES subjects (aged 12-35 years) were recruited within the Italian EIP program and completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). In accordance with the PNS criteria, we dichotomized FES individuals with and without PNS. In the FES group with PNS, a multiple linear regression analysis was conducted to examine relevant associations between longitudinal PNS levels and the specialized treatment components of our EIP protocol.

RESULTS

Twenty (15%) FES participants met the PNS criteria. At baseline, PNS levels had relevant positive correlations with functioning decline and PANSS total score. At the end, the 2-years follow-up period, FES subjects with PNS showed a significant decrease in PNS levels. In our linear regression analysis, this reduction was associated with a higher number of individual psychotherapy and case management sessions delivered during our follow-up (together with a shorter DUP [Duration of Untreated Psychosis]).

CONCLUSIONS

PNS are clinically relevant in a minority of FES individuals. Our results suggest that patient-tailored psychosocial interventions can reduce clinical severity of PNS over a 2-year period.

Identifying clinical and psychological correlates of persistent negative symptoms in early-onset psychotic disorders

Persistent negative symptoms (PNS) contribute to impairment in psychosis. The characteristics of PNS seen in youth remained under-investigated. We aimed to demonstrate clinical, treatment-related, and psychosocial characteristics of PNS in early-onset schizophrenia-spectrum disorders (EOSD). 132 patients with EOSD were assessed with Positive and Negative Symptom Scale, Brief Negative Symptom Scale, Calgary Depression Scale for Schizophrenia, and Simpson-Angus Scale. Parenting skills and resilience were evaluated using Parental Attitude Research Instrument and Child and Youth Resilience Measure-12. Longer duration of untreated psychosis (DUP) and prodromal phase were found in primary and secondary PNS groups, compared to the non-PNS group. The primary PNS group was characterized by earlier age-onset, lower smoking rates, and more common clozapine use. Resilience and egalitarian/democratic parenting were negatively correlated with symptoms related to motivation/pleasure and blunted expression. More blunted expression-related symptoms and longer DUP in the first episode significantly predicted primary/secondary PNS at follow-up. Using the data from total negative symptom scores and DUP, Receiver Operating Characteristic analyses significantly differentiated primary/secondary PNS groups from the non-PNS counterparts. PNS associated with blunted expression and low motivation/pleasure in the first episode could persist into clinical follow-up. Effective pharmacological treatment and psychosocial interventions are needed in youth.

Deficit syndrome in Chinese patients with first-episode drug naïve schizophrenia: Prevalence, demographic and clinical characteristics

BACKGROUND

Deficit syndrome (DS) is a common subgroup of schizophrenia. However, few studies have examined the prevalence and risk factors for DS in Chinese Han patients with schizophrenia. The aim of this study was to assess prevalence, demographic and clinical characteristics of DS in Chinese Han patients with first-episode drug naïve (FEDN) schizophrenia.

METHODS

In total, 235 patients with schizophrenia were recruited, and clinical and demographic data were collected. The Positive and Negative Syndrome Scale (PANSS) was utilized for the psychopathological symptoms, and the 17-item Hamilton Depression Rating Scale (HDRS-17) for depressive symptoms. The Proxy for the Deficit Syndrome (PDS) was adopted to identify DS.

RESULTS

The prevalence of DS in the cohort of first-episode schizophrenia patients was 23.0%. Compared to those patients without DS, patients with DS had younger age, lower education level, and were more likely to be single. Further, DS patients had significantly lower scores of positive symptoms, general psychopathology, and depression than non-DS patients. Patients with DS had fewer suicide attempts, but they had more severe negative symptoms and cognitive impairment (all p < 0.05). Multiple regression showed that poor cognitive functioning, lower levels of depression and younger age at onset were predictors of DS.

CONCLUSIONS

Chinese Han patients with FEDN schizophrenia have high prevalence of DS. Some demographic and clinical parameters may be associated with DS.

A Network of Psychopathological, Cognitive, and Motor Symptoms in Schizophrenia Spectrum Disorders

Schizophrenia spectrum disorders (SSDs) are complex syndromes involving psychopathological, cognitive, and also motor symptoms as core features. A better understanding of how these symptoms mutually impact each other could translate into diagnostic, prognostic, and, eventually, treatment advancements. The present study aimed to: (1) estimate a network model of psychopathological, cognitive, and motor symptoms in SSD; (2) detect communities and explore the connectivity and relative importance of variables within the network; and (3) explore differences in subsample networks according to remission status. A sample of 1007 patients from a multisite cohort study was included in the analysis. We estimated a network of 43 nodes, including all the items from the Positive and Negative Syndrome Scale, a cognitive assessment battery and clinical ratings of extrapyramidal symptoms. Methodologies specific to network analysis were employed to address the study's aims. The estimated network for the total sample was densely interconnected and organized into 7 communities. Nodes related to insight, abstraction capacity, attention, and suspiciousness were the main bridges between network communities. The estimated network for the subgroup of patients in remission showed a sparser density and a different structure compared to the network of nonremitted patients. In conclusion, the present study conveys a detailed characterization of the interrelations between a set of core clinical elements of SSD. These results provide potential novel clues for clinical assessment and intervention.

Dynamic Interplay Between Insight and Persistent Negative Symptoms in First Episode of Psychosis: A Longitudinal Study

Persistent negative symptoms (PNS) are an important factor of first episode of psychosis (FEP) that present early on in the course of illness and have a major impact on long-term functional outcome. Lack of clinical insight is consistently associated with negative symptoms during the course of schizophrenia, yet only a few studies have explored its evolution in FEP. We sought to explore clinical insight change over a 24-month time period in relation to PNS in a large sample of FEP patients. Clinical insight was assessed in 515 FEP patients using the Scale to assess Unawareness of Mental Disorder. Data on awareness of illness, belief in response to medication, and belief in need for medication were analyzed. Patients were divided into 3 groups based on the presence of negative symptoms: idiopathic (PNS; n = 135), secondary (sPNS; n = 98), or absence (non-PNS; n = 282). Secondary PNS were those with PNS but also had clinically relevant levels of positive, depressive, or extrapyramidal symptoms. Our results revealed that insight improved during the first 2 months for all groups. Patients with PNS and sPNS displayed poorer insight across the 24-month period compared to the non-PNS group, but these 2 groups did not significantly differ. This large longitudinal study supported the strong relationship known to exist between poor insight and negative symptoms early in the course of the disorder and probes into potential factors that transcend the distinction between idiopathic and secondary negative symptoms.

Neurocognitive functions in persistent negative symptoms following a first episode of psychosis

Negative symptoms are present at the onset of psychosis and their persistence is significantly associated with poor psychosocial functioning and lower quality of life. Persistent negative symptoms (PNS) may be idiopathic or secondary to other factors such as depression, positive symptoms, and medication side-effects. Several studies have examined neurocognitive functions in early psychosis patients with PNS relative to non-PNS, but have not systematically controlled for secondary PNS (sPNS). The latter may have a distinct neurocognitive profile that could obscure differences between PNS and non-PNS. Using a large (n = 425) sample, we examined neurocognitive functions in PNS, sPNS, and non-PNS and hypothesized that PNS would be associated with greater impairments relative to non-PNS. Following admission to an early intervention program, a neurocognitive battery was administered after at least 3 months of treatment, and symptom data collected during a subsequent 6-month period were used to classify patients as PNS, sPNS and non-PNS. At month 12, both PNS and sPNS groups had significantly lower level of functioning relative to the non-PNS group but the sPNS group experienced higher levels of depressive and positive symptoms and were on a higher dose of antipsychotics. Relative to non-PNS, PNS patients exhibited significant impairments in verbal memory and working memory, whereas sPNS patients exhibited a trend towards greater impairments in verbal memory. This study confirms that the presence of PNS or sPNS negatively influences functioning with more selective cognitive impairments found in PNS, providing evidence that these groups of patients could benefit from different personalised interventions.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

Persistent negative symptoms in youth at clinical high risk for psychosis: A longitudinal study

BACKGROUND

Severity of negative symptoms has been associated with poor functioning, cognitive deficits, and defeatist beliefs in schizophrenia patients. However, one area that remains understudied is persistent negative symptoms (PNS). Negative symptoms, including PNS, have been observed in those at clinical high-risk (CHR) for psychosis. The aim of this study was to determine if PNS were associated with functioning, neurocognition, and defeatist beliefs in a CHR sample.

METHOD

CHR participants (n = 764) were recruited for the North American Prodrome Longitudinal Study. Negative symptoms were rated on the Scale of Psychosis-risk Symptoms. Generalized linear mixed models for repeated measures were used to examine changes over time between and within groups (PNS vs non-PNS).

RESULTS

The PNS group (n = 67) had significant deficits in functioning at baseline, 6, 12, 18, and 24-months compared to the non-PNS group (n = 673). Functioning improved over time in the non-PNS group, while functioning in the PNS group remained relatively stable and poor over a two-year period. A consistent trend emerged demonstrating higher defeatist beliefs in the PNS group; however, this result was lost when controlling for persistent depressive symptoms. There were no significant differences between the groups on neurocognition, social cognition, and transition to psychosis.

CONCLUSIONS

PNS exist in youth at CHR for psychosis, resulting in significant and persistent functional impairment, which remains when controlling for persistent depressive symptoms. PNS remain even in CHR youth who do not transition to psychosis. Thus, PNS may represent an unmet therapeutic need in CHR populations for which there are currently no effective treatments.

Does Yoga Have a Role in Schizophrenia Management?

PURPOSE OF REVIEW

To review the efficacy of add-on yoga therapy in improving symptoms of schizophrenia and quality of life and examine the possible underlying biological mechanisms of yoga in schizophrenia.

RECENT FINDINGS

Quality of life, cognitive symptoms, and negative symptoms have been found to improve with add-on yoga therapy in schizophrenia (pooled mean effect size 0.8, 0.6, and 0.4, respectively). Yoga also seems to have a small effect on improving positive symptoms. Less explored areas include adverse effects of yoga itself as well as its effects on antipsychotic-induced complications. Preliminary findings suggest that the effects of yoga may be mediated by neurohormonal mechanisms and functional changes in brain activity. Add-on yoga therapy is a potential treatment option for improving quality of life, cognitive symptoms, and negative symptoms in schizophrenia. Future studies should explore efficacy in multicentric trials as well as possible neurobiological changes underlying the effects.

Relapse rates following antipsychotic discontinuation in the maintenance phase after first-episode of schizophrenia: Results of a long-term follow-up study

BACKGROUND

When the antipsychotic treatment should be discontinued after first-episode of schizophrenia (FES) in patients who had a good response to initial treatment is still controversial. The aim of this naturalistic follow-up study was to determine the rate of antipsychotic discontinuation in the maintenance phase and its consequences, after FES.

METHODS

FES patients (n = 105) were followed-up for at least 24 months and up to 22 years (mean = 99.1 months). After minimum one-year antipsychotic treatment without relapse, some patients' antipsychotics were discontinued by psychiatrist. We compared the clinical characteristics of this group to those who stopped their medication themselves and analyzed the predictors of being relapse-free after discontinuation.

RESULTS

Seventeen (16.2%) of the patients' antipsychotic was discontinued by their psychiatrist. Using the same antipsychotic during the first year was the predictor of discontinuation by the psychiatrist in logistic regression analysis. Ten (58.8%) of them relapsed. Thirty-nine patients (37.1%) discontinued their antipsychotic themselves, relapse rate was 76.9% (n = 30). There was no clinical difference between these two groups. Overall, the patients who had no relapse after discontinuation had better role and global functioning at baseline, were more likely to meet remission criteria, and their antipsychotic was discontinued by psychiatrist and use same antipsychotic during the first year.

CONCLUSION

Our findings suggest that antipsychotic discontinuation by psychiatrist was possible for only small portion of the FES patients, and relapse rates are high after discontinuation even in these selected patients.

Persistent negative symptoms in recent-onset psychosis: Relationship to treatment response and psychosocial functioning

Negative symptoms are associated with poor clinical and psychosocial outcome in schizophrenia. Their prevalence and identification in first-episode patients remains controversial. In a large cohort of patients in the early stage of schizophrenia, schizophreniform or schizoaffective disorder, we investigated, over the different phases of the OPTiMiSE trial (baseline, 4, 10 and 22 weeks of treatment), the prevalence of negative symptoms of moderate severity, unconfounded by depression and extrapyramidal symptoms at baseline. Moreover, we assessed symptomatic remission, attrition rate and psychosocial functioning in subjects with short-term (4 weeks) persistent unconfounded negative symptoms (PNS) and in those with negative symptoms that did not persist at follow-up and/or were confounded at baseline (N-PNS). Negative symptoms of moderate severity were observed in 59% of subjects at baseline. They were associated with worse psychosocial functioning and longer duration of psychosis at intake in the study. Eleven percent of subjects had PNS unconfounded at baseline and 7.9% had PNS unconfounded at both baseline and end of 4-week treatment. Psychosocial functioning was comparable in PNS and N-PNS subjects at baseline but it was significantly worse in the former group after 4-weeks. PNS subjects showed lower remission and higher attrition rates at the end of all treatment phases. Fifty-six percent of subjects completing phase 3 (clozapine treatment) had PNS, and 60% of them were non-remitters at the end of this phase. The presence of short-term PNS during the first phases of psychosis was associated with poor clinical outcome and resistance to antipsychotic treatment, including clozapine.

Negative Symptoms and Functioning in Youth at Risk of Psychosis: A Systematic Review and Meta-analysis

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate the relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

AIM

Youth at CHR for psychosis often demonstrate significant negative symptoms and poor functioning, though the magnitude and direction of the relationship between the two remains unknown. The objective of this systematic review is to summarize the relationship between negative symptoms and functioning in CHR samples.

METHOD

Electronic databases CINAHL, EBM, Embase, MEDLINE, and PsycINFO were searched from inception. Studies were selected if they included any study that reported a relationship between negative symptoms and functioning in youth at clinical high risk (CHR). The correlation coefficient r was converted to Cohen's d, and all random-effects meta-analyses were performed using the transformed values.

RESULTS

Forty-one studies met the inclusion criteria, including a total of 4574 individuals at CHR for psychosis. Negative symptom total scores were significantly associated with poorer global functioning (d, -1.40; 95% CI, -1.82 to -0.98; I = 79.4%; p < .001 [9 studies, n = 782]), social functioning (d, -1.10; 95% CI, -1.27 to -0.93; I = 10.40%; p < .001 [12 studies, n = 811]), and role functioning (d, -0.96; 95% CI, -1.17 to -0.76; I = 41.1%; p < .001 [9 studies, n = 881]). In addition, negative symptoms were consistently associated with poor premorbid functioning. When examining negative symptom domains, avolition, anhedonia, and blunted affect were each significantly and independently associated with poorer social functioning and role functioning. In terms of prediction models, negative symptoms contributed to the prediction of lower functioning across multiple studies.

CONCLUSION

This meta-analysis demonstrates a strong relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

Negative symptoms in first-episode psychosis: Clinical correlates and 1-year follow-up outcomes in London Early Intervention Services

AIM

Negative symptoms (NS) have been associated with poor outcome and remain difficult to treat in patients with psychosis. This study examined the association of NS with clinical features at first presentation to mental health services for psychosis and with outcomes at 1-year follow-up.

METHODS

Clinical data were utilized from five London Early Intervention Services (EIS) included in the MiData audit database. The sample comprised 484 first-episode psychosis patients with complete Positive and Negative Syndrome Scale data at baseline and 1-year follow-up. Multiple imputation (N = 50) was conducted to account for missing follow-up data.

RESULTS

Baseline NS were associated with male gender (B = -1.63, P < .05), younger age at onset (B = -.15, P <. 05), a higher level of impairment on the Global Assessment of Functioning (disability) Scale at baseline (B = -.19, P <. 010), an absence of reported substance misuse prior to baseline assessment (B = -3.05, P <. 001) and unemployment at baseline (B = -.93, P <. 01). At 1-year follow-up, NS at presentation were associated with worse Global Assessment of Functioning Scale for symptom (B = -.28, P < .01) and disability (B = -.27, P <. 05) and with hospital admission (OR = 1.06, P < .01).

CONCLUSIONS

Negative symptoms at presentation to EIS were associated with worse functioning at entry and poorer outcomes 1 year later. Future research is required to better understand the aetiology and trajectories of NS in early psychosis and propose novel targeted interventions.

Persistent negative symptoms in individuals at Ultra High Risk for psychosis

Persistent negative symptoms (PNS) defined as negative symptoms that persist for at least six months in the absence of high levels of positive, depressive and extrapyramidal symptoms, are evident early in the course of schizophrenia from the first episode of psychosis. However, their presence even earlier in the illness, in those at Ultra High Risk of psychosis, has not been investigated. In this study, we examined the prevalence, baseline correlates and outcome of PNS in 363 Ultra High Risk individuals. Assessments were conducted at baseline and 2-14 years later (mean follow up time 7.4 years). Baseline assessments included demographic, clinical and neurocognitive measures, which were repeated at follow up. The prevalence of PNS in the UHR group was 6.1%. Poor premorbid social adjustment, deficits in verbal fluency and childhood maltreatment, specifically emotional neglect, were evident at baseline in the PNS group compared to the group without PNS. PNS were associated with poor psychosocial functioning and deficits in processing speed at follow up. Our findings suggest that PNS can be detected early, allowing for the identification of a subset of Ultra High Risk patients who are likely to have poor outcome. These individuals could be the target for specific intervention. Further research is needed into the pathophysiology of these PNS to develop specific interventions.

Early-Stage Negative Symptom Trajectories and Relationships With 13-Year Outcomes in First-Episode Nonaffective Psychosis

Negative symptoms are a key treatment target in early psychosis intervention. There is a paucity of research examining longitudinal course of negative symptoms across the initial years of treatment for first-episode psychosis using individual-based trajectory analysis. No study has been conducted investigating differential relationships of early-stage negative symptom trajectories with long-term distal outcomes. This study examined patterns and baseline predictors of negative symptom trajectories over the first 3 years of treatment in 138 patients aged 18-55 years presenting with first-episode nonaffective psychosis, using latent class growth analysis based on symptom ratings measured at 4 different time points (baseline, 1, 2, and 3 years). We further explored prospective relationships of identified trajectory classes with functional and negative symptom outcomes at 13-year follow-up. Our results revealed 3 distinct negative symptom trajectories including minimal-stable (59.6%), mild-stable (29.4%), and high-increasing (11.0%) trajectories. Poorer premorbid adjustment, more severe global cognitive impairment, and depressive symptoms at baseline were found to predict high-increasing trajectory. Among 3 trajectory classes, patients in high-increasing trajectory had the worst functional and negative symptom outcomes at 13-year follow-up, with post hoc analyses demonstrating significant outcome differences between high-increasing and minimal-stable trajectories. Our findings thus affirm a heterogeneous course of negative symptoms in first-episode psychosis and indicate that early-stage negative symptom trajectories are critically associated with long-term outcomes. Patients displaying persistently high negative symptom levels in the initial 3 years of treatment may represent a specific subgroup who necessitates an extended period of early intervention specifically targeting at negative symptoms to promote early functional recovery.

Effects of Prodromal Stage and Untreated Psychosis on Subsequent Psychopathology of Schizophrenia: A Path Analysis

BACKGROUND

To examine psychopathology present under prolonged antipsychotic treatment in schizophrenia and to analyse their relationship to both the duration of the prodromal stage (DPS; time between onset of first unspecific psychological symptoms and first schizophrenic symptoms) and the duration of untreated psychosis (DUP; time between the onset of psychosis and the initiation of antipsychotic treatment).

METHODS

The psychopathology of 93 patients was assessed cross-sectionally using the Scales for the Assessment of Negative and Positive Symptoms and the Brief Psychiatric Rating Scale. DPS and DUP were assessed by means of the patient records and the Interview for the Retrospective Assessment of the Onset and Course of Schizophrenia and Other Psychoses. A path analysis using maximum likelihood estimation was conducted with the program Analysis of Moment Structures for Windows.

RESULTS

The resulting path model indicated that DPS was predictive for a more severe negative symptomatology in schizophrenia, whereas DUP was associated with a more severe positive symptomatology in the long-term. Furthermore, DUP showed an inverse correlation with the age of the patients at the onset of both first unspecific psychological symptoms and first schizophrenic symptoms.

CONCLUSION

A long prodromal stage suggests an increased risk of a long-term progression with negative symptoms in schizophrenia, whereas a delayed start of antipsychotic treatment could lead to an increased manifestation and severity of positive symptoms in the long term. These results underline the need to shorten the duration of the prodrome by an early detection and adequate intervention in patients with increased risk to develop psychosis.

Cognitive remediation can improve negative symptoms and social functioning in first-episode schizophrenia: A randomized controlled trial

BACKGROUND

Meta-analyses have reported that the effects of cognitive remediation might go beyond improvement in cognition to include unexpected benefits for schizophrenia patients such as negative symptom reduction and improvements in functioning. In addition, some evidence indicated that these potentially beneficial effects are also present in the initial course of schizophrenia, but work in this area is still developing.

METHOD

A RCT compared Cognitive Remediation (CR) to Healthy Behaviors Training (HBT) in 80 patients (78% male) with a mean age of 21.9years and mean education of 12.3years who had a first psychotic episode within two years of study entry. Participants were trained using CR programs or received HBT involving 50 sessions over 6months and then booster sessions over the next 6months. The SANS and BPRS were used to assess symptoms. The UCLA Social Attainment Survey assessed social functioning.

RESULTS

Using GLMM, improvements over 12months were found favoring CR for SANS Expressive Symptoms (p<0.01), which was composed of Affective Flattening (p<0.01) and Alogia (p=0.04), and for SANS Experiential Symptoms, composed of Avolition/Apathy (p=0.04) and Anhedonia/Asociality (p<0.01). CR was associated with improvements in social functioning (p=0.05) as compared to HBT.

CONCLUSIONS

We confirmed that the beneficial effects of CR appear to extend beyond cognition to improvements in negative symptoms and social functioning in early course schizophrenia patients. These results suggest that cognitive remediation might have an impact when the reduction of risk factors for chronicity is most critical for promoting recovery.

[Personality disorders and schizophrenic defect (problem of comorbidity)]

AIM

To test the main hypothesis that the deficit phenomena in schizophrenia act not in the 'pure' form, but in the form of aggravating personality characteristics, forming so-called 'common' syndromes with personality disorders (PD).

MATERIAL AND METHODS

The results of the psychopathological study (with the use of psychometric methods) of deficit disorders in a sample of 170 patients with schizophrenia and schizophrenia spectrum disorders (63 men, 107 women) are presented in relation to the abnormal structure of premorbid personality (PD of clusters A, B, C). An analysis of negative symptoms according to the comparability of defect to the profile of premorbid personality made it possible to distinguish three groups of deficit states associated with PD - 'common syndromes': defensive schizoidy by the type of deficit schizoid and expansive schizoidy by the type of 'verschroben' (cluster A); pathological hysterical infantilism, malignant hysteria and defective erotomania (cluster B); pseudo-psychasthenia and pathological rationalism (cluster C).

RESULTS

It has been found that the symptomatology of 'common syndromes' is subject to patterns reflecting the dichotomy of the basic defect. This pattern is valid not only for one single cluster of PD, but extends to all psychopathy-like disorders, regardless of their affiliation with a particular cluster. The pathocharacterological component of the 'common syndromes' coexisting with the deficit symptom complexes is subject to the basic deficit component of the defect and is separated into polar dimensions (defensive-expansive) within specific clusters of PD, and then unified in accordance with the dichotomy of schizophrenic defect in categories with the predominance of emotional or apathoabulic disorders.

CONCLUSION

Psychopathy-like symptom complexes in the space of 'common syndromes' can be qualified as a psychopathological construct secondary to basic deficit disorders, and their isolation as an independent entity of negative disorders appears to be unjustified.

Revisiting the persistent negative symptoms proxy score using the Clinical Assessment Interview for Negative Symptoms

OBJECTIVE

The present study aimed to validate a severity cut-off of negative symptoms for persistent negative symptoms (PNS) identification using the Clinical Assessment Interview for Negative Symptoms (CAINS).

METHOD

A total of 206 patients with schizophrenia were recruited and divided into the PNS group (n = 57) and the Non-PNS group (n = 149) using PNS criteria based on the SANS and the SAPS. To determine the appropriate cut-offs on the CAINS in identifying PNS, Receiver Operating Characteristic (ROC) curve analysis was conducted in the PNS and Non-PNS groups.

RESULTS

Our results showed that the cutoffs for identifying PNS on the CAINS total score, the Motivation and Pleasure (MAP) subscale score and the Expression (EXP) subscale score were 25, 17, and 5 respectively. Area Under the Curve (AUC) analysis indicated excellent discrimination of the PNS group from the Non-PNS group using the cut-off for the CAINS total score. However, discrimination was somewhat better for the MAP subscale score than the EXP subscale score. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the MAP subscale were 81.54% and 97.16%.

CONCLUSION

We found that the cut-off scores derived from the CAINS to identify PNS are comparable to existing scales. The CAINS offers an alternative means in identifying PNS patients in clinical trials that overcomes methodological and conceptual limitations of older scales.

Duration of untreated psychosis and neurocognitive functioning in first-episode psychosis: a systematic review and meta-analysis

BACKGROUND

Previous reviews suggest there is minimal evidence for an association between duration of untreated psychosis (DUP) and neurocognition. This is based on tallied findings of studies with small samples and neurocognition viewed as a single construct. We aimed to conduct a systematic review and meta-analysis examining the association between DUP and individual neurocognitive domains and tests in first-episode psychosis (FEP).

METHOD

MOOSE and PRISMA guidelines were followed. Forty-three studies involving 4647 FEP patients were included. For studies providing correlations between DUP and neurocognition, 12 separate meta-analyses were performed based on neurocognitive domains/indices. The influence of demographic/clinical variables was tested using weighted linear meta-regression analyses.

RESULTS

The relationship between DUP and most neurocognitive domains/indices was not significant. Longer DUP was associated with a larger cognitive deterioration index, i.e. current minus premorbid intellectual functioning (N = 4; mean ES -0.213, 95% confidence interval (CI) (-0.344 to -0.074), p = 0.003). Findings were homogeneous, with no evidence of publication bias or significant influence from moderators. For studies providing mean and standard deviations for neurocognitive measures and DUP, 20 meta-regressions were performed on individual neurocognitive tests. One significant finding emerged showing that longer DUP was associated with fewer Wisconsin Card Sorting Test-perseverative errors (mean ES -0.031, 95% CI (-0.048 to -0.013), p < 0.001). Exploratory meta-regressions in studies with mean DUP <360 days showed longer DUP was significantly associated with poorer performance on Trail Making Test A and B and higher Full-Scale IQ.

CONCLUSION

There may not be a generalised association between DUP and neurocognition, however, specific cognitive functions may be associated with longer DUP or delayed help-seeking.

Grey matter reduction in the caudate nucleus in patients with persistent negative symptoms: An ALE meta-analysis

OBJECTIVES

In the present study, we used Activation Likelihood Estimation (ALE) meta-analysis to quantitatively examine brain grey matter reduction in schizophrenia patients with persistent negative symptoms (PNS).

METHOD

A total of 12 voxel-based morphometry (VBM) studies were included in ALE meta-analysis using more stringent criterion of PNS.

RESULTS

Significant grey matter reduction in the PNS group relative to controls was observed in the left caudate nucleus, the left precentral region, the left middle frontal region, the bilateral parahippocampal region, the left anterior cingulate region, the bilateral medial frontal gyrus, the thalamus and the insula.

CONCLUSION

Our results suggest that brain regions in the reward network may be specifically related to PNS, especially the left caudate nucleus. It is possible that abnormality in reward processing may constitute the neural basis of PNS.

Schizophrenia heterogeneity revisited: Clinical, cognitive, and psychosocial correlates of statistically-derived negative symptoms subgroups

Traditional efforts to delineate the clinical heterogeneity of schizophrenia have been unsuccessful because of the absence of a valid, stable, and meaningful subtyping scheme. A clinically-informed nosology supported by multivariate statistical classification methods may provide a better approach for classifying schizophrenia. The goals of the current study were to 1) use multivariate classification methods to validate a clinical subtyping scheme based on the profile of negative symptoms; and 2) following validation to contrast the statistically-derived subgroups to ascertain distinguishing demographic, clinical, cognitive, and functional characteristics. In the current study, 706 people with schizophrenia completed measures of positive and negative symptoms, premorbid adjustment, cognition, and psychosocial functioning. Latent class analysis served to identify the number of negative symptom subgroups in schizophrenia. Next, statistical classification methods-Bayes Theorem and the Base Rate Classification Technique-were used to assign participants into the identified subgroups. Subgroups were compared on external validation variables not used in the classification process via logistic regression and discriminant function analysis. Latent class analysis supported a three-class model of schizophrenia that included deficit, persistent, and transient negative symptom subgroups. Posthoc comparisons showed that demographic characteristics, positive symptoms, premorbid adjustment, and cognitive profiles can distinguish the schizophrenia subgroups with moderate accuracy. The deficit subgroup had the greatest impairments in psychosocial functioning and quality of life variables. Findings suggest that schizophrenia encapsulates qualitatively distinct negative symptom subgroups that differ in their demographic, symptomatic, neuropsychological, and functional profiles. Schizophrenia heterogeneity reflects a combination of non-arbitrary subgroups and severity-based differences in negative symptoms.

Relationship Between Persistent Negative Symptoms and Findings of Neurocognition and Neuroimaging in Schizophrenia

Negative symptoms are defined as loss or reduction of otherwise present behaviors or functions in illness situation, and they have constituted an important aspect of schizophrenia. Although negative symptoms have usually been considered as a single entity, neurobiological investigations yielded discrepant results. To overcome challenges that derive from this discrepancy, researchers have proposed several approaches to structure negative symptoms into more homogenous constructs. Concept of persistent negative symptoms (PNS) is one of the proposed approaches, and includes both primary and secondary negative symptoms that persist after adequate treatment. PNS is relatively easy to assess, and by definition, more inclusive; yet it represents an unmet therapeutic need. Therefore, it is a target of several neurobiological and pharmacological studies. There are several structural and functional brain alterations associated with negative symptoms. On the other hand, neurocognitive investigations in patients with schizophrenia have revealed deficits in several domains that showed correlations with negative symptoms. There are several shared features between negative symptoms and neurocognitive deficits in schizophrenia such as prevalence rates, course through the illness, prognostic importance, and impact on social functioning. However, exact mechanisms behind the neurobiology of PNS and how it interacts with neurocognition remain to be explained. Earlier reviews on neuroimaging and neurocognitive correlates of PNS have been focused on studies with broadly defined negative symptoms that were selected by methodological closeness to PNS. In this review, we focus on neural correlates and neurocognitive associations of PNS, and we discuss PNS findings available to date.

A prospective cohort study of community functioning among psychiatric outpatients

The present study analyzed the community functioning among Chinese people with common mental disorders and their relationships with different factors under the framework of Model of Human Occupation. The research team followed up a stratified random sample of 238 patients in three public psychiatric specialist outpatient clinics in Hong Kong in one year. The patients completed assessments at baseline and 12-month follow-up in four areas of community functioning (i.e., self-care, independent living skills, social skills, and work skills), self-esteem, self-efficacy, physical functioning, behavioral regulation, mental states, family expressed emotion, and perceived social stigma. The data showed that after 12 months, the patients had positive changes in self-care, work skills, and behavioral regulation. Those patients who had higher levels of self-esteem at baseline and reduced their negative reactions to stigma were more likely to improve social skills, while those patients who perceived less discrimination at baseline and enhanced their self-esteem would have a higher likelihood of making improvement in work skills. The findings implied that the rehabilitation services for people with common mental disorders might target on the enhancement of self-esteem and reduction of discrimination experience to facilitate their improvement in social skills and work skills.

The course of negative symptoms in first-episode schizophrenia and its predictors: A prospective two-year follow-up study

AIMS

This study aimed to investigate the course of negative symptoms and its stability over a two-year period following a first-episode schizophrenia (FES) and the possible predictors of higher severity in this symptomatology after this period.

METHODS

In this longitudinal two-year prospective follow-up study we included 268 patients with a FES, according to DSM-IV. Analysis of variance was conducted in patients who completed the full follow-up to study changes in negative symptoms over three visits. Regression analyses were conducted to show correlates and potential predictors of negative symptoms at two-year follow-up.

RESULTS

There was a significant effect for time in negative symptomatology, which was less severe at one-year follow-up after a FES and remained stable up to two years (Time 1>Time 2>Time 3); F(2,151)=20.45, p<0.001. Poorer premorbid adjustment (p=0.01) and higher negative symptoms at baseline (p<0.001) made a significant contribution to the changes in the negative symptoms severity at two-years after a FES (R²=0.21, p<0.001).

CONCLUSIONS

We found a reduction in the negative symptomatology at one-year after a FES. This change remained stable at two-year. Our results suggested that the presence of this symptomatology early in the course of the illness, together with a poorer premorbid adjustment, predict more severe negative symptoms at mid-term outcome.

Primary and persistent negative symptoms: Concepts, assessments and neurobiological bases

Primary and persistent negative symptoms (PPNS) represent an unmet need in the care of people with schizophrenia. They have an unfavourable impact on real-life functioning and do not respond to available treatments. Underlying etiopathogenetic mechanisms of PPNS are still unknown. The presence of primary and enduring negative symptoms characterizes deficit schizophrenia (DS), proposed as a separate disease entity with respect to non-deficit schizophrenia (NDS). More recently, to reduce the heterogeneity of negative symptoms by using criteria easily applicable in the context of clinical trials, the concept of persistent negative symptoms (PNS) was developed. Both PNS and DS constructs include enduring negative symptoms (at least 6months for PNS and 12months for DS) that do not respond to available treatments. PNS exclude secondary negative symptoms based on a cross-sectional evaluation of severity thresholds on commonly used rating scales for positive symptoms, depression and extrapyramidal side effects; the DS diagnosis, instead, excludes all potential sources of secondary negative symptoms based on a clinical longitudinal assessment. In this paper we review the evolution of concepts and assessment modalities relevant to PPNS, data on prevalence of DS and PNS, as well as studies on clinical, neuropsychological, brain imaging electrophysiological and psychosocial functioning aspects of DS and PNS.

The stability of negative syndrome, persistent negative syndrome and deficit syndrome in a twenty-year follow-up study of schizophrenia patients

AIMS

To assess the prevalence and stability of negative symptoms in schizophrenia according to the BPRS-withdrawal/retardation, persistent negative symptoms and deficit syndrome over twenty years.

METHOD

Fifty people diagnosed with schizophrenia were evaluated during their first psychiatric hospitalisation and after three, seven, twelve and twenty years. the presence of negative symptoms was assumed when at least one of the BPRS-withdrawal/retardation symptoms (blunted affect, emotional withdrawal, motor retardation), equalled three or more points at the discharge from the index hospitalisation. The groups with persistent negative symptoms and deficit syndrome were identified based on two measurements taken at the index discharge and one year later. The Proxy for the Deficit Syndrome (PDS) was employed to identify deficit syndrome.

RESULTS

The prevalence of BPRS-withdrawal/retardation, persistent negative symptoms and deficit syndrome after one year was 20%, 4% and 6% respectively. Four of the ten people with BPRS-withdrawal/retardation symptoms maintained them at all follow-ups. No symptoms, however, were found in any of the members of the persistent negative symptoms and deficit syndrome group after twelve and twenty years.

CONCLUSIONS

The prevalence of primary, persistent negative symptoms after the first episode of psychosis was minimal. A long-term observation does not confirm their stability.

Frontal-striatum dysfunction during reward processing: Relationships to amotivation in schizophrenia

Schizophrenia is characterized by deficits of context processing, thought to be related to dorsolateral prefrontal cortex (DLPFC) impairment. Despite emerging evidence suggesting a crucial role of the DLPFC in integrating reward and goal information, we do not know whether individuals with schizophrenia can represent and integrate reward-related context information to modulate cognitive control. To address this question, 36 individuals with schizophrenia (n = 29) or schizoaffective disorder (n = 7) and 27 healthy controls performed a variant of a response conflict task (Padmala & Pessoa, 2011) during fMRI scanning, in both baseline and reward conditions, with monetary incentives on some reward trials. We used a mixed state-item design that allowed us to examine both sustained and transient reward effects on cognitive control. Different from predictions about impaired DLPFC function in schizophrenia, we found an intact pattern of increased sustained DLPFC activity during reward versus baseline blocks in individuals with schizophrenia at a group level but blunted sustained activations in the putamen. Contrary to our predictions, individuals with schizophrenia showed blunted cue-related activations in several regions of the basal ganglia responding to reward-predicting cues. Importantly, as predicted, individual differences in anhedonia/amotivation symptoms severity were significantly associated with reduced sustained DLPFC activation in the same region that showed overall increased activity as a function of reward. These results suggest that individual differences in motivational impairments in schizophrenia may be related to dysfunction of the DLPFC and striatum in motivationally salient situations.

Social cognition as an RDoC domain

While the bulk of research into neural substrates of behavior and psychopathology has focused on cognitive, memory and executive functions, there has been a recent surge of interest in emotion processing and social cognition, manifested in designating Social Cognition as a major RDoC domain. We describe the origins of this field's influence on cognitive neuroscience and highlight the most salient findings leading to the characterization of the "social brain" and the establishments of parameters that quantify normative and aberrant behaviors. Such parameters of behavior and neurobiology are required for a potentially successful RDoC construct, especially if heritability is established, because of the need to link with genomic systems. We proceed to illustrate how a social cognition measure can be used within the RDoC framework by presenting a task of facial emotion identification. We show that performance is sensitive to normative individual differences related to age and sex and to deficits associated with schizophrenia and other psychotic disorders. Neuroimaging studies with this task demonstrate that it recruits limbic and frontal regulatory activation in healthy samples as well as abnormalities in psychiatric populations. Evidence for its heritability was documented in genomic family studies and in patients with the 22q11.2 deletion syndrome. Measures that meet such criteria can help build translational bridges between cellular molecular mechanisms and behavior that elucidate aberrations related to psychopathology. Such links will transcend current diagnostic classifications and ultimately lead to a mechanistically based diagnostic nomenclature. Establishing such bridges will provide the elements necessary for early detection and scientifically grounded intervention.

Psychopathological Symptoms Assessed by a System-Specific Approach Are Related to Global Functioning in Schizophrenic Disorders

BACKGROUND

By mostly using a positive-negative approach, several studies have identified factors that influence day-to-day functioning. We applied a different, system-specific approach to expand the knowledge of this issue.

SAMPLING AND METHODS

We recruited a sample of 100 inpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Psychopathological characteristics were assessed with the Bern Psychopathology Scale (BPS) and functional characteristics with the Global Assessment of Functioning (GAF) scale. Linear regression analyses were performed with the GAF score as the dependent variable and the global values of the BPS subscores as independent variables. The model was controlled for confounding variables. Spearman rank correlation analyses were used to identify associations between the relevant BPS subdomains and global functioning.

RESULTS

Higher absolute global values of the BPS domains language (px2009; = x2009;0.038) and motor behavior (px2009; = x2009;0.049) were significantly associated with lower GAF scores. These findings remained stable after adjusting for potential confounding variables. A statistically significant negative correlation was found between both qualitative symptoms (rx2009; = x2009;-0.273, px2009; = x2009;0.006) and indirect signs (rx2009; = x2009;-0.269, px2009; = x2009;0.007) of the language domain and GAF scores. Also, quantitative (rx2009; = x2009;-0.211, px2009; = x2009;0.035) and qualitative symptoms (rx2009; = x2009;-0.214, px2009; = x2009;0.033) in the motor behavior domain were associated with poorer functioning.

CONCLUSIONS

A system-specific approach can describe subgroups of patients with poor functioning. Identifying such subgroups could help to utilize targeted treatment opinions in a timely manner. Another goal of future research is to clarify the underlying neurobiological deficits.

Self esteem and self agency in first episode psychosis: Ethnic variation and relationship with clinical presentation

The impact of self esteem and Locus of Control (LoC) on clinical presentation across different ethnic groups of patients at their first psychotic episode (FEP) remains unknown. We explored these constructs in 257 FEP patients (Black n=95; White British n=119) and 341 controls (Black n=70; White British n=226), and examined their relationship with symptom dimensions and pathways to care. FEP patients presented lower self-esteem and a more external LoC than controls. Lower self esteem was associated with a specific symptoms profile (more manic and less negative symptoms), and with factors predictive of poorer outcome (longer duration of untreated psychosis (DUP) and compulsory mode of admission). A more external LoC was associated with more negative symptoms and an insidious onset. When we explored these constructs across different ethnic groups, we found that Black patients had significantly higher self esteem than White British. This was again associated with specific symptom profiles. While British patients with lower self esteem were more likely to report delusions, hallucinations and negative symptoms, Black patients with a lower self esteem showed less disorganization symptoms. These findings suggest that self esteem and LoC may represent one way in which social experiences and contexts differentially influence vulnerable individuals along the pathway to psychosis.

The Longitudinal Course of Gross Motor Activity in Schizophrenia - Within and between Episodes

Schizophrenia is associated with heterogeneous course of positive and negative symptoms. In addition, reduced motor activity as measured by wrist actigraphy has been reported. However, longitudinal studies of spontaneous motor activity are missing. We aimed to explore whether activity levels were stable within and between psychotic episodes. Furthermore, we investigated the association with the course of negative symptoms. In 45 medicated patients, we investigated motor behavior within a psychotic episode. In addition, we followed 18 medicated patients across 2 episodes. Wrist actigraphy and psychopathological ratings were applied. Within an episode symptoms changed but activity levels did not vary systematically. Activity at baseline predicted the course of negative symptoms. Between two episodes activity recordings were much more stable. Again, activity at the index episode predicted the outcome of negative symptoms. In sum, spontaneous motor activity shares trait and state characteristics, the latter are associated with negative symptom course. Actigraphy may therefore become an important ambulatory instrument to monitor negative symptoms and treatment outcome in schizophrenia.

Thinking and acting beyond the positive: the role of the cognitive and negative symptoms in schizophrenia

Since currently available antipsychotic medications predominantly treat hallucinations, delusions, disorganized thoughts and behavior, and related agitation/aggression, attention has traditionally been focused on managing positive symptoms. However, prominent negative symptoms and clinically relevant cognitive impairment affect approximately 40% and 80% of people with schizophrenia, respectively. Moreover, negative and cognitive symptoms are closely related to functional outcomes, and contribute substantially to the overall illness burden. Therefore, approaches to describe, measure, and manage these symptom domains are relevant. This article summarizes the phenomenology, prevalence, assessment, and treatment of negative and cognitive symptoms in patients with schizophrenia, including pharmacologic and nonpharmacologic management strategies that can be used in clinical care now, as well as pharmacologic approaches that are being tested. Currently, no approved treatments targeting negative or cognitive symptomatology in schizophrenia are available. It is hoped that progress in the understanding of the neurobiology of these important symptom domains of schizophrenia will help develop effective treatment strategies in the future. However, until this goal is achieved, clinicians should avoid therapeutic nihilism. Rather, the severity and impact of negative and cognitive symptoms should be determined, quantified, and monitored. Further, psychosocial treatments have shown therapeutic benefits. Thus, cognitive behavioral therapy, cognitive remediation, social skills training, and computer-assisted training programs should be offered in conjunction with antipsychotic treatment. Several non-antipsychotic augmentation strategies can be tried off-label. Treatment plans that incorporate currently available management options for negative and cognitive symptomatology in patients with schizophrenia should be adapted over time and based on the individual's needs, with the aim to enhance overall outcomes.